Seizure History Taking – OSCE Guide

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Taking a history from a patient presenting after a suspected seizure is an important skill that is often assessed in OSCEs. This guide provides a structured approach to taking a seizure history in an OSCE setting.


Background

Transient loss of consciousness (TLOC)

Loss of consciousness seen by lay people is a sudden change in behaviour, where people suddenly change body posture and become unresponsive. This may be accompanied by a complete absence of movement, or excessive abnormal movements (which people may say is a seizure). These episodes can be due to inadequate brain perfusion (syncopal episodes) or seizure activity.

This article will cover taking a history from an adult patient following a seizure, and it assumes that there was witnessed limb jerking or other features suggestive of a seizure.

For more information on other causes of loss of consciousness (besides seizures), see the Geeky Medics guide to taking a history from a patient with loss of consciousness. We also have a summary of syncope which might be helpful.

Seizures

Seizures are clinical manifestations of abnormal synchronous discharges of neurones.1

Epilepsy is often used synonymously with the term seizures, but there are other causes of seizures besides epilepsy. 

Epilepsy refers to a large group of syndromes where there is a predisposition to having seizures. Epilepsy has many underlying aetiologies broadly categorised as genetic, structural, immune, infectious, metabolic or unknown.2 A diagnosis of epilepsy may be suspected following a seizure episode, but a specialist assessment is required to make a diagnosis of epilepsy. 

You might also be interested in our OSCE Flashcard Collection which contains over 2000 flashcards that cover clinical examination, procedures, communication skills and data interpretation.

Opening the consultation

Wash your hands and don PPE if appropriate.

Introduce yourself to the patient including your name and role.

Confirm the patient’s name and date of birth.

Explain that you’d like to take a history from the patient.

Gain consent to proceed with history taking.

General communication skills

It is important you do not forget the general communication skills which are relevant to all patient encounters. Demonstrating these skills will ensure your consultation remains patient-centred and not checklist-like (just because you’re running through a checklist in your head doesn’t mean this has to be obvious to the patient).

Some general communication skills which apply to all patient consultations include:

  • Demonstrating empathy in response to patient cues: both verbal and non-verbal.
  • Active listening: through body language and your verbal responses to what the patient has said.
  • An appropriate level of eye contact throughout the consultation.
  • Open, relaxed, yet professional body language (e.g. uncrossed legs and arms, leaning slightly forward in the chair).
  • Making sure not to interrupt the patient throughout the consultation.
  • Establishing rapport (e.g. asking the patient how they are and offering them a seat).
  • Signposting: this involves explaining to the patient what you have discussed so far and what you plan to discuss next.
  • Summarising at regular intervals.

Presenting complaint

Use open questioning to explore the patient’s presenting complaint:

  • “What’s brought you in to see me today?”
  • “Tell me about the issues you’ve been experiencing.”

Provide the patient with enough time to answer and avoid interrupting them.

Facilitate the patient to expand on their presenting complaint if required:

  • “Ok, can you tell me more about that?”
  • “Can you explain what that pain was like?”
Open vs closed questions

History taking typically involves a combination of open and closed questions. Open questions are effective at the start of consultations, allowing the patient to tell you what has happened in their own words. Closed questions can allow you to explore the symptoms mentioned by the patient in more detail to gain a better understanding of their presentation. Closed questions can also be used to identify relevant risk factors and narrow the differential diagnosis.


History of presenting complaint

With many seizures involving reduced or absent awareness, it is essential to obtain a collateral history.

It is important to identify patients who have had a seizure, as opposed to common mimics (e.g. syncope) and to establish what happened before, during and after the event.

Once you have a high suspicion that the event was a seizure, consider why they have seized, and how this is going to affect the individual (covered in the past medical and social history).

Immediately before the event

Is there anything that indicates this may be a syncopal episode?

  • Cardiogenic syncope: “Before the event did you feel sweaty, hot, lightheaded, breathless, or have chest pain or palpitations?” “Were you exerting yourself before this happened?”
  • Orthostatic: “Were you sitting or standing for a long time?” “Were you in a hot or stuffy environment?
  • Postural syncope: “Did you move from sitting to standing, or lying to standing immediately before this happened?”

Is there a non-syncopal mimic at play?

  • Rigors (can often be mistaken for seizures): Did you feel like you had a temperature? – Remember that children can have febrile seizures.
  • Transient ischaemic attack: “Did this happen while you were looking up at something?” – Shaking limb TIAs can be caused by reduced brain perfusion before onset, such as neck hyperextension, or lying to standing. Suspicion of this can be further raised if there was no loss of consciousness.3

Establish if there was any abnormal brain activity (e.g. aura or focal seizures) before the event:

  • “Did you experience any abnormal sensations before the event?” – Focal seizures may be heralded by a subjective sensory aura. The aura will be determined by the area of the cortex affected. For example, some temporal seizures may be preceded by smell disturbance, a rising sensation in the epigastrium, palpitations, or déjà vu/jamais vu.1
  • “Did you have any arm or leg weakness before the episode?”
  • “Did you find that your body moved into an abnormal position before the episode?”
  • “Did you have any movements that you felt you were not doing voluntarily?”
  • “Did you, or anyone around you, notice any change to your behaviour before the episode?”

Ask about features suggestive of the underlying aetiology of the seizure: 4,5,6

  • “Did you have a headache before the episode started?” – This may herald a serious underlying vascular pathology such as a subarachnoid haemorrhage
  • “Had you had any falls or head injuries before this episode started?” – In older people, it can take subdural haemorrhages days to weeks to manifest clinically
  • “Have there been any abnormal movements in your limbs or face noticed by yourself or anyone else?” – Abnormal hyperkinetic disorders may indicate a potential underlying autoimmune encephalitis

With all of these features, it is important to clarify how close in time they happened to the seizure. 

During the event

Seizure semiology (the clinically observed pattern of motor, sensory, behavioural, or psychiatric changes during a seizure) has been classified by the International League Against Epilepsy (Table 1).

Table 1. The classification of seizures (ILAE).

Focal onset
The seizure is likely to involve part of the brain
Generalised onset Unknown onset

Aware

Of self and environment; formerly known as simple partial seizure

Impaired awareness

Of self and environment

Motor

  • Tonic-clonic
  • Other motor

Nonmotor (absence)

Motor onset

  • Tonic-clonic
  • Epileptic spasms

Nonmotor onset

  • Behaviour arrest

Motor onset

  • Automatisms – repeated stereotyped movements
  • Atonic
  • Clonic
  • Epileptic spasms
  • Hyperkinetic
  • Myoclonic
  • Tonic

Nonmotor onset

  • Autonomic
  • Behaviour arrest
  • Cognitive*
  • Emotional**
  • Sensory

Unclassified

“Due to inadequate information or inability to place in other categories.”

*impaired language or other cognitive domains or positive features such as déjà vu, hallucinations, illusions, or perceptual distortions

**involve anxiety, fear, joy, other emotions, or appearance of affect without subjective emotions

Can you find objective evidence of the suspected seizure?

Did anyone record what happened on video?

Has another healthcare professional recorded a description of the event? Sometimes the paramedics will have written a detailed account of what happened at the scene.

From collateral history taking, identify core features of the episode in terms of the above seizure descriptions:

  • “Was the patient alert or unresponsive?”
  • “Was there abrupt generalised muscle stiffening with rapid recovery?” – this indicates a tonic seizure
  • “Was there generalised stiffening, followed by subsequent rhythmic jerking of limbs?” – this indicates a tonic-clonic seizure
  • “Did they stop what they were doing and become vacant?” – this indicates an absence seizure
  • “Was there a sudden loss of muscle tone?” – atonic seizure
  • “Were there any repetitive movements of the face or limbs?” – patients may enact learned behaviours in automatisms

Identify other features that indicate seizure or non-seizure activity:7-11

  • “Was there any head turning?” – Head turning to one side may indicate a seizure – if the head is turning side to side during the event, non-epileptic seizures may be the underlying aetiology
  • “Were their eyes looking one way or the other?” – Eye deviation to one side may indicate a seizure
  • “Was there any tongue biting?” –  Lateral tongue biting is purported to be a reliable sign of generalised motor seizure activity, although the evidence is not brilliant
  • “Was there any pelvic thrusting?” – This is a very sensitive but non-specific sign for non-epileptic attacks
  • “Did their skin or lips go blue?” – Cyanosis occurs when the proportion of carbon dioxide (CO2) in the blood reaches a certain level – it may develop in generalised seizures due to airway occlusion and lack of ventilation. Cyanosis early on in the event may indicate another cause of CO2 accumulation that precipitates seizure activity. Cyanosis occurring later on during an episode suggests it is likely a seizure causing hypoventilation
  • “Did they go pale?” –  Pallor at the start of an event is suggestive of hypoperfusion as a result of a syncopal event

Historically, healthcare professionals have been taught to ask about incontinence. However, this is not a specific sign of seizures, as people may have incontinence with any type of loss of consciousness.7,9

Following the event

How was the seizure stopped? Ask the following from collateral or documentation available:

  • “How long did it take for the seizure to stop?” – Knowing the duration of the seizure is helpful in understanding the risk of sequelae such as hypoxic brain injury in generalised seizures
  • “Did any drugs need to be given for the seizure to stop?” – This information can be gained from paramedic reports. The time course is important as this may affect ongoing management.

Are there post-ictal features that increase suspicion of a seizure? Post-ictal phenomena predominantly only occur in generalised tonic, clonic, or tonic-clonic seizures:7,9,12

  • “When the episode stopped how long was the patient unconscious for?” – Greater than 5 minutes of loss of consciousness after the event is suspicious for a seizure
  • “Did you/they know where they were when they woke up?” – People may be disorientated after a seizure
  • “Can you/they recall what has happened since the seizure in full?” – Anterograde amnesia may occur after seizures
  • “Did you feel sleepy or tired after the event?” 
  • “Did you have muscle pain after the event?” – Uncontrolled muscle contraction will cause soreness
  • “Have you bitten the side of your tongue?” – Lateral tongue biting may indicate a generalised seizure

Tongue biting and prolonged unresponsiveness with the absence of typical syncopal symptoms at onset is strongly suggestive of a seizure.7

Are there any sequelae of the seizure?

  • “Do you have any joint pain or difficulty moving anywhere?” – Injuries including dislocations and trauma may have occurred during generalised seizures
  • “Are you coughing anything up?” or “Did they seem to aspirate anything during the event?” – Patients who have had generalised seizures are at high risk of aspirating secretions

Ideas, concerns and expectations

A key component of history taking involves exploring a patient’s ideas, concerns and expectations (often referred to as ICE) to gain insight into how a patient currently perceives their situation, what they are worried about and what they expect from the consultation.

The exploration of ideas, concerns and expectations should be fluid throughout the consultation in response to patient cues. This will help ensure your consultation is more natural, patient-centred and not overly formulaic.

It can be challenging to use the ICE structure in a way that sounds natural in your consultation, but we have provided several examples for each of the three areas below.

Ideas

Explore the patient’s ideas about the current issue:

  • “What do you think the problem is?”
  • “What are your thoughts about what is happening?”
  • “It’s clear that you’ve given this a lot of thought and it would be helpful to hear what you think might be going on.”

Concerns

Explore the patient’s current concerns:

  • “Is there anything, in particular, that’s worrying you?”
  • “What’s your number one concern regarding this problem at the moment?”
  • “What’s the worst thing you were thinking it might be?”

Expectations

Ask what the patient hopes to gain from the consultation:

  • “What were you hoping I’d be able to do for you today?”
  • “What would ideally need to happen for you to feel today’s consultation was a success?”
  • “What do you think might be the best plan of action?”

Summarising

Summarise what the patient has told you about their presenting complaint. This allows you to check your understanding of the patient’s history and provides an opportunity for the patient to correct any inaccurate information.

Once you have summarised, ask the patient if there’s anything else that you’ve overlooked. Continue to periodically summarise as you move through the rest of the history.

Signposting

Signposting, in a history taking context, involves explicitly stating what you have discussed so far and what you plan to discuss next. Signposting can be a useful tool when transitioning between different parts of the patient’s history and it provides the patient with time to prepare for what is coming next.

Signposting examples

Explain what you have covered so far: “Ok, so we’ve talked about your symptoms, your concerns and what you’re hoping we achieve today.”

What you plan to cover next: “Next I’d like to quickly screen for any other symptoms and then talk about your past medical history.”


Systemic enquiry

systemic enquiry involves performing a brief screen for symptoms in other body systems which may or may not be relevant to the primary presenting complaint. A systemic enquiry may also identify symptoms that the patient has forgotten to mention in the presenting complaint.

Deciding on which symptoms to ask about depends on the presenting complaint and your level of experience.

Some examples of symptoms you could screen for in each system include:

  • Systemic: fevers (e.g. cerebral abscess, meningitis), weight change (e.g. malignancy), confusion (e.g. CNS infection)
  • Cardiovascular: palpitations (e.g. arrhythmia), chest pain (acute coronary syndrome), shortness of breath (e.g. heart failure)
  • Respiratory: dyspnoea, cough (e.g. pneumonia), pleuritic chest pain (e.g. pulmonary embolism)
  • Gastrointestinal: diarrhoea, vomiting (e.g. dehydration/hypotension/electrolyte disturbances)
  • Genitourinary: oliguria (e.g. dehydration/hypotension)
  • Neurological: visual symptoms (e.g. pre-syncope), headache (e.g. brain tumour), meningism (e.g. CNS infection), motor or sensory disturbances (e.g. stroke)
  • Musculoskeletal: head injury (e.g intracranial haemorrhage), trauma (e.g. secondary to syncope), joint swelling/pain (e.g. lupus/vasculitis)
  • Dermatological: rashes (e.g. meningococcal sepsis, Lupus, vasculitis)

Past medical history

History of epilepsy

Ask if the patient is known to have epilepsy and ask about details of their condition:13

  • “What do your seizures normally look like?”
  • “When was the last seizure you had before this one?”
  • “Was this episode like your normal seizures or was this a different type of seizure?”  – It is important to note that there is a higher risk of non-epileptic attacks in an epileptic patient. Patients can have both epilepsy and non-epileptic attack disorder.

If the patient has epilepsy, explore if there are any triggers which may be lowering their seizure threshold:

  • “Have you been under more stress recently?”
  • “Have you had any disruption to your sleep pattern?”
  • “Did you consume any alcohol or recreational drugs before this episode?”
  • “Have you been remembering to take your medication?”
  • “Have you started taking any new prescribed drugs, over-the-counter drugs, or supplements?

Other medical conditions

Ask if the patient has any other medical conditions: 

  • “Do you have any other medical conditions?”
  • “Are you currently seeing a doctor or specialist regularly?”

If the patient does have a medical condition, you should gather more details to assess how well controlled the disease is and what treatment(s) the patient is receiving. It is also important to ask about any complications associated with the condition including hospital admissions.

Ask if the patient has previously undergone any surgery or procedures (e.g. coronary artery bypass grafts, pacemaker insertion):

  • “Have you ever previously undergone any operations or procedures?”
  • “When was the operation/procedure and why was it performed?”
Examples of relevant medical conditions 

Medical conditions relevant to seizures include:12

  • Structural CNS abnormalities: congenital malformations, vascular malformations (e.g. cavernomas), previous strokes
  • Diabetes and hypertension: may cause chronic small vessel ischaemia in deep white matter that can predispose to seizures
  • Neurodegenerative conditions (e.g. Alzheimer’s)
  • Endocrine or metabolic conditions: can cause depression in CNS activity if poorly controlled
  • Dialysis patients: electrolyte shifts may predispose to seizures after dialysis
  • Immunosuppression: either pharmacologically (e.g. renal transplant) or pathologically (e.g. immunodeficiency). This may predispose the patient to CNS infections that may manifest as seizures.
  • Autoimmune/rheumatological conditions: lupus and vasculitis may predispose to seizures through CNS vasculitis.
  • Chronic infections: some treatments associated with chronic infections can promote infection. For example, isoniazid (used for tuberculosis) affects GABAergic transmission, which may make it more likely that a seizure will happen.

Allergies

Ask if the patient has any allergies and if so, clarify what kind of reaction they had to the substance (e.g. mild rash vs anaphylaxis).


Drug history

Ask if the patient is currently taking any prescribed medications or over-the-counter remedies:

  • “Are you currently taking any prescribed medications or over-the-counter treatments?”

If the patient is taking prescribed or over-the-counter medications, document the medication name, dose, frequencyform and route.

Ask if the patient has recently started any medications which may have precipitated a seizure (e.g. nefopam) or caused a syncopal episode (e.g. antihypertensive):14

  • “Have you recently started any new medications?” – Some antibiotics can reduce the seizure threshold through interaction with antiepileptics (e.g. meropenem reduces the therapeutic plasma levels of sodium valproate)

Ask the patient if they’re currently experiencing any side effects from their medication:

  • “Have you noticed any side effects from the medication you currently take?”

Ask the patient if they’ve recently stopped any medications or had any doses changed as this may have precipitated a seizure (e.g. gabapentin withdrawal) or resulted in hypotension (e.g. corticosteroid withdrawal causing adrenal insufficiency):

  • “Have you recently stopped any medications?”

Ask if the patient is following a specific dietary or herbal/vitamin regimen. These can have unintended interactions with medications, or be directly toxic.

Medication examples

Medications relevant to seizures include:

  • Hypoglycaemic agents: increased risk of hypoglycaemia and seizures
  • Anticonvulsants: if doses recently changed may precipitate a seizure
  • Tricyclic amines: associated with orthostatic hypotension and seizures
  • Short-acting benzodiazepines: associated with seizures upon withdrawal
  • Contraceptive pills: some antiepileptic medications can affect the breakdown of contraceptive pills and make them less effective

Family history 

Ask the patient if there is any family history of seizures:

  • “Do any of your parents or siblings have any heart problems or have they experienced seizures in the past?” 

Clarify at what age the disease developed (disease developing at a younger age is more likely to be associated with genetic factors):

  • “At what age did your father suffer his first heart attack?”

If one of the patient’s close relatives is deceased, sensitively determine the age at which they died and the cause of death:

  • “I’m really sorry to hear that, do you mind me asking how old your dad was when he died?”
  • “Do you remember what medical condition was felt to have caused his death?”

If the patient reports unexplained sudden deaths in young relatives, consider the possibility of inherited cardiac arrhythmias (e.g. Brugada syndrome, long QT syndrome).


Social history

Explore the patient’s social history to both understand their social context and identify potential risk factors. It is also important to understand the lifestyle implications of seizures and explore underlying risk factors.

General social context

Explore the patient’s general social context including:

  • the type of accommodation they currently reside in (e.g. house, bungalow) and if there are any adaptations to assist them (e.g. stairlift)
  • who else the patient lives with and their personal support network
  • what tasks they are able to carry out independently and what they require assistance with (e.g. self-hygiene, housework, food shopping)
  • if they have any carer input (e.g. twice daily carer visits)

Understanding the patient’s daily activities allows you to consider the risk posed by further episodes of seizures. If the patient lives alone, there is a 5-fold increased risk of sudden unexpected death in epilepsy (SUDEP).

Smoking

Record the patient’s smoking history, including the type and amount of tobacco used.

Calculate the number of ‘pack-years‘ the patient has smoked for to determine their cardiovascular risk profile:

  • pack-years = [number of years smoked] x [average number of packs smoked per day]
  • one pack is equal to 20 cigarettes

Alcohol

Record the frequencytype and volume of alcohol consumed on a weekly basis.

Patients drinking significant volumes of alcohol regularly are at increased risk of seizures, particularly if they suddenly stop drinking (i.e. alcohol withdrawal seizures). Patients who binge drink are also at increased risk of seizures secondary to acute intoxication.

Chronic alcohol excess increases the risk of epilepsy.

Recreational drug use

Ask the patient if they use recreational drugs and if so determine the type of drugs used and their frequency of use. Recreational drugs can cause seizures, either as a direct neuroexcitatory effect or through withdrawal. 

Occupation

Ask about the patient’s current occupation:

  • Explore what tasks the patient performs at work to identify high-risk activities (e.g. working at heights, operating heavy machinery).
  • If the patient is experiencing seizures and works with heavy machinery or at heights, it is important to advise them to take time off work until they have been fully investigated.

The following social history elements are more specific to an epilepsy history but are helpful when taking a seizure history.

Driving

If the patient drives and has presented with a seizure it is important to advise them not to drive until they have been fully investigated and to inform the relevant driving authority (e.g. Driver and Vehicle Licensing Agency – DVLA) of their current medical issues.

It is also important to determine if they have a class 2 licence (which allows them to drive a vehicle over 7.5 tonnes) as there will be a difference in driving rules imposed by the DVLA. The DVLA are ultimately the organisation that decides whether someone should continue to drive (rather than the healthcare professional).

If patients do not inform the DVLA, they will not be covered by insurance if there is another seizure episode.

Children or other dependents

If the patient is a parent with young children, you could consider asking the following:

  • Do they carry their child? There may be significant anxiety about dropping the child. Adjustments including attaching wheels to a carrycot and wheeling the baby alongside may be helpful. Alternatively, a baby could be strapped into a car seat and then the car seat carried.
  • Feeding: there may be concerns about antiepileptic drugs and breastfeeding; this is usually not a problem.
  • If breastfeeding, it is advisable for mothers to sit on the floor with their back to the wall and a cushion on either side so that a baby does not have far to fall if the patient loses consciousness. The Royal College of Obstetricians and Gynaecologists recommend monitoring for adverse effects and feeding before taking antiepileptic drugs.
  • If bottle feeding, a patient could consider setting a high chair at the lowest height and sitting on the floor while feeding the baby.
  • Nappy changing: this is best carried out on a waterproof mat on the floor, not furniture where the baby may roll off if unattended,

Sleep

Disrupted sleep may increase the risk of further seizures if there is an underlying epilepsy diagnosis. Identifying modifiable sleep disruptions can be helpful.

Bathing and swimming

Advice for bathing is to only bathe when someone else is at home and able to stand outside the bathroom door. For showering, patients should sit on a chair when having a shower.

Advice regarding swimming and water sports can be found on the Epilepsy Society website.

Family planning

Women who are planning to start a family, and have epilepsy, should consider taking a folic acid supplement of 5mg per day to reduce the risk of birth defects.


Closing the consultation

If the patient has ongoing concerns, they can be signposted to information websites such as Epilepsy Action.

An epilepsy specialist nurse can be a helpful point of contact for the patient.

If there are ongoing concerns regarding medication in women who are pregnant, or who may be trying for a pregnancy, they can be signposted to the Best Use of Medicines in Pregnancy (BUMPS) website.

Summarise the key points back to the patient.

Ask the patient if they have any questions or concerns that have not been addressed.

Thank the patient for their time.

Dispose of PPE appropriately and wash your hands.


Reviewer

Dr Stuart Weatherby

Consultant Neurologist

University Hospitals Plymouth


Editor

Dr Chris Jefferies


References

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