MARTIN · Seizure / Epilepsy

Patient Details

Name: David / Dotty Martin
Age: 40 years
Opening statement: “I fainted at home and my partner made me come”

Clinical Details (First Consultation)

3 days prior to this consultation you were at home with your partner one evening. Your partner was upstairs in the bath when they heard you drop some crockery. Hearing nothing afterwards, they got out of the bath and went downstairs where they found you lying on the kitchen floor, initially unconscious but slowly coming round.

Response Guidance

Open questions

If asked to say more, describe the events as above.

Closed questions only

You remained drowsy for some 20 minutes afterwards but insisted you would be alright and that your partner should not call an ambulance.
You recall seeing a sudden flash of light, but nothing else until your partner found you.
The next day you felt fine and attributed it to a faint (extremely busy, skipped breakfast, been out jogging, followed by a “pint”, preparing for visitors).
Agreed to see the GP for partner’s sake — “just for a check-up”.
No other associated symptoms before collapse. No fevers, weight loss, headaches, visual changes, GI symptoms or residual symptoms.
Side of tongue was painful on waking (think you bit it). Will admit to having wet yourself during the event (very embarrassed) but feel this can be normal when you faint as you “lose control of everything”.
You drive and it is very important that you can continue to do so (no other way to get to work). If told you cannot drive you become very worried about losing your job and being unable to pay bills.
If told an underlying cause needs to be excluded you become extremely concerned. If the doctor is insensitive you strongly deny the possibility of something serious and lose confidence. If discussed sensitively you want to know as much as possible, showing increasing concern.

Patient’s Perspective (ICE & Feelings)

Ideas: You think you fainted because you were hot and had skipped breakfast.
Concerns: You are not worried about it being anything serious; you just need to get back to work.
Expectations: You think the doctor will agree it was a faint and send you on your way.
Feelings: Not particularly worried or anxious, but put up walls if further tests are suggested. Become very anxious if advised you can’t drive.

Past Medical History

Age 20: admitted to hospital with viral meningitis. Slow but uncomplicated recovery.
No other significant illnesses. General health good.

Drugs & Allergies

Nil regular medication
No known allergies

Family History

Nil of note — both parents and sets of grandparents still alive and well. No siblings.

Social History

Computer programmer — recently recommended to apply for a head of department post
Lives in terraced house
Regular partner for last 10 months
Divorced 5 years ago — 2 children (12 and 10 years)
Non-smoker
Alcohol: 20 units/week (beer/wine)

Important Social, Cultural or Behavioural Characteristics

At the first consult you need to get back to work (busy job; potential management promotion at risk if you cannot keep up with current workload). Initially dismissive of others’ (partner, GP) concerns. Unreasonably confident and expecting to be told everything is alright. Will gladly accept explanation of a “faint” due to stress or not having eaten properly.

On being told epilepsy: initial denial (no tests done to confirm; you feel fine now). If handled badly → anger against partner and GP.

At the second consult: reluctant to accept the diagnosis, but if done sensitively and persuaded, you have questions about treatment, confirmation of diagnosis, effect on job, driving, hobbies and relationship. Degree of acceptance depends on how the diagnosis is explained.

Simulated Patient Non-Verbal Behaviour / Demeanour

Casually dressed — planning on going straight to work after this appointment. Assertive, articulate. Rather feels that this is all a waste of time — partner worrying unnecessarily and GP jumping to wrong diagnosis.

Information for the Student (before first consultation)

Name: D Martin · Age: 40
PMH: Viral meningitis age 20 (slow but uncomplicated recovery). No other significant illnesses.
Last consultations: 3 years ago – ankle sprain; 6 years ago – flu; 8 years ago – URTI
Current medication: None

Physical Examination Findings

Normal peripheral and CNS examination
Heart sounds normal
Pupils equal and reactive to light and accommodation (PERLA)

Facilitator Notes – Diagnosis

Most likely: Single fit — sudden, preceded by flash of light (aura), drowsy afterwards.

Less likely: Syncope — common, but should have recovered faster.

This case is in 2 parts: (1) history-taking of a straightforward seizure presentation — recognise it was a seizure not a faint; suggest next steps (referral/imaging/EEG) and potentially broach the no-driving conversation; (2) review hospital letter and discuss official diagnosis as breaking bad news.

Second Consultation – Information for Student

Hospital letter (Dr Pye):

Thank you for referring this pleasant computer programmer who unfortunately had what sounds like a first grand mal epilepsy attack. Examination is normal and I have arranged an EEG and CT scan (to exclude underlying pathology relating to a first fit at this stage).

They are obviously very reluctant to accept the idea that he may have epilepsy but for the time being I have advised them against driving, dangerous sports and to avoid prolonged viewing of TV screens/monitors especially in the dark or sitting close to such. I have suggested they use an LCD type display as much as possible.

PS – Results:
• EEG: abnormal activity compatible with epilepsy focus
• CT Scan: Normal

Primary Care Block · University of Buckingham