Medical History for Patients Presenting to the ED with Seizures
A thorough medical history is essential for patients presenting to the ED with seizures, focusing on identifying the underlying cause, risk factors for recurrence, and appropriate management.
Core History Elements
- Seizure characteristics: Obtain detailed description of the event including duration, focal vs. generalized onset, loss of consciousness, tongue biting, incontinence, and post-ictal state 1, 2
- Timing and circumstances: When the seizure occurred, any precipitating factors, and whether the patient has returned to baseline 1
- Prior seizure history: First-time seizure vs. recurrent seizures, including frequency and pattern of previous episodes 1, 2
- Medical conditions: History of stroke, traumatic brain injury, CNS infections, brain tumors, or other neurological disorders that increase seizure risk 1
- Medication history: Current medications, recent changes, adherence to antiepileptic drugs if previously prescribed, and potential drug interactions 1, 3
Risk Factors and Precipitants
- Alcohol use and withdrawal: Recent alcohol consumption or history of alcohol dependence 1, 4
- Recreational drug use: Recent use of illicit substances that may lower seizure threshold 2, 5
- Sleep deprivation: Recent changes in sleep patterns or significant sleep deprivation 2, 6
- Metabolic disorders: History of diabetes, kidney disease, or electrolyte abnormalities 1, 3
- Trauma: Recent head injury or trauma that could cause intracranial bleeding 1, 2
- Pregnancy status: For women of childbearing age, as this affects testing and treatment decisions 2, 3
Specific Historical Elements to Identify Serious Causes
- Fever or signs of infection: May indicate meningitis or encephalitis requiring urgent evaluation 1, 2
- Headache: Persistent headache may suggest intracranial pathology requiring immediate imaging 1, 2
- Cancer history: Increases risk of brain metastases or paraneoplastic syndromes 1, 2
- Immunocompromised status: HIV or other conditions that increase risk of CNS infections 1, 3
- Anticoagulant use: Increases risk of intracranial hemorrhage 1, 2
Family History
- Family history of seizures or epilepsy: Suggests possible genetic predisposition 7, 6
- Family history of neurological disorders: May indicate hereditary conditions with seizure risk 7, 6
Post-Seizure Information
- Return to baseline: Whether and how quickly the patient returned to normal mental status 1
- Post-ictal symptoms: Presence and duration of confusion, headache, focal weakness (Todd's paralysis), or speech difficulties 1, 6
- Recurrent seizures: Any additional seizures since the initial event, as this may indicate status epilepticus or increased recurrence risk 1, 4
Practical Considerations
- Witness accounts: Obtain descriptions from witnesses whenever possible, as patients often have limited recall of the event 2, 6
- Driving status: Document current driving habits as seizures have significant implications for driving privileges 7, 6
- Occupation: Identify high-risk occupations where seizures could pose safety concerns 7, 6
Clinical Pitfalls to Avoid
- Assuming all seizure-like events are epileptic seizures: Syncope, psychogenic non-epileptic seizures, and other conditions can mimic seizures 7, 6
- Overlooking alcohol withdrawal: Alcohol withdrawal seizures should be a diagnosis of exclusion, especially in first-time seizures 1, 8
- Missing subtle focal features: Focal onset seizures that secondarily generalize may indicate structural brain abnormalities requiring imaging 1, 2
- Incomplete medication history: Failure to identify medications that lower seizure threshold or drug interactions 2, 3
By systematically obtaining this medical history, emergency physicians can better determine the appropriate diagnostic workup, need for neuroimaging, and disposition decisions for patients presenting with seizures.