Taking the History for an Adult patient with Seizures

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

2. 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

3. 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

4. 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?

5. 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

6. 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?

7. 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

8. 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

9. Temporal lobe auras • Gustatory hallucinations • Olfactory hallucinations • Visual distortions • Deja or jamais vu • Deja or jamais entendu • Dream-like state • Fear • Abdominal rising sensation

10. 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!

11. Medication history • Importance? • Relevant details

12. 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)

13. 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.).