Epilepsy no pathological reflexes, no meningeal signs. Investigation

Epilepsy in heavy truck
driver

Patient history

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Male patient, 47,
Indian, brought to GP room by fellows. On exam – unresponsive, generalized
tonic-clonic seizures. Bouts started ~10min ago. Fellows witnessed onset. Fellows
witnessed sudden loss of consciousness, seizures started with “strange sound
from mouth”, patient “bended arch” first and then started “shaking in all
limbs”. No injury prior to onset.

Series of bouts
continued in GP room, for few seconds followed by seizure free intervals for
several minutes. Patient remains unresponsive between seizures.

Medical history from
fellows: patient was regularly taking “some medicine”, which he had always in
pockets. Roommate reported this was second episode he witnessed, with previous
one occurred ~month ago. Previous episode was similar, but short with sudden
consciousness loss, no warning signs, when patient was in bed preparing to
sleep. After seizures patient was drowsy and fell asleep. Next morning he was
fine, but he did not remember seizures.

Occupational history
from roommate: 6 months ago patient joined transport company as driver of long
goods vehicle carrying pipes. Patient is immigrant from India working in Middle
East. He speaks only native language, illiterate, with very limited English command.
He normally communicates to others through fellow mates if English is needed.

No family or social
history available.        

Clinical examination

In GP room: unresponsive,
bouts of tonic-clonic seizures lasting few seconds. Remains unresponsive
between bouts. 

Carbamazepine tablets
were found in pocket.

T36.6°C

SpO2 room
air 96%

Respiration 18/min,
vesicular sounds, no respiratory distress, no cyanosis

HR 120BPM

BP 110/70mmHg

ECG: sinus rhythm,
normal ECG

CBG 5.6mmol/l  

HEENT – unremarkable,
pupils are equal and reactive to light.

Brief neurologic
assessment: symmetric face, extremities muscle tone lowered, tendon reflexes are
brisk, no pathological reflexes, no meningeal signs.    

Investigation and results

Ambulance transported
patient to ER. Patient regained consciousness en-route, remained drowsy, cannot
remember episode, completely oriented. Vital signs en-route – normal. Admission
in ER tertiary hospital.

Additional medical
history: 2 years treatment with carbamazepine for epilepsy in private clinic.
Poor adherence to treatment course.

Family history:
unremarkable. Denies alcohol consumption. Non-smoker.   

Seizures repeated in
ER.

Hospital contacted
attending physician for details.

CT and MRI brain: no
abnormality. Trauma and stroke ruled out.

Urgent neurologist
consultation obtained to confirm diagnosis and treatment correction.

EEG: epileptiform
activity.

Comprehensive
metabolic panel: all normal.

ECG – normal.

Diagnosis and treatment

In-hospital Dx: Idiopathic
generalized epilepsy. Generalized tonic-clonic seizures, grand mal.    

Patient discharged in
5 days with carbamazepine and sodium valproate.

Hospital strong
recommendation: to surrender driving. 

Case management (OH management and prevention)

In 7 days after
admission employee reported in office to obtain driving permit. As company was
small subcontracting business, pre-employment medical was not obtained. HR was
advised to refer employee for occupational health (OH) assessment to in-house
contactor company.

Patient consented to OH
service to obtain medical records from private clinic and hospital after
admission. External specialist consultation booked. 

Additional
occupational history: last 6 months – LGV driver with current employer.
Previous 5 years – taxi driver in private service at home country.

Driving license Group
2 issued 5 years ago and remained valid for 5 years. Employee did not disclose
his condition to drivers licensing authority since time of diagnosis as he did
not believe he had medical condition that may affect driving. Attending
physician was unaware of job of his patient as patient did not disclose
information to his doctor. Current employer was unaware of medical condition as
pre-employment medical screening was not performed. Employee was unaware he had
to notify employer. 

Day-to-day activities
are well preserved. Employee managed well with routine self-care.  

OH service suspended
employee from driving until fitness status was re-examined and performed safety
risk assessment in work place(3). Multiple risk factors identified:

–       Driving
long heavy vehicle with trailer

–       Long
driving hours, long distance driving, night time driving, lone driving

–       Heavy
load transport in busy traffic, safety critical areas in construction area

–       Driving
under influence of medications affecting CNS

–       Poor
compliance with treatment

–       Possible
sleep deprivation

–       Unpredictable
frequent spells  

OH service performed
medical fitness assessment. Employee failed to satisfy requirements of Section
2-3.3 and 2-22.1 of OGUK Guidance(11). Based on provided risk
assessment employee was classified as Category 1 risk prone occupations, where
“sudden impairment of cautiousness may… affect safety of, or result in… injury
to or death of, either themselves or others”(11).

Employee was in
breach of obligation to notify drivers licensing authority of illness that can
affect safe driving(8,13). As driver did not satisfy fitness
standards on epilepsy (Chapter 1, Appendix B-Epilepsy regulations, Chapter 8,
Medications effects)(1) OH service in writing offered employee to
surrender driving license immediately with notification to licensing authority
and employer. However, employee rejected to disclose medical condition as he
“did not believe he had bad illness”, and driving license was “the only mean of
financial support to family”.     

Unfit certificate for
driving was issued and communicated to employer to protect safety of other
employees.  

Equality Act is
likely to apply(2,5,14). As employee had not had chance to inform
employer on his condition, employer had no chance to provide adjustments to
work place. Thus, OH service advised on redeployment with reasonable adjustment(2,3,5,14):

Safety low critical
job

Any work related to
driving is prohibited

Work at height is
prohibited

Lone working is
prohibited

Shift work is not
recommended

Work near moving
vehicles prohibited

Employee refused
consent and legal obligation of responsible driver. OH service owed duty to employer
and public interests, it had to disclose information to licensing authority without
consent for protection of public interest and safety, notifying employee in
writing. Corresponding records left in file.

To develop action and
emergency plan and continue education and information on his condition in
language and form acceptable to employee, OH service referred him to specialist,
who he attended for follow-up(6,7). 

Follow up

Following
recommendation of OH service employee was redeployed as garage technician in
another branch. Further follow up was not possible. 

Clinical discussion

Epilepsy is large
group of neurological disorders with variable clinical presentation, having in
common predisposition to unprovoked recurrent seizures(6,7,10,12). Patient
should present at least twice with unprovoked seizures as neurological
manifestation to be diagnosed with epilepsy(6,7). International
League Against Epilepsy defines epilepsy as “brain disorder characterized by an
enduring predisposition to generate epileptic seizures and by the
neurobiologic, cognitive, psychological and social consequences of this
condition(10)”.

When diagnosing
epilepsy thorough patient history, detailed clinical examination, and
additional tests are required to differentiate immediately identifiable cause(6,7,10,12).

Patients suspected
for epilepsy should be seen by specialist within 2 weeks for diagnosis and
management(6,7).

Diagnostic enquiry
includes neuroimaging (MRI, CT-scan), EEG, and appropriate laboratory workup to
differentiate from conditions mimicking seizures(6,7,10,12).

Management requires
multidisciplinary approach and patient-centred care. Patient should receive
individually tailored written treatment plan, emergency contacts of specialists
to access care between scheduled reviews(6,7). Treatment plan should
be individualized to meet needs and requirements of the patient, and form of
epilepsy, selected and reviewed regularly by specialist. Treatment goal is to
achieve seizure free periods with minimal adverse effect from therapy. Monotherapy
is preferred(6,7).  

Patient should
receive education and information in form and language acceptable to patient(6,7)
to ensure or increase adherence of patient to selected plan.

Diagnosis carries
social, psychological and physical implications for patient(2,5). It
increases probability of injuries and accidents during seizures, and increased
mortality rate due to accidents and injuries, status epilepticus, and sudden
unexpected death in epilepsy(6,7,12).

Diagnosis would
attract occupational issues in work life. Under HASAWA employer is obliged to
provide safe work place to all employees and ensure protection of workers and
public from possible dangers(9). On the other hand, employee is
under duty to notify employer on health condition that can jeopardize safety of
others, or result in injury to, or death, in safety critical job(1,8,9).
However, employer must give opportunity to employee to provide this information
in confidence(2,5,13,14).   

Disability
discrimination legislation protects employee diagnosed with epilepsy(3,5,14).
It requires employer to make reasonable adjustments in work place to minimize
risks. However, employer must be aware of the fact of disability, and in
specific cases should perform risk assessment to implement reasonable
adjustments(2,5,14). Redeployment of employee with diagnosis of
epilepsy to work place with low safety risk away from possible hazards is one
of the reasonable adjustments options(2,3,14).

It is reasonable if
health care provider elaborates work place care plan, and plan is shared with employer
representatives to provide information what they can / shall do if seizures
occur in work place(2,3,14).  

Epilepsy may affect
medical fitness to drive. Drivers and health care providers have legal duty to
notify driving licensing authority on medical conditions that can preclude from
driving(1,8,14).  

Principles of medical
ethics and confidentiality are cornerstone in relations between OH provider and
patient. Driver should behave responsibly and notify medical examiner and
licensing authority on diagnosis(4,8,13).

In case where driver fails
to notify employer and medical examiner in reasonable manner, employer can
refuse driving job, particularly driving heavy vehicle, or high risk occupation
in consideration of safety to others(13,14).

If driver with continued
seizures refuses consent to disclose information, ethical guidelines of health
regulators allow medical provider to breach confidentiality on ground of
protection of public interest(1,8). All decisions and
recommendations offered by OH service are documented in patient notes(4).  

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