HPI Template for a Patient Presenting After a Witnessed Seizure
A comprehensive HPI template for a patient presenting after a witnessed seizure should include details about the seizure event, precipitating factors, post-ictal state, and relevant medical history to guide appropriate management and reduce morbidity and mortality. 1
Chief Complaint
- "Witnessed seizure" or specific description provided by patient/witness
Key Elements to Document
Seizure Characteristics
Time of onset and duration
- Exact time seizure began
- Total duration (critical for distinguishing status epilepticus)
- Whether seizure was self-limited or required intervention
Description of seizure activity (from witness)
- Initial body part involved (focal vs. generalized onset)
- Progression of movements
- Tonic phase (stiffening)
- Clonic phase (rhythmic jerking)
- Eye movements or gaze deviation
- Automatisms (lip smacking, picking movements)
- Vocalization during event
Level of consciousness
- Fully unconscious vs. preserved awareness
- Response to verbal or painful stimuli during event
Pre-ictal Phase
Prodromal symptoms (hours to days before)
- Mood changes, irritability, fatigue
- Sleep disturbances
Aura (seconds to minutes before)
- Sensory symptoms (visual, auditory, olfactory, gustatory)
- Rising epigastric sensation
- Déjà vu or jamais vu experiences
- Emotional changes (fear, anxiety)
Post-ictal Phase
- Duration of post-ictal state
- Mental status changes
- Confusion, disorientation
- Agitation or combativeness
- Time to return to baseline mental status
- Focal neurological deficits (Todd's paralysis)
- Headache, muscle soreness, fatigue
- Memory of event (complete vs. partial amnesia)
- Tongue biting, urinary/fecal incontinence
Precipitating Factors
- Medication compliance (if known epilepsy)
- Last dose of antiepileptic medication(s)
- Recent medication changes or missed doses
- Potential triggers
- Sleep deprivation
- Alcohol consumption or withdrawal
- Recreational drug use
- Fever or acute illness
- Stress
- Flashing lights or other sensory triggers
- Missed meals/hypoglycemia
Past Medical History Relevant to Seizure
- Prior seizures
- First-time seizure vs. known epilepsy
- Frequency and pattern of previous seizures
- Date of last seizure
- Typical seizure semiology if known epilepsy
- Relevant neurological conditions
- History of stroke, TBI, CNS infection, tumor
- Developmental disorders
- Neurodegenerative conditions
- Other medical conditions
- Diabetes, renal failure, liver disease
- Cardiac conditions (arrhythmias)
- Recent infections
- Electrolyte disorders
- Thyroid disease
Medication History
- Current medications
- Antiepileptic drugs and adherence
- Other medications that lower seizure threshold
- Recent medication changes
- Allergies
Social History
- Alcohol use (amount, frequency, last drink)
- Recreational drug use (type, amount, last use)
- Sleep patterns (recent changes, deprivation)
- Occupation and driving status
- Living situation and available support
Family History
- Family history of seizures or epilepsy
- Family history of neurological disorders
Review of Systems
- Recent fever, headache, neck stiffness (meningitis concerns)
- Recent head trauma
- Changes in vision, speech, or motor function
- Recent illness or infection
- Pregnancy status (if applicable)
Documentation Example
"56-year-old male with history of hypertension and previous stroke 3 years ago presented after a witnessed seizure that occurred today at 10:30 AM while at work. According to his coworker, the patient suddenly stopped talking mid-sentence, stared blankly for approximately 10 seconds, then developed stiffening of all extremities followed by rhythmic jerking movements of all limbs lasting approximately 2 minutes. No aura reported. Patient was unconscious during the event with urinary incontinence noted. Post-ictally, patient was confused for approximately 20 minutes with gradual return to baseline mental status. No tongue biting or focal weakness noted after the event. Patient reports compliance with atorvastatin but denies being on antiepileptic medications. Reports poor sleep over past week (averaging 4-5 hours/night) due to work stress. Denies alcohol use, recreational drugs, or recent illness. No prior seizures reported. Last meal was breakfast at 7 AM."
Critical Pitfalls to Avoid
- Failing to document exact seizure duration (critical for identifying status epilepticus)
- Not obtaining witness description when available
- Overlooking potential provocative factors (medication non-compliance, alcohol withdrawal)
- Missing signs of serious underlying causes (fever, headache, focal deficits)
- Failing to document time to return to baseline (important for disposition decisions) 2, 1