Collapse at home — the day after

Candidates: do not open until you have consulted.

Persona and manner

• Luke Forster, 28, self-employed electrician with your own van. Your partner Jess is a primary school teacher on maternity leave; your son Noah is five weeks old.
• Practical, a bit embarrassed, playing it down. You are tired — four hours of broken sleep a night since Noah was born.

Opening line — say this verbatim

• “Jess made me come. Apparently I had some sort of fit last night. I feel fine now — I’m just shattered, to be honest.”

Volunteer freely if given the space

• You were on the sofa watching television at about eight. The next thing you remember is the paramedics in the living room.
• Your tongue is sore on one side and you ache all over today, “like I’ve done a day’s labouring”.

Only if asked

• Morning jerks: only if asked about jerks, twitches or dropping things — your arms sometimes jump soon after waking, and you threw a mug of tea across the kitchen last week. Otherwise keep it until you are invited to add anything.
• What Jess saw: you went “vacant”, made a groaning noise, went stiff and slid off the sofa, then all four limbs jerked for about two minutes. Your lips went blue. You wet yourself. Afterwards you did not know where you were for about half an hour, then you slept.
• No warning beforehand: no light-headedness, sweating or feeling hot, no chest pain or palpitations. You were sitting down, not standing.
• No head injury — the floor is carpeted. No headache or fever beforehand. No weakness, numbness or speech problem since.
• Never had a blackout or fit before; no fits with fevers as a child; no serious head injury or meningitis. Nobody in the family has epilepsy, and nobody has died suddenly young.
• Alcohol: nothing in the week. On Saturday night, the night before, you had six or seven pints “wetting the baby’s head”. No drugs. No tramadol, no new tablets or supplements.
• Sleep: four hours a night, broken, for five weeks.
• You drove yourself here this morning.
• Work: domestic rewires — ladders, lofts, live circuits. You are the only earner while Jess is on maternity leave. A big job starts tomorrow.

Impact on daily life — home and work (only if asked)

• “If I can’t drive, I can’t work. It’s that simple.” The van is the business.
• You do the 2 am feed and carry Noah up and down the stairs; you bath him most evenings.
• Jess was terrified. She has not slept since.

Ideas, concerns and expectations

• Idea: “Exhaustion — the baby. And maybe Saturday’s beers.”
• Concerns: a brain tumour (“it’s the first thing that comes up when you search it”); losing your licence and the business; whether it is safe to hold Noah.
• Expectation: “a scan to make sure”, and perhaps a sick note for a couple of days.

Cues to deliver, timed

• Minute 3: “I drove here this morning, so I can’t be that bad, can I?”
• Minute 5: “I’ve got a rewire starting tomorrow — it’s all ladders.”
• If driving has not been mentioned by minute 6: “I’m all right to drive, aren’t I?”

If the doctor summarises and asks whether you want to add anything

• If the morning jerks have not come up: “One thing — my arms sometimes jump in the mornings. I threw a mug of tea across the kitchen last week. I thought everyone got that.”
• If they have: “Is it safe for me to be on my own with Noah?”

How to respond to the doctor

• If the doctor explains that this sounds like a seizure, and why, that one seizure is not the same as epilepsy, and that you need to be seen in a specialist clinic within two weeks, with tests such as a brain-wave test and, if the specialist advises it, a brain scan: you nod — “OK. That makes sense.”
• If the driving rule is explained with empathy — that it is the law, that the DVLA decides how long, at least six months and sometimes twelve depending on what the specialist finds, and the doctor asks how you will manage: upset, then practical — “Six months at least. Right. My brother-in-law could drive the van.”
• If the doctor says “best to avoid driving for a bit”: “So it’s up to me, then?”
• If the doctor says nothing about getting home: you get up to drive home.
• If asked about Noah: you accept the advice (not bathing him alone, changing him on the floor, sharing the night feeds) — “Jess will be relieved you’ve said that.”
• If the doctor dismisses it (“probably just a faint — see how you go”): relieved, and leave.

Do not

• Volunteer the morning jerks, the Saturday drinking or that you drove here, unless asked or invited to add anything (apart from the timed cues).
• Become angry. You are worried and practical.

Domain marks — with the key facts that earn a 4 at this station

Examiner's overall judgement (standard-setting only — it does not decide your result): ☐ Unsatisfactory   ☐ Borderline   ☐ Satisfactory   ☐ Good

Marks are 1 to 4 in each domain; the generic descriptor for each mark is on the mark scheme page, and the structure of the eight minutes is on the 8-minute station page. The full standard for this case is in section 3 and the GMC feedback statements, with examples from this case, are in section 4.

The top row is the full picture of what a competent F2 could do at this station, including the working diagnosis with its justified differentials, the safety-net and the follow-up; lower rows describe how performance falls away. It is a debriefing aid, not a checklist to recite: nobody says every line in eight minutes, and a 4 is a judgement that the essentials — the italic key facts on the mark sheet — were done well, in plain language and at the patient’s pace. Acumen training standard — the GMC does not publish station mark sheets.

A feedback statement marks where underperformance was identified in the consultation. With PLAB 2 results the GMC may attach any combination of the ten statements to a station — none, one or several. The right-hand column shows what each one looks like at this station. Record the statements that applied in the practice log.

Points of fact the examiner should have to hand

1. NICE NG217: refer adults urgently after a first suspected seizure — to be seen by a specialist within two weeks. Do a 12-lead ECG; be aware that metabolic disturbance, including hypoglycaemia, can cause seizures — baseline bloods are reasonable practice, not a NICE requirement. Give information on recognising and managing a further seizure, and safety advice, while waiting.
2. Seizure versus syncope: lateral tongue biting, cyanosis, prolonged jerking and post-event confusion lasting many minutes favour a seizure; posture, a light-headed prodrome, pallor and recovery within seconds favour a faint. Brief jerks can occur in a simple faint.
3. Early-morning myoclonic jerks with a first tonic–clonic seizure after sleep deprivation and alcohol suggest juvenile myoclonic epilepsy — a diagnosis for the specialist, but a history the GP should obtain.
4. One seizure is not epilepsy. Anti-seizure medication is started by a specialist, usually after a second unprovoked seizure or when tests show a high risk of recurrence.
5. Driving (DVLA): the patient must stop driving and must notify the DVLA. After a first unprovoked (isolated) seizure, driving a car or motorcycle must stop for six months from the date of the seizure, or twelve if there is an underlying factor that raises the risk of recurrence; for lorries and buses it is five years. If the specialist diagnoses epilepsy the rule is twelve months free of all seizures — and the DVLA counts limb jerks, auras and absences. Sleep deprivation is not on the DVLA’s list of provoking causes; a seizure associated with alcohol intoxication or withdrawal may be treated as provoked, but driving must still stop — the DVLA decides for how long.
6. GMC (Confidentiality: patients’ fitness to drive): explain that the condition may affect driving, that he has a legal duty to tell the DVLA and that you may have to disclose if he continues to drive; record the advice. If he continues, make every reasonable effort to persuade him to stop; if that fails and others are at risk of death or serious harm, contact the DVLA’s medical adviser promptly — try to tell him first, and confirm to him in writing afterwards.
7. Safety while awaiting assessment: showers not baths; avoid heights, ladders, unguarded machinery and swimming alone; with a baby — change and dress him on the floor, do not bath him alone, carry him on the stairs as little as possible.
8. First aid: time the seizure, cushion the head, do not restrain or put anything in the mouth, recovery position afterwards. Call 999 if it lasts more than five minutes, if another follows without recovery, if he is injured, or if it happens in water.

Where candidates lose marks at this station

• “Probably just a faint — you’re exhausted.”
• “Best not to drive for a little while.”
• Letting him drive home.
• Forgetting the ladders and the baby’s bath.
• Starting anti-seizure tablets from the GP surgery.
• No instructions for Jess if it happens again.

Guidelines for this station

• NICE NG217 — Epilepsies in children, young people and adults
• GOV.UK — Epilepsy and driving
• DVLA — Neurological disorders: assessing fitness to drive
• GMC — Confidentiality: patients’ fitness to drive and reporting concerns to the DVLA or DVA
• Epilepsy Action — First aid for seizures

Record your three domain marks, your station total, the GMC feedback statements that applied (where underperformance was identified), and what you will keep and change. The form is already labelled with this case and its web address; a copy of your entry is emailed to you, so your practice log builds up in your inbox and can be downloaded.

Record my marks and reflection for P2-10