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GP Interaction 14

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 Scenarios

GP Interaction 14
By Amina Adnan   .   January 26, 2024 .   Last reviewed:   24/09/24 .    




Summary

In this scenario, a trainee GP visits a pharmacist to seek information about stopping Lamotrigine. The pharmacist should collect essential patient information and ensure effective communication throughout the conversation. 

Please ensure that this scenario and mark scheme aligns with the most up-to-date guidelines from the UK NICE and the BNF when using it for your OSCE assessment.

You will need a student pharmacist and an actor for this OSCE station.

Revision Topics
Be aware, this may reveal any answers!

Epilepsy 

Student Instructions

You are a pharmacist working in a community pharmacy. A local trainee GP has come to the pharmacy seeking information about stopping epilepsy medication. 

The trainee GP would like more information for her learning and to be able to answer the patient's questions. The patient has been referred to a neurologist. 


To do: 

  1. Collect accurate patient details and a brief medication history, emphasising any newly prescribed medications. 

  1. Provide pharmacological information on reducing and withdrawing medications safely using up-to-date guidance. You must provide relevant advice. 


You have 10 minutes.
You have access to the BNF.

Actor AI 🤖 (Beta)
Actor Instructions

You are Dr. Stephan George (Stef-uhn, Jorj) 

 

Opening statement: “I have a patient who has been seizure-free for 10 years and wants to stop their epilepsy medication. I have referred them to the neurologist but just had a few questions about withdrawing epilepsy medication.” 

 

Patient information:
Provide this information when prompted.

  • Name: Kelly Clarkson (Kell-Lee, Kah-lark-Sun) 

  • Age: 44 

  • Past medical history:  

    • “Epilepsy diagnosed approximately 22 years ago.” 

    • “She had a history of tonic-clonic seizures.” 

  • Medication History:  

    • “Lamotrigine 200mg tablets -  one tablet taken twice a day.” 

  • Allergies: 

    • “None.” 

  • Symptoms: 

    • “Patient says she has been symptom-free for 10 years and has not had any seizures.” 

 

 
 

Please ask these questions to prompt the student for an answer if they do not provide the information. 

  1. “When is it safe to stop a patient's epilepsy medication?” 

  1. “How do you stop the medication?” 

  1. “Who is at risk of relapse?” 

  1. “What do you do if the patient has seizures again?” 

  1. “Is the patient able to drive during the tapering process?” 

Mark Scheme

Introduction 
0 / 2
Introduce yourself with an appropriate greeting
+1
Confirm patient details: Name and age
+1
Medical History 
0 / 5
Asks about symptoms
+1
Confirms medication history including dose, frequency, indication, including any over-the-counter products and herbal remedies 
+1
Confirms patient's past medical history
+1
Confirms past medication history
+1
Check for allergies
+1
Question 1: 
0 / 3
Model Answer (Maximum 3 marks awarded):
It is possible to consider stopping anti-epileptic medication if the patient has been seizure-free for 2 years or more.
In adults with epilepsy who have been free of seizures for 2 years then about 60% will have no further seizures when medication is withdrawn.
Assess further risk of seizures by discussing that the patient would need a normal neurological examination or EEG  
States the importance of continued monitoring even after successful withdrawal of medication
Question 2: 
0 / 3
Model answer (Maximum 3 marks awarded):
It is best to taper the medication gradually to avoid a relapse of seizures
Additionally, this prevents symptoms like anxiety and restlessness during withdrawal
Patient on lamotrigine is advised to reduce the dose by 10% every 2-4 weeks (According to SIGN)
In the BNF it is specified that the medication should be tapered off over 2 weeks or longer
Question 3: 
0 / 4
Patients at risk of relapse (Maximum 4 marks awarded):
Have had epilepsy since childhood
Patients who need more than one medication to control their epilepsy 
Patients who have had seizures while on medication
Those with myoclonic or tonic-clonic seizures
Patients with an abnormal EEG in the last year
Patients with known underlying brain damage
Question 4: 
0 / 1
The same antiepileptic regimen may be recommended if the patient begins to have seizures again
+1
Question 5: 
0 / 2
DVLA advises the following:
Drivers should usually be advised not to drive from the start of the withdrawal period and for 6 months after treatment cessation
+1
States the DVLA considers that a person remains as much at risk of seizure during the withdrawal as during the following 6 months.
+1
Communication 
0 / 4
Knowledge and understanding of the topic is apparent?
+1
Ensure the healthcare professional understanding and signposts to further resources (e.g. NICE CKS guidelines) 
+1
Concludes the conversation well by asking if there are any further questions
+1
The student did not say anything that could harm the patient  
+1
This includes but is not limited to, providing incorrect information or medication, misdiagnosing conditions, neglecting to inquire about allergies, making incorrect referrals, or failing to act on red-flag symptoms.
Time Management
0 / 1
Completed the scenario in time and achieved 70% of marks
+1

Any criteria in red must be written down accurately to pass this OSCE station. 




red flag Red Flags missed: 0

Total Score
0/
Skills
professionalism 0/2
communication 0/12
information gathering 0/6
patient safety 0/20
knowledge 0/18
patient-centred care 0/4
Time Management 0/1


Please login to save your score.
Referral Criteria

Referral Criteria for Epilepsy 

 
Refer to Accident & Emergency (A&E) if: 

  • First seizure or new onset of seizures:A new or first seizure warrants immediate medical evaluation to determine the cause and appropriate treatment. 

  • Status epilepticus:Seizures lasting more than 5 minutes or multiple seizures occurring without full recovery in between require urgent intervention. 

  • Severe injury during a seizure:Any injury sustained during a seizure, such as head trauma or severe cuts, requires immediate medical care. 

  • Signs of significant neurological impairment:Symptoms such as difficulty breathing, loss of consciousness, or persistent confusion after a seizure may indicate a serious underlying condition. 

  • Seizures with signs of infection or fever:Seizures accompanied by high fever, especially in children, could be due to an infection requiring urgent treatment. 

  • Seizures in pregnant patients:Seizures during pregnancy need immediate assessment due to potential risks to both the mother and foetus. 

 

Refer a Patient for an Urgent GP Appointment if: 

  • New or worsening seizures:Any change in the frequency, type, or intensity of seizures should be evaluated to adjust treatment and investigate potential causes. 

  • Seizures occurring despite medication compliance:Persistent seizures despite adherence to prescribed antiepileptic medication may require reassessment of the treatment plan or further diagnostic testing. 

  • Recent changes in medication or health status:Changes in medication, such as starting or stopping antiepileptic drugs, or changes in overall health that could impact seizure control should be reviewed. 

  • Non-compliance or issues with medication adherence:Patients who struggle with adhering to their treatment plan may need additional support or alternative strategies to manage their seizures if the pharmacist cannot achieve this in the community. 

  • Presence of significant side effects from medication:Severe side effects from antiepileptic medications that impact quality of life or safety require evaluation and potential adjustment of treatment. 

 
Refer for routine GP appointments for: 

  • Ongoing monitoring of seizure control:Regular follow-ups with a healthcare provider are recommended to monitor seizure control and adjust treatment as needed. 

References

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