Taking the History for an Adult patient with Seizures Neurology Resident Teaching Series

The setting 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 Longitudinal history Medication history

Describe your seizure 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

bystander perspective 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? Urinary or bowel incontinence? Can also happen frequently in other conditions, such as syncope

Risk Factors 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

Temporal lobe auras 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!

Medication history 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)

Summary • 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.).