Documentation HPI Template for Patients with Seizures
A comprehensive HPI template for seizure patients should include detailed information about the seizure characteristics, precipitating factors, and associated symptoms to facilitate accurate diagnosis and management.
Seizure Event Details
Onset and timing:
- Date and time of the most recent seizure
- Frequency of seizures (daily, weekly, monthly)
- Pattern of occurrence (specific time of day, clustering)
- Duration of each seizure episode
Seizure characteristics:
- Pre-ictal symptoms (aura): visual changes, unusual smells, emotional changes, déjà vu
- Ictal phase description:
- Level of consciousness
- Motor activity (tonic, clonic, tonic-clonic, absence, myoclonic)
- Lateralizing signs (head/eye deviation, unilateral limb involvement)
- Automatisms (lip smacking, picking movements)
- Vocalization
- Urinary or bowel incontinence
- Post-ictal phase:
- Duration of post-ictal state
- Confusion, headache, muscle soreness, fatigue
- Focal neurological deficits (Todd's paralysis)
- Return to baseline mental status
Classification Information 1
- Seizure type:
- Provoked seizure (occurring within 7 days of acute neurologic, systemic, metabolic, or toxic insult)
- Unprovoked seizure (no acute precipitating factors)
- Status epilepticus (continuous seizure activity lasting >5 minutes or recurrent seizures without recovery between episodes)
Precipitating Factors
Potential triggers:
- Missed antiepileptic medications
- Sleep deprivation
- Alcohol consumption or withdrawal
- Recreational drug use
- Metabolic abnormalities (hypoglycemia, hyponatremia, hypocalcemia) 1
- Infection or fever
- Emotional stress
- Flashing lights or specific stimuli
- Medication changes or new medications
Toxicology considerations: 2
- Alcohol use (timing of last drink, amount, pattern of use)
- Acetaminophen or other medication ingestion
- Illicit substance use
Medical History
Seizure history:
- Age at first seizure
- Previous seizure types and frequency
- Previous diagnostic workup (EEG, imaging, laboratory studies)
- Previous hospitalizations for seizures
- History of status epilepticus
Current medications:
- Antiepileptic drugs (names, doses, compliance)
- Other medications that may lower seizure threshold
- Recent medication changes
Past medical history relevant to seizures:
- Head trauma
- CNS infections
- Stroke or cerebrovascular disease
- Brain tumors
- Developmental disorders
- Psychiatric conditions
Family History
- Family history of seizures or epilepsy
- Family history of neurological disorders
Social History
- Occupation and driving status
- Alcohol and substance use
- Living situation and available support
- Impact of seizures on quality of life
Review of Systems
Neurological:
- Headaches
- Visual disturbances
- Weakness or numbness
- Balance problems
- Cognitive changes
Psychiatric:
- Mood changes
- Anxiety
- Depression
- Sleep disturbances
Witness Account
- Description of the event from observers
- Consistency with patient's account
- Video documentation if available
Current Episode Context
- Activities preceding the seizure
- Location when seizure occurred
- Injuries sustained during the seizure
- Emergency medical services involvement
- Treatment administered before arrival
Documentation Pitfalls to Avoid
- Failing to distinguish between epileptic seizures and non-epileptic events (syncope, psychogenic non-epileptic seizures)
- Incomplete documentation of seizure semiology
- Missing information about medication compliance
- Overlooking potential metabolic causes of seizures
- Not documenting post-ictal state duration and characteristics
- Failing to obtain witness accounts when available
- Not addressing safety concerns and driving status
This template provides a structured approach to documenting seizure patients' history of present illness, ensuring comprehensive information collection that will guide appropriate diagnostic testing and management decisions.