Taking the History for an Adult patient with Seizures

Neurology Resident Teaching Series

First time seizure

Recurrence of seizures in a patient with known epilepsy

Elective admission for characterization of events (event monitoring) or medication changes

The setting

First time seizure

Setting

Semiology (or description) of the event

Provoking factors

Risk factors

Clues - level of education, temporal lobe auras

Recurrence of seizures in a patient with known epilepsy

Similar to first time seizure history unless the items below are not documented

Elective admission for characterization of events (event monitoring) or medication changes

Semiology of typical events

Duration and Frequency

Triggers

Risk factors

Longitudinal history

Medication history

The setting

Aura or warning signs?

Loss of awareness or consciousness? Lapse of time?

Unusual movements?

Typical or unusual noises?

Fall to ground or slump over?

Duration?

Simple partial and complex partial

Generalized convulsions

Status epilepticus

Frequency?

Typical triggers?

Describe your seizure

Aura or warning signs?

Loss of awareness or consciousness? Lapse of time?

Unusual movements?

Automatisms such as lip smacking or picking at clothes

Tonic stiffening, posturing, head drop

Limb myoclonus or clonus

Typical or unusual noises?

Moaning or yelling

Fall to ground or slump over?

Duration?

Simple partial and complex partial - seconds to minutes

Generalized convulsions - 1-3 minutes

Status epilepticus - variable definition

Frequency?

Typical triggers?

Sleep deprivation, antibiotics, alcohol, cocaine, amphetamines, bupropion, infection, pregnancy

Describe your seizure

Loss of awareness or consciousness? “Unresponsive?”

Unusual movements?

Typical or unusual noises?

Fall to ground or slump over?

Duration?

Mouth trauma?

Head turn?

Eye deviation?

Urinary or bowel incontinence?

bystander perspective

Loss of awareness or consciousness? “Unresponsive?”

Unusual movements?

Mild convulsions can also happen with syncope (but usually for a shorter period of time)

Typical or unusual noises?

Fall to ground or slump over?

Duration?

Mouth trauma?

Tongue bite (often more posterior and lateral rather than anterior)

Lip laceration

Head turn?

Away from the seizing cerebral hemisphere

Eye deviation?

Away from the seizing cerebral hemisphere

Urinary or bowel incontinence?

Can also happen frequently in other conditions, such as syncope

bystander perspective

Neonatal injury

Perinatal stroke, cerebral palsy

Genetic or metabolic disorders

Febrile seizures

Family history

Head trauma

Significant = impairment of awareness or consciousness

Meningitis/encephalitis

Stroke or hemorrhage

Personal history of malignancy

Metastatic disease

Recurrence of intracranial neoplasm

Risk Factors

Gustatory hallucinations

Olfactory hallucinations

Visual distortions

Deja or jamais vu

Deja or jamais entendu

Dream-like state

Fear

Abdominal rising sensation

Temporal lobe auras

Gustatory hallucinations

Brief (seconds), often unpleasant (metallic)

Olfactory hallucinations

Brief (seconds), often unpleasant (burning flesh, petrol)

Visual distortions

Macropsia/micropsia (think “Alice in Wonderland”), “tableau” (freezing of the scene)

Deja or jamais vu (previously seen or never seen but cannot explain)

Deja or jamais entendu (previously heard or never heard but cannot explain)

Dream-like state

Sensation of the surroundings being unreal, feeling of detachment

Fear

Sudden, unprovoked

Abdominal rising sensation

Brief, recurrent, must differentiate from gastroesophageal reflux!

Temporal lobe auras

Importance?

Relevant details

Medication history

Importance?

Multiple indications - taken for seizures or other disorder?

Effective dose - was a seizure prevention dose achieved?

Side effects - did the patient have any major adverse side effects? (or effects perhaps caused by other meds?)

Medication interactions - did the patient take two or more medications that altered levels?

Relevant details

Medication name

Medication formulation (brand or generic)

Highest dose achieved

Time/date of initiation

Duration of treatment

Concurrent medications

Reason for discontinuation (if applicable)

Adverse effects (if applicable)

Medication history

• Patients with seizures or suspected seizures typically present either with a first time

event, a recurrence of seizures, or for an elective admission to characterize events or

change medications.

• Descriptions of initial or recurrent seizures should be obtained from both the individual

and any witnesses (as the patient may not recall the event due to loss of awareness or

consciousness).

• Most adult patients with focal epilepsies have temporal lobe seizures (possibly due to

kindling), so assessing for temporal lobe auras may help improve diagnostic yield.

• Taking a detailed medication history can help guide medication changes or help

determine the appropriateness of evaluation for advanced therapeutics (surgery,

stimulators, etc.).

Summary