Non-epileptic events and functional seizures — formative SAQs

SAQ 1 — Fourteen-year-old with treatment-resistant spells (10 marks, 15 minutes)

A fourteen-year-old girl is referred to the epilepsy service for spells that began a year ago and occur several times a week. Each lasts five to ten minutes: she slumps, her eyes are closed and she resists them being opened, her limbs move in a variable thrashing pattern, she occasionally groans, and within a minute of the event ending she is tearful but fully oriented. She has been started on two escalating antiseizure medications without any change in the events. Her parents separated six months ago, and her mother has a history of depression. [2]

a) What is the most likely diagnosis, and which four features of the events support it over epilepsy? Explain why the antiseizure drugs have not worked. (4 marks) [1] [2]

b) Describe the investigation that confirms the diagnosis, how it is performed, and what it must demonstrate. State why a normal interictal electroencephalogram alone is not sufficient. (3 marks) [1] [8]

c) Outline the stepwise management, including the conversation you would have with the girl and her family about the nature of the events, the role of the antiseizure drugs, and the pathway to recovery. (3 marks) [3] [10]

SAQ 2 — Sixteen-year-old in a prolonged flurry in the emergency department (10 marks, 15 minutes)

A sixteen-year-old boy is brought to the emergency department after a series of attacks that began two hours ago and have not stopped. He thrashes with his eyes closed for several minutes at a time, resists examination, and is fully oriented and tearful between attacks. The triage nurse asks whether this is status epilepticus and whether he needs a benzodiazepine and an intensive-care review. He has a long-standing epilepsy and takes an antiseizure drug. [5]

a) What is the most likely diagnosis, and how do you distinguish this prolonged functional flurry from convulsive status epilepticus at the bedside? (4 marks) [1] [5]

b) Outline your immediate management of the episode, and explain why escalating benzodiazepines and anaesthesia are inappropriate and potentially harmful. (3 marks) [5] [7]

c) He has known epilepsy and continues his antiseizure drug. Explain how you would manage the coexistence of the two conditions, and describe the psychosocial and safeguarding assessment you would undertake once the episode has settled. (3 marks) [12] [2]