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Q1: "A 25-year-old man has a first generalised tonic-clonic seizure in the waiting room. Talk me through your immediate assessment." (3 min)
Examiner expectation: ABCDE, time-critical bundle, recognition of status, treat reversible precipitants.
- Stabilise: ABCDE, recovery position to protect the airway, high-flow oxygen, IV access. Bedside capillary glucose first — hypoglycaemia is the most important reversible precipitant and mimic; treat with IV dextrose. Give thiamine if alcohol misuse suspected.
- If still convulsing at 5 minutes — status epilepticus: IV lorazepam 4 mg, repeat once at 10 minutes; if no IV access, IM midazolam 10 mg (RAMPART).
- Stage 2 if still fitting: IV levetiracetam 60 mg/kg, OR IV fosphenytoin 20 mg PE/kg, OR IV valproate 40 mg/kg (ESETT showed these are equivalent).
- Stage 3 refractory: ICU, intubate, anaesthetic infusion (propofol/midazolam/thiopentone) with continuous EEG.
- Find the precipitant concurrently: AED non-adherence (most common in known epilepsy), infection, alcohol withdrawal, metabolic disturbance (Na, Ca, Mg), stroke, tumour, anoxia.
Q2: "He recovers fully. His EEG is normal. His MRI shows a small left temporal cavernoma. Do you start an AED?" (3 min)
Examiner expectation: ILAE operational definition, decision to treat after first seizure.
- The patient meets the ILAE definition of epilepsy with ONE unprovoked seizure and a structural lesion (the cavernoma) giving an estimated recurrence risk over 60% over 10 years.
- A single normal interictal EEG does NOT exclude epilepsy — sensitivity is only about 50% on one recording.
- Yes, start an AED. A focal structural lesion is a high-recurrence-risk scenario, and the cavernoma itself is amenable to neurosurgical discussion if seizures recur.
- First-line for focal epilepsy (per SANAD/SANAD-II): lamotrigine or levetiracetam. Avoid valproate here as first-line (less effective for focal), and never use carbamazepine/phenytoin if there is any absence or myoclonic component (they worsen it).
Q3: "Three years later he is seizure-free on levetiracetam and asks to stop driving and stop the drug. Counsel him." (2 min)
Examiner expectation: AED withdrawal principles, driving rules, recurrence risk.
- Never stop abruptly — withdrawal can precipitate status epilepticus. If withdrawal is contemplated, taper over at least 2–3 months, one drug at a time.
- His recurrence risk on withdrawal is roughly 40% at 2 years — and he has a structural lesion, which argues AGAINST withdrawal. Most specialists would advise continuing.
- Driving: he can already drive (seizure-free over 1 year). If he stops the drug and remains seizure-free through the taper, he retains the licence; if a seizure occurs he loses it for a further year. The pragmatic issue is that most patients prefer to keep both the drug and the licence.
Q4: "What is SUDEP, and how do you reduce his risk?" (2 min)
Examiner expectation: definition, risk factors, prevention.
- SUDEP = sudden, unexpected, non-traumatic, non-drowning death in a person with epilepsy, with or without a seizure, no structural/toxic cause at post-mortem. Incidence ~1 per 1000 adults per year.
- Risk factors: generalised tonic-clonic seizures, nocturnal seizures, frequent seizures, drug-resistant epilepsy, intellectual disability, non-adherence.
- Reduction: seizure freedom through adherence is the single most effective measure; discuss SUDEP with every patient; nocturnal supervision for those with nocturnal seizures. His structural lesion puts him in a higher-risk group, reinforcing the case for continued treatment.