Station 58
Sarah Collins
Age: 28 year old female
Examiner
Marking Scheme
Data Gathering and Diagnosis
- Ask about the onset/first episode of the collapse
- Ask the patient for a detailed description of the incident
- Ask if anyone witnessed the episode
- Ask how long the patient was unconscious
- Ask about symptoms prior to the collapse, including dizziness, light-headedness, nausea, vomiting, weakness, or visual disturbance
- Ask whether the episode occurred during exercise, while lying down, or when sitting or standing
- Ask if there were any palpitations, chest pain, or shortness of breath
- Ask what happened during the recovery phase, including incontinence, amnesia, drowsiness, dizziness, sleepiness, or tongue biting
- Ask if the patient has experienced similar episodes in the past
- Ask if the patient had been feeling unwell prior to the event, such as with flu-like symptoms, sore throat, or fever
- Ask about headache or any recent head injury
- Ask if there have been any new medications started recently
- Ask about smoking history and alcohol intake
- Ask about driving status and occupation, particularly if the job involves operating machinery or poses safety risks
- Ask about family history of epilepsy
- Make a working diagnosis of possible seizure activity(epilepsy). Since there have been two episodes, this raises the possibility of epilepsy.
Example of explanation to patient
Sarah, based on what you’ve told me, it’s possible that you may have had seizures. These happen when there’s a sudden change in the brain’s electrical activity, which can cause someone to collapse, shake, and sometimes wet themselves, just like what you’ve experienced. Because this has now happened more than once, this raises the possibility of epilepsy, a condition where seizures can happen repeatedly.
I’d like to refer you to a special clinic called the ‘First Seizure Clinic’. When you go there, they may do some tests, like a scan of your brain and another test that looks at the electrical activity of your brain. This will help us understand what’s going on and how to manage it.
In addition, would it be okay if I see you in person today so I can examine your nerves, listen to your heart, and check your blood pressure? We’ll also do some blood tests to help us gather more information.
While we’re waiting for those results, I need to ask you not to drive for now, just to keep you and others safe. I also suggest letting your workplace know what’s been happening, and they can arrange an occupational health assessment. This will help identify any adjustments you might need to stay safe and supported at work.
You mentioned you’re worried about having an episode at work, and I completely understand that can be concerning. One helpful step is making sure your colleagues are aware of your condition and know what to do if you ever have a seizure while at work. That way, it doesn’t take them by surprise, and they can support you in the right way if something does happen.
It’s also a good idea to avoid situations where a seizure episode could be dangerous, like swimming alone or working at heights. I’ll send you some leaflets that explain what people around you should do if you ever have another episode.
Also, you might want to think about wearing a medical alert bracelet. It lets others know about your condition in case you have another episode when you’re out in public.
Finally, if anyone sees you have another episode that lasts more than 5 minutes, they should call 999.
Management
Management
- Offer a face-to-face appointment to perform a full neurological examination and cardiovascular examination (e.g. listen to heart sounds, check blood pressure and pulse)
- Arrange an ECG and routine blood tests
- Refer to the “First Fit Clinic” or “First Seizure Clinic”; explain that the clinic may offer a brain scan and an EEG (electrical tracing of brain activity) to investigate further. They typically aim to see patients within two weeks.
- Advise the patient to stop driving until seen by a specialist and a diagnosis is confirmed and they should inform the DVLA
- Advise informing her employer and arranging an occupational health assessment for potential adjustments at work
- Inform her that you will send some leaflets with emergency precautions that those around her can follow to help keep her safe in the event of another seizure. Emphasise the importance of educating her colleagues at work about her condition, so they are prepared to assist her appropriately if an episode occurs.
- Recommend avoiding high-risk situations where a seizure episode could lead to harm, such as working at heights or swimming alone
- Suggest that she consider wearing a medical alert bracelet, so that if she has a seizure in a public place where people may not know her, they will be aware of her condition and able to get help quickly.
- Safety net: advise that if another seizure occurs and lasts more than 5 minutes, anyone present should call 999 immediately
Learning point from this station:
When assessing a patient with episodes of collapse, a structured history is essential and should focus on three key phases:before, during, and after the event. This approach can help distinguish between different underlying causes such as vasovagal syncope, epilepsy, or cardiac events.
Pre-collapse: Ask about any warning signs. Light-headedness, nausea, or visual changes may suggest vasovagal syncope. An aura, such as a strange sensation or feeling of impending collapse, may point towards epilepsy. However, epilepsy can also present suddenly without warning. Similarly, a collapse that occurs abruptly with no preceding symptoms may raise concern for a cardiac cause, such as an arrhythmia
During the collapse: Determine the duration and characteristics of the episode. Vasovagal syncope typically lasts less than 30 seconds, though it may occasionally extend to 1–2 minutes. In contrast, epileptic seizures usually last over one minute and can extend up to 5 minutes. Seizures lasting longer than 5 minutes may indicate status epilepticus and require urgent medical attention.
Post-collapse: In epilepsy, features such as tongue biting, post-ictal incontinence, drowsiness, confusion, and amnesia are common. In vasovagal syncope, recovery is usually rapid and complete, with the person typically feeling only mildly tired and retaining full memory of the event.
All patients with a first suspected seizure should be referred urgently to a First Seizure Clinic, where the aim is to be seen within two weeks. Investigations at the clinic typically include brain imaging and an EEG to assess for underlying neurological causes.
It is also essential to inform the patient about DVLA guidance. They must stop driving immediately and notify the DVLA
Education plays a key role in management — both the patient and their family or colleagues should be made aware of how to respond appropriately in the event of a seizure. This includes basic first aid measures, when to call emergency services, and understanding seizure safety in day-to-day life