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Rose Acia is a 51 year old lady who has presented to clinic for review of her chronic medical condition. Her regular medications include:

Epilim 1000mg BD Epilim 500mg morning Keppra 1000mg afternoon

Please take a histoy from Rose and perform the relevant examination. Please focus on her recent management of her long-term medical problem.

You are Rose Acia, a 51 year old librarian who enjoys trips to the countryside and your six pet cats: Bengie, Arnold, Rufus, Molly, Polly and Nemesis.

HPC: You have had epilepsy since you were a little girl. You have had a variety of experiences with it, and it has formed part of who you are. You were bullied heavily about it in school, and can remember having fits during class on so many occasions. This continued throughout your twenties, and affected your confidence: you have never felt confident enough to go dating or have a partner for fear they will judge you about your epilepsy. You have long since accepted this, though. You don’t need someone else to make you happy! Things had improved about ten years ago, when your doctor put you on the epilim medicine. This stopped the seizures in their tracks for a good year. What a year it was too: you even went on holiday! However, this honeymoon period fell apart abruptly when you had about six seizures over a few weeks. Since then, you have been upping your epilim dose, and have had something called ‘keppra’ added. That final change was made about three years ago. Things seemed to be going according to plan until around 1 month ago. You were admitted to hospital after a seizure. It came on all of a sudden whilst you were out shopping. You remember reaching over for the cat food, and the next thing you know, a load of people were looking down at you. To make matters worse, you urinated yourself in the process, and bit your tongue. Apparently you had a fit where you jerked your arm around for about 2 minutes. Luckily a friendly junior doctor was walking by and realised what was happening and made sure you were kept safe until an ambulance came.

Since then you have had one further fit, which was a similar nature. Indeed, all of your seizures tend to be dramatic, you never have those ‘absence’ seizures where you just stare into space. No, when you stare into space, it’s just because you’re bored!

PMH: You don’t really have any other medical conditions to note – it’s just the epilepsy, and that’s more than enough thank you!

ICE: You’re worried that the epilepsy is starting to flare up again, which is very depressing considering you had the beast under control for so long. You’re concerned that one of these days you’ll have a fit somewhere dangerous – like crossing the road, or that you’ll hit your head. For that reason, you’ve stopped going out as much, which you do recognise is a shame.

FH: You know that your dad had epilepsy, but unfortunately he died when you were very young, in a car crash. He had a fit at the wheel, which has meant that you have never learned to drive: you would never feel comfortable being in that position. It’s a great shame, as when you were very little you wanted to be a pilot. Unfortunately you would never have had the confidence to pursue that dream when you were younger. Being a librarian can be exciting in its own ways, though!

SH: You live alone in a cottage with the cats. You get about ok and enjoy long walks. You’re thinking about getting an allotment and maybe a rabbit that can eat the lettuce you grow.

Please observe the student take a history of this patient’s epilepsy. Excellent candidates will assess the profound impact that Rose’s long term condition has had on her life and how it has influenced her choices in life. It would be relevant also to take a brief, focused history on the most recent seizure episodes. A neurological examination would be appropriate: whether this is a cranial nerve examination or motor examination would be irrelevant, as findings are likely to be normal regardless. An appropriate differential diagnosis would sound something like:

“My differential diagnosis would be a neurological cause, more specifically epilepsy. Rose describes her life having being shaped by epilepsy since she was very young and has discussed multiple episodes of treatment failure and subsequent adjustment. An alternative diagnosis in an individual seizure for epilepsy would include migraine, cardiac syncope, arrhythmia or vertigo.” Possible questions for discussion would include:

  • How is epilepsy diagnosed?
  • What may the next step be in Rose’s management?
  • What is status epilepticus? How is it managed?
  • If Rose was to become pregnant, what advice should she be given regarding her therapy?
  • If Rose had learned to drive, what would be your advice regarding driving given her recent epilepsy activity?