EXAMINER ONLY INFORMATION

QUESTIONS

Q1. What are the key differential diagnoses for James’s episode?

• Prompt: How do you differentiate between epilepsy and other causes of transient loss of consciousness?
• Prompt: What red flags would indicate an urgent need for further investigations?

Q2. What further history and investigations would be useful in this case?

• Prompt: What are common seizure triggers to explore?
• Prompt: What tests help confirm the diagnosis of epilepsy?

Q3. How would you explain the diagnosis and next steps to James?

• Prompt: How do you communicate uncertainty while awaiting EEG results?
• Prompt: How do you address concerns about driving and lifestyle impact?

Q4. Outline your management plan for James’s seizure episode.

• Prompt: When would you initiate anti-epileptic medication?
• Prompt: What safety precautions should he follow while awaiting diagnosis?

Q5. What preventive strategies should James follow to reduce seizure recurrence?

• Prompt: How can he modify his lifestyle to minimise seizure risk?
• Prompt: When should he seek urgent medical attention?

THE COMPETENT CANDIDATE

The competent candidate should be able to:

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Q1: What are the key differential diagnoses for James’s episode?

A structured approach is required to differentiate between epileptic and non-epileptic causes of loss of consciousness (LOC).

• Epileptic Seizures (Most Likely in This Case):
  • Generalised tonic-clonic seizure (GTC) – Loss of consciousness, convulsions, postictal confusion.
  • Focal seizure evolving to GTC – Potential subtle warning signs (aura), localised onset.
• Non-Epileptic Causes (Must Exclude):
  • Vasovagal syncope – Preceding dizziness, pallor, brief LOC, rapid recovery.
  • Cardiac syncope – Sudden LOC without prodrome, palpitations, abnormal ECG.
  • Psychogenic non-epileptic seizures (PNES) – Prolonged events, no postictal phase, fluctuating symptoms.
  • Hypoglycaemia – Preceding confusion, diaphoresis, relief with glucose intake.
• Serious Causes (Red Flags to Exclude):
  • Meningitis/encephalitis – Fever, headache, neck stiffness, altered mental state.
  • Brain tumour – Persistent headaches, focal neurological deficits, progressive symptoms.
  • Stroke/TIA – Sudden onset focal deficits, speech difficulty, gaze deviation.

A competent candidate prioritises epilepsy but ensures other causes are ruled out, especially cardiac and neurological red flags.

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Q2: What further history and investigations would be useful in this case?

• Further History:
  • Seizure characteristics: Aura, duration, postictal confusion, tongue biting, incontinence.
  • Triggers: Sleep deprivation, stress, alcohol, flashing lights, missed meals.
  • Previous episodes: Any unrecognised seizures, déjà vu, or myoclonic jerks.
  • Family history: Epilepsy or sudden unexplained death.
• Investigations:
  • Electroencephalogram (EEG) – To assess for epileptiform activity.
  • Brain MRI – To exclude structural abnormalities, tumours, or scarring.
  • ECG – To exclude cardiac syncope (e.g., prolonged QT, arrhythmia).
  • Metabolic screening – Glucose, calcium, magnesium (metabolic triggers).

A competent candidate tailors investigations based on clinical suspicion and ensures epilepsy is not misdiagnosed.

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Q3: How would you explain the diagnosis and next steps to James?

1. Acknowledge concerns:
   • “I understand that having a seizure can be alarming, and you have concerns about what this means.”
2. Explain the findings:
   • “Your symptoms suggest you may have had a generalised seizure, but we need further tests to confirm this.”
3. Discuss next steps:
   • “We have arranged an EEG and MRI to assess for epilepsy.”
   • “Until we have more information, I recommend avoiding driving and high-risk activities.”
4. Address uncertainties and safety-netting:
   • “One seizure does not necessarily mean you have epilepsy. Some people have a single seizure due to lack of sleep, stress, or other triggers.”
   • “If you have another episode, seek urgent medical review.”

A competent candidate communicates clearly, reassures, and provides a structured plan for further assessment.

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Q4: Outline your management plan for James’s seizure episode.

1. Acute Safety Advice:
   • Driving restriction: No driving for at least 6 months (per Austroads guidelines).
   • Seizure precautions: Avoid swimming alone, climbing, working with heavy machinery.
2. Further Investigations and Specialist Referral:
   • Neurology referral – For EEG interpretation and long-term management plan.
   • MRI brain – If structural cause suspected.
3. Medication Considerations:
   • First-time seizure: No immediate medication unless high recurrence risk.
   • If epilepsy confirmed: Sodium valproate (if generalised seizures) or levetiracetam (if focal seizures).
4. Follow-Up Plan:
   • Review in 2 weeks for test results and further discussion.
   • Ongoing neurology follow-up for long-term seizure management.

A competent candidate ensures a structured approach, balancing safety, further assessment, and patient-centred decision-making.

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Q5: What preventive strategies should James follow to reduce seizure recurrence?

1. Lifestyle Modifications:
   • Optimise sleep – Aim for 7–9 hours per night.
   • Minimise alcohol – Avoid binge drinking, as withdrawal can trigger seizures.
   • Manage stress – Regular exercise, mindfulness, and relaxation techniques.
2. Trigger Avoidance:
   • Avoid flashing lights if photosensitive epilepsy suspected.
   • Regular meals and hydration to prevent hypoglycaemia.
3. Medication Adherence (if prescribed):
   • Consistent dosing – Missed doses can trigger seizures.
   • Discuss side effects and alternative options if needed.
4. When to Seek Urgent Medical Attention:
   • If seizure lasts >5 minutes (status epilepticus risk).
   • If multiple seizures occur without recovery in between.
   • If new neurological symptoms develop.

A competent candidate integrates lifestyle modifications, adherence strategies, and safety measures into long-term epilepsy management.

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SUMMARY OF A COMPETENT ANSWER

• Recognises epilepsy as the likely diagnosis, while ruling out syncope, cardiac causes, and metabolic triggers.
• Takes a structured history, identifying risk factors, seizure characteristics, and red flags.
• Orders appropriate investigations, including EEG, MRI, and ECG.
• Clearly explains the condition and driving restrictions, ensuring patient understanding and engagement.
• Develops a structured management plan, including neurology referral, medication considerations, and seizure precautions.
• Implements preventive strategies, ensuring long-term seizure control and patient safety.

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PITFALLS

• Failing to rule out serious cardiac causes, missing arrhythmias or sudden cardiac death risk.
• Not ordering EEG or MRI, leading to delayed epilepsy diagnosis.
• Misdiagnosing syncope or psychogenic seizures as epilepsy, causing unnecessary medication use.
• Not advising on driving restrictions, creating legal and safety risks.
• Neglecting lifestyle modifications, missing an opportunity to reduce seizure recurrence.

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REFERENCES

• RACGP – RACGP Guidelines on Epilepsy Management
• GP Exams – Epilepsy

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MARKING

Each competency area is on the following scale from 0 to 3.

☐ Competency NOT demonstrated
☐ Competency NOT CLEARLY demonstrated
☐ Competency SATISFACTORILY demonstrated
☐ Competency FULLY demonstrated

1. Communication and Consultation Skills

1.1 Communicates effectively and appropriately to provide quality care.
1.3 Engages the patient to gather information about their symptoms, ideas, concerns, and expectations.

2. Clinical Information Gathering and Interpretation

2.1 Gathers and interprets information effectively.
2.3 Identifies red flags and important diagnostic features.

3. Diagnosis, Decision-Making and Reasoning

3.1 Applies a structured approach to making a diagnosis.
3.3 Identifies and manages urgent and serious conditions.

Competency at Fellowship Level

☐ CLEARLY BELOW STANDARD
☐ BELOW EXPECTED STANDARD
☐ BORDERLINE
☐ AT EXPECTED STANDARD
☐ ABOVE STANDARD