What should I look for on physical examination (PE) in a patient with breakthrough seizures?

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Physical Examination Findings in Breakthrough Seizures

A thorough physical examination for breakthrough seizures should focus on identifying potential triggers including medication non-compliance, metabolic abnormalities, and neurological changes, with particular attention to vital signs, neurological status, and signs of injury.

Initial Assessment

Vital Signs

  • Check temperature: Fever may indicate infection as a trigger
  • Blood pressure: Hypertension could suggest hypertensive encephalopathy
  • Heart rate and rhythm: Arrhythmias can cause cerebral hypoperfusion
  • Oxygen saturation: Hypoxia can lower seizure threshold
  • Respiratory rate: Abnormal patterns may indicate postictal state or ongoing seizure activity

General Appearance

  • Level of consciousness: Assess for postictal state or non-convulsive status epilepticus
  • Evidence of trauma: Look for tongue biting, facial/scalp lacerations, shoulder dislocations
  • Skin examination: Check for needle marks (substance use), rashes (infectious causes), or bruising

Neurological Examination

Mental Status

  • Orientation: Assess for postictal confusion or altered mental status
  • Memory: Recent and remote memory deficits may indicate postictal state
  • Language: Aphasia may indicate focal seizure with Todd's paralysis

Cranial Nerves

  • Pupillary response: Asymmetry may indicate structural lesions
  • Extraocular movements: Nystagmus may be present with certain antiepileptic medications
  • Facial symmetry: Asymmetry may indicate Todd's paralysis

Motor System

  • Focal weakness: May indicate Todd's paralysis (temporary weakness following seizure)
  • Tone: Increased tone may indicate ongoing seizure activity
  • Deep tendon reflexes: Asymmetry may suggest focal lesion

Specific Findings to Look For

Signs of Medication Issues

  • Nystagmus, ataxia, or diplopia: May indicate toxic levels of antiepileptic drugs 1
  • Gingival hyperplasia: Associated with phenytoin use
  • Tremor: May indicate valproate toxicity
  • Skin rashes: May indicate drug reaction or Stevens-Johnson syndrome

Signs of Metabolic Derangements

  • Check for signs of:
    • Hypoglycemia: Diaphoresis, tachycardia
    • Hyponatremia: Confusion, lethargy
    • Hepatic encephalopathy: Asterixis, jaundice
    • Uremia: Uremic frost, confusion 1, 2

Signs of Substance Use/Withdrawal

  • Alcohol withdrawal: Tremor, tachycardia, hypertension, diaphoresis
  • Stimulant use: Mydriasis, tachycardia, hypertension
  • Ethanol and acetaminophen levels should be checked routinely in patients with breakthrough seizures 3

Special Considerations

For New-Onset vs. Breakthrough Seizures

  • In established epilepsy with breakthrough seizures, routine neuroimaging is not necessary unless there are new focal neurological findings 1
  • In contrast, new-onset seizures typically require neuroimaging (CT or MRI) 1

For Postictal Assessment

  • Document duration of postictal state
  • Assess for postictal Todd's paralysis (temporary weakness following seizure)
  • Check for postictal aphasia or other focal deficits that may localize seizure focus

Common Pitfalls to Avoid

  1. Missing subtle status epilepticus: Non-convulsive status epilepticus should be considered in any patient with unexplained confusion 2

  2. Overlooking medication non-compliance: Check for medication levels when available, particularly for medications with narrow therapeutic windows

  3. Failing to check for alcohol or drug use/withdrawal: These are common triggers for breakthrough seizures 3

  4. Neglecting to examine for traumatic injuries: Patients may have sustained injuries during seizure activity

  5. Missing signs of infection: Infections, particularly CNS infections, can lower seizure threshold

Documentation Recommendations

  • Document exact seizure semiology (as reported by witnesses)
  • Note time of last antiepileptic medication dose
  • Record duration of postictal state
  • Document any focal neurological findings and their evolution over time
  • Note any signs of injury sustained during seizure

By systematically evaluating these elements during physical examination, clinicians can better identify potential causes of breakthrough seizures and guide appropriate management decisions.

References

Guideline

Guideline Directed Topic Overview

Dr.Oracle Medical Advisory Board & Editors, 2025

Research

Medical causes of seizures.

Lancet (London, England), 1998

Guideline

Seizure Evaluation and Management

Praxis Medical Insights: Practical Summaries of Clinical Guidelines, 2025

Professional Medical Disclaimer

This information is intended for healthcare professionals. Any medical decision-making should rely on clinical judgment and independently verified information. The content provided herein does not replace professional discretion and should be considered supplementary to established clinical guidelines. Healthcare providers should verify all information against primary literature and current practice standards before application in patient care. Dr.Oracle assumes no liability for clinical decisions based on this content.

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