Transcript Taking the History for an Adult patient with Seizures Neurology

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
Risk factors
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?
Away from the seizing cerebral hemisphere
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.).