Clinical consultations Flashcards
Endocrine symptom screen
- ALWAYS ADDISONS! Nausea, vomiting, abdo pain, dizziness, pigmentation
- Thyroid symptoms
- Sexual dysfunction e.g. amenorrhea
Pituitary profile: initial bloods
think FLAT PEG
- FSH and LH
- Cortisol (9am)
- Thyroid profile
- Prolactin
- IGF-1
Which hormones are secreted from the pituitary gland?
Anterior: FLAT PEG
- FSH, LH
- ACTH
- TSH
- Prolactin
- Endorphins
- GH
Posterior:
- ADH
- Oxytocin
Acromegaly - symptoms
- Secondary to excess GH:
- Larger hands and feet
- Facial features changing
- Sweating - Secondary to pituitary adenoma:
- Headaches
- Bitemporal hemianopia - ask about not seeing vehicles overtaking for example, when driving
- Diplopia - Secondary to complications:
- Carpal tunnel - tingling in hands
- Diabetes - polyuria, polydipsia
- Colonic polyps - change in bowel habit, bleeding
- OSA - daytime somnolence - General endocrine screen
Acromegaly examination
Hands: large, spade shaped, Phalens test for carpal tunnel
Face: look from side for prominent supraorbital ridge and jaw
Mouth: Widened interdental gap
Eyes: visual fields and eye movements
Neck: goitre
Axilla: skin tags
Heart: apex beat and heart sounds
Bisphosphonates adverse effects
Oesophagitis - sit upright when swallowing
Osteonecrosis of jaw - needs regular dental checks
Crohn’s disease - extra-GI manifestations
Mouth ulcers
Uveritis
Rashes - erythema nodosum, pyoderma gangrenosum
Arthralgia (HLA B27 associated eg ank spond)
Initial investigations in IBD
Bedside:
Stool MCS, virology, OCP if recent travel
Faecal calprotectin
Bloods: FBC, U+Es, CRP, LFTs
Coeliac screen (anti-TTG and total IgA)
Imaging:
AXR to r/o toxic megacolon
Consider CTAP if peritonitic
Consider MRI small bowel if worried about enteritis
Flexi sig
Initial management IBD
Admit
IV fluids
Crohn’s - exclusive enteral nutrition
(nutritional supplements, water and black tea/coffee only)
UC - IV hydrocortisone
Flexible sigmoidoscopy
Indications for surgery in Crohn’s disease
Toxic megacolon
Intra-abdominal abscess
Fistulating disease
Refractory to medical treatment
Maintenance therapy in Crohn’s
- Tapering steroids with vitamin D and PPI cover
-Azathioprine/mercaptopurine/methotrexate - Anti-TNF e.g. infliximab
Sigmoidoscopy features in Crohn’s versus UC
Crohn’s
- Apthous ulcers
- cobblestone mucosa
- patchy inflammation
- transmural
Ulcerative colitis:
- Pancolitis starting at rectum and moving distally
- Superficial inflammation
Complications of IBD
Malnutrition - vitamin deficiency
Infections
- perianal abscess
- intra-abdominal abscess
Fistulating disease in Crohns
Skin - erythema nodosum, pyoderma gangrenosum
Joint pain
Chronic pain
Malignancy
10 years of symptoms -> index surveillance colonoscopy
Smoking in IBD
Smokers 2x as likely to develop Crohn’s
Smoking is often protective in UC!
Management of ulcerative colitis
Acute flare
- Admit
- IV fluids
- IV hydrocortisone
Maintenance
- Rectal ASA (mesalazine) or budesonide
- Severe: oral mesalazine or azathioprine
Ankylosing spondylitis - examination
Palpate down spine
Neck:
- Flexion and extension
- Lateral flexion
- Rotation
Lower back:
- Flexion and extension
- Lateral flexion
- Rotation
Tragus to wall distance
Modified Schober test:
- Mark the midpoint of dimples of venus
- Mark 5cm below and 10cm above
Heart - aortic regurg
Lung - fibrosis (typically apical)
Ankylosing spondylitis - complications
Interstitial lung disease
Uveitis
Ankylosing spondylitis - investigations
Bloods
- fbc, inflammatory markers, renal and liver function
- HLA-B27
Imaging
XR spine and pelvis - sacroilitis, syndesmophytes, spinal fusion
Echo - assess for AR
CXR - fibrosis and consider HRCT
Lung function tests and transfer factor
Ankylosing spondylitis Mx
Pharmacological:
Anti-inflammatories - NSAIDs
Intra-articular steroids may be used
DMARDs generally not used
Biologics e.g. adalimumab (anti TNF)
MDT approach including PT, OT
Smoking cessation
Checks before anti-TNF treatment
Check for latent or active TB
BBV screen
Up to date immunisation
Back pain red flags
Acute onset
Bladder/bowel dysfunction
Loss of perianal sensation
Focal weakness or sensory loss
Scoring system in ankylosing spondylitis
Bath Ankylosing Spondylitis score
measure of disease activity
Complications of Ehlers Danlos Syndrome
Hypermobility of joints -> pain and deformity
Cardiovascular
- Mitral valve prolapse/regurgitation
- Aortic regurgitation
- Conduction abnormalities
Vascular complications (worst prognosis)
- Aneurysms
- Haemorrhage
GI
- Oesophageal dysmotility
- Diverticular disease
Eyes
- Glaucoma
- Retinal disease
Management of Ehlers Danlos Syndrome
Supportive:
MDT approach
PT/OT
Analgesia
Management of specific complications
Ehlers Danlos inheritance
Several different subtypes - some AD, some AR, some de novo
Defective collagen synthesis
Ehlers Danlos examination
Joints:
- Thumb back to wrist
- Elbow hyperextension
Skin:
- Pull skin - elasticity
Cardiac:
- Apex beat
- Heart sounds (AR/MR)
- AF
Thyroid examination
Inspection:
- Clothing
- Eyes
- Hair loss
- Anxious/depressed
Hands:
- Tremor
- Sweating
- Dry skin
Neck:
- Goitre?
- Swallow water
- Stick tongue out (cyst would move up)
Eyes:
- Eye movements
- Lid lag
From behind:
- Palpate the thyroids
- Again ask patient to swallow and stick tongue out
- Lymphadenopathy
Sit back down opposite patient:
- Percuss retrosternally and to the sides
- Auscultate for bruits on both sides
Extra:
- Biceps/ankles reflexes
- Proximal myopathy
- Legs (pretibial myxoedema)
Hypothyroidism causes
Primary:
- Hashimoto’s (autoimmune) - most common
- Iodine deficiency
- Riedel’s thyroiditis (fibrosis of gland) (reduced TRH release)
Secondary:
- Reduced TSH release from pituitary
Hyperthyroidism DDx
Primary hyperthyroidism
- Graves disease = most common
- Toxic adenoma
- Toxic multinodular goitre
- De Quervains thyroiditis
- Amiodarone thyrotoxicosis
- Exogenous levothyroxine
Secondary hyperthyroidism (excess TSH release)
De Quervains thyroiditis disease course
hyper -> eu -> hypothyroid -> euthyroid
PAINFUL GOITRE
Management of hypothyroidism
Levothyroxine
Complications of hypothyroidism
Most concerning: myxoedema coma
(Hypothermia, bradycardia, hypoglycaemia, reduced GCS)
Metabolic:
- Hypercholesterolaemia
- Weight gain
Cardiac:
- Ischaemic heart disease
- Bradycardia
- Heart failure
Neuro
- Depression
- Peripheral neuropathy
- Cerebellar syndrome
Investigations in thyroid disease
- TFTs
- Anti-TSH receptor antibodies (Graves)
- Anti-TPO antibodies (Hashimotos)
- Screen for other autoimmune disease e.g. coeliac, hypoparathyroidism, etc
US neck - assess goitre
Consider iodine uptake scan
Iodine uptake scan - interpretation of results
Diffuse increased uptake = Graves
Hot spots of increased uptake = toxic multinodular goitre
Single hot spot = toxic adenoma
Diffuse reduced uptake = de Quervains
Management of Graves
Symptomatic: Propranolol
For the thyroid:
1) Carbimazole - risk of agranulocytosis.
- can ‘block and replace’
2) Propylthiouracil - better in Pregnancy and Pancreatitis
If any agranulocytosis develops…
STOP THYROID DRUGS
Offer radioiodine treatment
Management of toxic multinodular goitre hyperthyroidism
First line = radioiodine
Second line:
- Anti-thyroid drugs (carbimazole, propylthiouracil)
- Offer thyroidectomy
Management of toxic adenoma hyperthyroidism
First line = hemithyroidectomy or radioiodine
Cushing’s syndrome causes
Pituitary adenoma -> excess release of ACTH (Cushing’s disease)
Adrenal adenoma -> excess release of cortisol
Ectopic ACTH secretion e.g. lung Ca
Exogenous steroids
Cushing’s disease examination
General inspection:
- Central adiposity
- Hirsutism
- Fat re-distribution: Central adiposity, Moon face, bufallo hump
- Striae
- Buffalo hump
- Check for evidence of diabetes (CBG)
Check cardiac, respiratory and abdominal systems
Proximal myopathy
Blood pressure
Cushing’s investigations
Low dose dexamethasone suppression test - see if cortisol remains elevated
High dose dexamethasone suppression test
- Dexamethasone suppresses ACTH production, not cortisol
- Cushing’s syndrome: Low ACTH and low cortisol
- Adrenal adenoma: Low ACTH and high cortisol
- Ectopic tumour: High ACTH and high cortisol
Also
- HbA1c, renal profile
- Pituitary profile
- Blood gas would show hypokalaemic metabolic alkalosis
- MRI pituitary +/- CT chest (Ectopic) / abdomen (adrenal adenoma)
Cushing’s management
Disease: transsphenoidal resection of pituitary tumour
Syndrome: Treat underlying cause
- Wean exogenous steroids
- Adrenal tumour resection
- Ectopic tumour resection
- meds include metyrapone or ketoconazole to reduce cortisol production
Management of complications:
Hypertension
Hyperglycaemia
Osteoporosis definition
bone density if more than 2.5 standard deviations below the mean value for an adult of the same gender and race
Main modifiable risk factor for thyroid eye disease
SMOKING
Causes of clubbing
Cardiac:
- Cyanotic congenital heart disease
- Subacute endocarditis
Respiratory:
- Suppurative lung disease: CF, bronchiectasis
- Interstitial lung disease
- TB
Abdominal:
- Chronic liver disease
- IBD
Other:
- Idiopathic
DVLA rules for stroke/TIA
Group 1 license: no driving 1 month
Group 2 licence: no driving 1 year
Insulin DVLA rules
Group 1 license: Must inform DVLA
Group 2 license: stop driving until DVLA review
Angina DVLA rules
Group 1 license: no requirements
Group 2 license: need to inform DVLA
MI DVLA rules
Group 1 license:
- No need to tell DVLA
- 1 week off driving if successful and completed angioplasty
- Otherwise, 4 weeks off driving (i.e. if incomplete, unsuccessful or medical mx)
Group 2 license: Inform DVLA, 6 weeks off driving
Cardiac device DVLA rules
Must inform DVLA for all licenses, but can continue driving
Rheumatoid arthritis Ix
Bloods:
- RF and anti-CCP
- Anaemia
- CRP/ESR
XR hands:
- Joint deformities
- Narrowed joint space
- Subluxation
CXR - fibrosis
Baseline echo, lung function test
Rheumatoid arthritis/Psoriatic arthritis mx
Analgesia
MDT approach
1) Methotrexate with folate
(acute flare - steroids as well)
2) Sulfasalazine
3) Anti-TNF e.g. etanercept
Psoriatic arthritis XR findings
Pencil in cup appearance
Fluffy periosteitis
Psoriatic arthritis serology
RF and anti-CCP negative
HLAB27 +ve
Examination in small joint arthropathies
Hands: Look Feel Move
- check for active synovitis
- Functioning eg buttons
Elbows - nodules, psoriasis
Eyes - episcleritis
Ears/scalp - psoriasis
Neck - atlanto-axial instability
Chest - fibrosis
Migraine mx
Acute management - abortive
1) Paracetamol, NSAIDs, anti-emetics +/- Sumatriptan
Prevention
1) Propranolol
2) Topiramate (CI in pregnancy)
Headache clinic
Avoidance of triggers
Migraine and COCP
COCP contra-indicated in migraine with aura
Triptans are contra-indicated in
Ischaemic heart disease
CVA
SSRI use
Rheumatology questioning approach
1) Joints
- Swelling, pain, stiffness, symmetry
- Nodules
2) Skin
- Rashs
- Sun sensitivity, scaling, scalp involvement
- Hair loss
- Mucosal involvement
3) Systemic
- Fevers, fatigue, appetite, weight loss
- Pleuritis
4) Vascular
- Raynauds
- Scleritis/episcleritis
5) Other autoimmune conditions
General rheumatology investigations
Bedside: ECG and urine dip
Bloods: FBC, U+Es, CRP, ESR, LFTs
Connective tissue disease screen
Imaging:
- CXR
- XR of affected joints
- Baseline echo
Other:
- Baseline lung function tests
Systemic sclerosis: history
1) Joints: swelling/pain
- may have tightness restricting movement of hands
2) Skin
- Tightening, sclerodactyly
- Change to face shape (beaked nose, microstomia)
- Telangiectasia
3) Systemic
- Fevers, weight loss, fatigue
- Swallowing difficulties
- Sicca
4) Vascular
- Raynauds
- Digital ulceration
- Scleritis/episcleritis
5) Other autoimmune conditions
Systemic sclerosis: examination
General appearance: facial features (beaked nose, microstoma, telangiectasia)
Hands:
- Calcinosis
- Sclerodactyly
- Scars of digital ulceration
- Check elbows for any calcinosis/nodules
Face:
- Beaked nose
- Microstoma
- Telangiectasia
Cardiac:
- Check JVP, RVH, loud P2, heart sounds
- Could have a functional TR
Resp:
- fibrosis
Management of scleroderma
Avoid steroids where possible
Non-steroid immunomodulators e.g. methotrexate
Patient education + smoking cessation
Treatment of complications
- Vasodilators e.g. CCB for ulcers
- Tx pulmonary htn e.g. iloprost
- Scleroderma renal crisis: ACEi
Steroids can make scleroderma renal crisis worse
SLE history
1) Joints
- Symmetrical small join arthropathy
- Jaccouds arthropathy: reversible deforming arthropathy, no erosions
2) Skin
- Photosensitive rash
- Butterfly rash
- Hair loss
- Mucosal involvement
3) Systemic
- Fevers, weight loss, fatigue
- Pleurisy e.g. chest pain
- Breathing difficulty
4) Vascular
- Raynaud’s
- Scleritis/episcleritis
5) Any other autoimmune disease
- Drug history - triggering drugs include beta blockers, lithium
SLE examination
Hands: any arthropathy, skin changes
Face: butterfly rash, check for mouth ulcers, behind scalp
Lungs: auscultate, percuss for pleural effusion
Cardiac: check for pulm HTN
Legs: rashes or swelling
SLE management
Acute flare: steroids
Maintenance: AZT or MTX
Symptom control
Smoking cessation
SLE investigations
Bedside: ECG, urine dip
Bloods: anti-dsDNA, anti-histone Abs, complement (C3 and C4)
Imaging:
- CXR
- XR hands, if arthropathy (no erosions)
- Echo
Other:
Lung function tests
Polymyositis and dermatomyositis: history
1) *Muscle weakness
- Difficulty getting up from a chair/going up stairs
- Difficulty reaching into a cupboard above you
- Muscle tenderness
2) Skin
- Red scales on hands, no itchy
- Purple rash across face
- Hair loss, mucosal involvement
3) Systemic
- Weight loss, fevers, fatigue
- Ask about malignancy symptoms: haemoptysis, PR bleeding, breast lumps, bloating
4) Vascular
- Ask about GCA sx (DDx: PMR)
5) Any other autoimmune conditions
- Drug history - statin, steroids
Difference between polymyositis and dermatomyositis
Polymyositis: Muscle involvement without skin features
Dermatomyositis: Muscle involvement with skin features (often paraneoplastic)
Polymyositis DDx
Other causes of proximal myopathy:
- Cushing’s
- Osteomalacia
- Polymyalgia rheumatica
- Hypothyroidism
- Statin induced myopathy
- Myasthenia gravis (fatiguability)
Poly/dermatomyositis Ix
Bedside: ECG, urine dip
Bloods: Raised CK, anti-Jo Abs, anti-Mi Abs
Imaging: CT abdomen pelvis for malignancy screening
Other:
- EMG
- Muscle biopsy
Poly/dermatomyositis treatment
1) Steroids for acute flare
2) Steroid-sparing immunomodulators: methotrexate, azathioprine
3) Treat symptoms, PT/OT
4) Treat complications
Causes of young hypertension
Essential hypertension
Secondary causes:
- Renal: renal artery stenosis
- Endocrine: CHAP
Cushing’s, Hypothyroidism, Acromegaly, Phaeochromocytoma
- Cardiac: coarctation of aorta
Young hypertension investigations
Bedside: ECG, urine dip, offer fundoscopy
Bloods: FBC, U+Es, inflammatory markers, HbA1c, pituitary profile
Imaging: CXR, echo
If deranged renal function: US KUB, consider MRA kidneys
Young hypertension: examination
General appearance - Cushingoid?
Hands: Pulse, radio-radial delay
Face:
- Moon face? Hair loss? Acromegaly?
- Offer fundoscopy
Heart: auscultation
Resp: auscultation
Abdomen: ballot kidneys, renal bruits
Check for proximal myopathy
Examine thyroid
Headache red flags/key questions
Reduced GCS
Seizures
Vomiting
Amnesia
Focal neurology
Photophobia
Worse on waking
Headache examination
Hands: pulse
Face: Pupils, cranial nerves
Neck: CAROTID BRUITS!
UL and LL neuro
KERNIG’S SIGN!
Cardiac - murmurs or arrhythmias
Calves - DVT
Subarachnoid haemorrhage investigations
CT Head
If CT head negative, but high suspicion, do LP for xanthrochomia
Meningitis CSF interpretation
Bacterial: high WCC (neutrophils), low glucose, high protein
Viral: High WCC (lymphocytes), normal glucose, high protein
Cluster headache treatment
Abortive: High fow O2 and subcutaneous sumatriptan
Preventative: Verapamil
Sudden onset headache DDx:
Subarachnoid haemorrhage
Cavernous sinus venous thrombosis
Cervical artery dissection
- This can be carotid or vertebral artery dissection
- Think about sudden head movements, whiplash, head held back in any position
Optic atrophy - history
Reduction in colour vision
MS
- ask if worse after hot bath
- Other neurology - time and space
Drugs history - isoniazid
Cardiovascular risk factors
Optic atrophy DDx
1) Demyelination: MS
2) Inflammatory: vasculitis
3) Compressive: SOL
4) Metabolic: B12 deficiency, diabetes
5) Toxins: Isoniazid
Argyll Robertson pupil
Affected eye is dilated
Does not accommodate or react to light
Associated with absent ankle jerks
Reassurance
Holme’s Adie pupil
Affected eye is dilated
Accomodates, but does not react to light
Associated with syphilis
3rd nerve palsy presentation and cause
Down and out pupil with ptosis
Causes: 3 Ms, 2 Cs
- Mononeuritis multiplex
- deMyelination (MS)
- Midbrain infarct
- posterior Communicating artery aneurysm
- Cavernous sinus pathology
6th nerve palsy presentation and cause
Failure of abduction in affected eye
Causes
- Diabetic retinopathy
- Mononeuritis multiplex e.g. SLE
- Compressive e.g. SOL, raised ICP, aneurysm
- Denyelination e.g. MS
Causes of facial nerve palsy
Inflammatory:
- Bell’s Palsy
- SLE
- Vasculitis
- Sarcoidosis (can be bilateral)
Compressive:
- SOL (cerebello-pontine angle tumour - ask about hearing changes)
Demyelinating: MS, GBS (miller-fisher)
Infective: HIV, Lyme disease
Symptoms to ask about in facial nerve palsy
- Timing, onset
- Neuropathic pain
- Hyperacuisis
- Hearing changes
- Rash (herpes zoster)
- Vision changes
Features of SOL
- Headache, personality/memory change
- Hearing loss!
Features of demyelination
- Neurology time/space
Previous surgery - parotid scars
Facial nerve palsy - examination
Inspection
- Ptosis
- Vesicular rash
- Check behind ears for parotid scars
Facial movements: Eyebrows involved in LMN
Eye movements
Cerebellar exam
Gait
UL/LL if time
Internuclear ophthalmoplegia - pathophysiology, examination and causes
Lesion in the medial longitudinal fasciculus
Examination:
- Failure of adduction of eye on the affected side
- Nystagmus in the contralateral eye
Causes
- Demyelination (MS) is most common
- Cerebrovascular e.g. midbrain stroke
- Inflammatory/vasculitis
- SOL
Relative afferent pupillary defect - examination, causes
Examination: Swinging light test
- When light shone on unaffected eye, normal consensual constriction
- When light shone on affected eye, both eyes appear to dilate
Causes
- In over 50s: GCA until proven otherwise (tx steroids)
- Optic neuritis e.g. MS
- Optic atrophy e.g. diabetic neuropathy, B12 def
- Vascular e.g. CRAO or CRVO
Hereditary haemorrhagic telangiectasia - inheritance
Autosomal dominant
Hereditary haemorrhagic telangiectasia - history
Abnormal bleeding:
- Epistaxis
- Haemoptysis
- GI bleeding
- Menorrhagia
- Previous strokes or intracranial bleeds
Anaemia sx: angina, dizziness, palpitations, SOB
Family history of similar
Hereditary haemorrhagic telangiectasia - investigations
Bloods: FBC, haematinics, U+Es, LFTs, clotting profile
Imaging: CXR, MRI brain, TTE
Genetic testing
Hereditary haemorrhagic telangiectasia - complications
Anaemia
Epistaxis
Pulmonary haemorrhage
AV malformations (brain, hepatic etc)
Can lead to ICH, stroke
Portal HTN from vascular disease -> hepatomegaly and splenomegaly
Hot swollen joint DDX
Crystal arthropathy
Septic joint
Psoriatic arthropathy
Reactive arthritis
Haemarthrosis
Risk factors for crystal arthropathy
Obesity
Dehydration/Diuretics/CKD
Diet: red meat, shellfish, port/red wine
High turnover states: myeloproliferative disease
Risk factors for septic arthritis
Prosthetic joint
IVDU
Immunosuppression esp. diabetes
Investigations for acute hot swollen joint
Bloods: FBC, U+Es, CRP/ESR, LFTs
HLA B-27
Urate is low in acute gout
May consider XR of affected joint
Joint aspiration - fluid microscopy, culture, gram-staining and crystals
Prosthetic joints must be aspirated in theatres!
Management of crystal arthropathy
Acute: NSAIDs, colchicine
Maintenance: allopurinol
Lifestyle modification
Management of septic arthritis
IV Abx ideally after joint aspiration
Joint washout by orthopaedics
Reactive arthritis risk factors
STI - gonorrhea, chlamydia
Gastroenteritis
Sarcoidosis - history
Joints: may have joint swelling
Skin: lupus pernio, erythema nodosum
Systemic: Weight loss, fatigue,
- Hypercalcaemia sx: bones, stone, moans and groans
- Breathlessness
- Bilateral facial nerve palsy
- Uveitis
Sarcoidosis: examination
Hands: skin changes
Face: lupus pernio, bilateral facial nerve palsy
Chest: apical fibrosis
Heart sounds: ?pulm HTN
Abdomen: Splenomegaly
Sarcoidosis: investigations
Bloods: FBC, U+Es, CRP/ESR, LFTs, BONE PROFILE, Serum ACE, Myeloma screen
Urine: Bence jones proteins
CXR: BHL, apical fibrosis
Baseline echo
Biopsy (peripheral ideally) -> non-caseating granuloma
Sarcoidosis: management
Supportive
Steroid indications:
- Parenchymal lung disease
- Uveitis
- Neuro involvement
- Cardiac involvement
- HyperCa
Steroid-sparing agents can be used
Facioscapulohumeral muscular dystrophy
Inheritance
Autosomal dominant
Facioscapulohumeral muscular dystrophy examination
Screening: winged scapula, ask patient to whistle
Inspection: facial/proximal muscle wasting, may have hearing aids
Tone: flaccid
Power: Proximal weakness, winged scapula
Coordination: intact
Sensation: intact
Facioscapulohumeral muscular dystrophy complications
Sensorineural hearing loss
Restrictive lung disease (mechanical)
Functional limitations
Hyperviscosity syndrome - causes
Increased immunoglobulins:
- Multiple myeloma
- Waldenstroms macroglobulinaemia
Cell hyperproliferation:
- Essential thrombocytosis
- Polycythaemia
- Myeloproliferative disorders / leukaemia
Reduced RBC deformability
- Sickle cell disease
- hereditary spherocytosis
Seizure DVLA rules
Group 1 licence: License revoked until 6 months seizure free (including changes to medications)
Group 2:
- One off seizure: License revoked until 5 years seizure-free and off medications
- Multiple seizures: License revoked until 10 years seizure-free and off medications
OSA DVLA rules
No driving until symptoms under control
MUST TELL DVLA
