First Seizure/New-Onset Seizure Evaluation Note

Date/Time: [Encounter date and time]

Care Setting: [ED / inpatient consult / clinic]

Chief Complaint: "[Patient's own words]" (Use patient's words when available, e.g., "passed out and shook," "seizure," "spell.")

Historian(s): [Patient / witness / EMS / video / chart review] (Specify sources; note reliability concerns such as postictal amnesia or intoxication; note interpreter if used.)

Records Reviewed: [EMS run sheet, outside records, prior neurology notes, prior imaging/EEG as applicable]

Event Overview

[Brief 2–4 sentence synopsis: what happened and when (date/time/location), witnessed vs unwitnessed and by whom, return to baseline (yes/no/partial and timeframe), immediate safety outcomes (injury, aspiration concern, prolonged confusion, focal deficit).]

History of Present Illness

Pre-event context

Reported: [Baseline neurologic status and last known normal; activity and posture at onset; sleep status and recent pattern; recent illness or fever; recent medication changes or missed doses; alcohol pattern and last drink; recreational drug use or toxic exposures; pregnancy possibility if applicable.]

Observed: [Pertinent clinician observations at presentation relevant to pre-event context.]

Inferred: [Clinical interpretation linking context to seizure risk or mimics.]

Prodrome/warning symptoms

Reported: [Presence/absence/unknown of seizure-suggestive symptoms (déjà vu, rising epigastric sensation, focal sensory phenomena, sudden fear, automatisms) and syncope-suggestive symptoms (lightheadedness, tunnel vision, nausea, warmth/diaphoresis, palpitations, chest pain).]

Inferred: [Interpretation regarding seizure vs syncope based on reported warnings.]

Ictal description (Prioritize witness/video account; if unavailable, explicitly state limitation.)

Reported: [Onset character (abrupt vs gradual; focal vs generalized vs unknown); motor features (tonic stiffening, clonic jerks, automatisms, atonia); eye/head version or deviation; responsiveness during event; autonomic features (cyanosis, drooling, incontinence); tongue bite (lateral vs tip if known); duration estimate with source (witness count, phone timestamp, video); number of episodes; rescue medications or EMS interventions.]

Observed: [Clinician observations if any episode or residual signs were directly witnessed or recorded.]

Inferred: [Clinical interpretation of semiology and onset classification.]

Postictal course

Reported: [Confusion, agitation, or somnolence and time to baseline; post-event amnesia; focal deficits (Todd's paresis, aphasia, visual changes) and duration; headache or myalgias; injuries (tongue laceration, scalp/facial trauma, shoulder injury); safety events (aspiration, fall, motor vehicle involvement).]

Observed: [Current mental status and behavior; focal deficits; injuries noted on examination.]

Inferred: [Implications for seizure likelihood, localization, and severity.]

Prior events

Reported: [Any prior similar spells; childhood seizures or febrile seizures; prior EEG or brain imaging; prior diagnoses (epilepsy, syncope, arrhythmia, functional/psychogenic seizures).] (If none: "No prior seizures or similar spells reported.")

Observed: [Relevant historical documentation corroborated in records.]

Provoking Factors Screen

• Metabolic derangement (hypoglycemia, hyponatremia, uremia, hepatic failure, hypoxia): [Present / Absent / Unknown] — [Details and supporting evidence]
• Medication/substance related (intoxication, withdrawal, pro-convulsant medications): [Present / Absent / Unknown] — [Details and supporting evidence]
• Structural/vascular (recent head trauma, suspected stroke/hemorrhage, known mass): [Present / Absent / Unknown] — [Details and supporting evidence]
• Infectious/inflammatory (fever, meningismus, encephalopathy): [Present / Absent / Unknown] — [Details and supporting evidence]
• Sleep deprivation: [Present / Absent / Unknown] — [Details]

Provoked/acute symptomatic determination: [If yes, document specific provoker and supporting evidence; if no or indeterminate, state here.]

Background History

• Prior brain insult (stroke, TBI, tumor, neurosurgery): [Yes / No / Unknown] — [Details]
• Family history of epilepsy: [Yes / No / Unknown] — [Details]
• Substance use disorder: [Yes / No / Unknown] — [Details]
• Psychiatric history relevant to functional seizure consideration: [Yes / No / Unknown] — [Details]

Medications and Allergies

• Current medications: [List with dose and last taken] (Highlight antiseizure medications, benzodiazepines, opioids, antidepressants/antipsychotics, stimulants, anticoagulants.)
• Recent medication changes or missed doses: [Details / None reported / Unknown]
• Medications that may lower seizure threshold: [List / None identified]
• Allergies: [List with reaction type / NKDA]

Review of Systems

(Focused review only; include systems that inform the differential.)

• Constitutional (fever, recent illness): [Positive / Negative / Unknown] — [Details]
• Cardiac (palpitations, chest pain, syncope history): [Positive / Negative / Unknown] — [Details]
• Neurologic (new headache, focal symptoms, vision changes): [Positive / Negative / Unknown] — [Details]
• Infectious symptoms: [Positive / Negative / Unknown] — [Details]

Physical Examination

Exam timing: [Time relative to event, e.g., "examined 2 hours post-event"]; Patient status: [at baseline / not at baseline — details]

• Vitals: BP [value], HR [value], RR [value], Temp [value], SpO2 [value] (Include orthostatic vitals if syncope plausible.)
• General/Trauma: [Scalp/facial inspection; tongue exam noting lateral vs tip bite; signs of intoxication or withdrawal]
• Cardiovascular: [Rhythm, murmurs, perfusion]
• Neurologic: [Mental status; cranial nerves; motor and sensory exam; coordination; gait if safe to assess]

Key negatives affecting disposition: Returned to baseline mentation: [Yes / No / Partial]; Persistent focal neurologic deficit: [None / Present — details]

Diagnostic Results

(Include only findings that materially affected decision-making.)

• Point-of-care: Glucose [value]; Pregnancy test [result / not indicated]; Toxicology screen [results / not performed]
• Laboratory: [Pertinent abnormalities and key normals relevant to decisions (sodium, glucose, CBC if infection concern)]
• ECG: Rhythm [description]; QTc [value]; [Ischemic changes / arrhythmia findings / normal] — Interpretation: [summary]
• Neuroimaging: [Study type and timing]; Findings: [key findings]; Limitations: [if any] (If deferred, state rationale.)
• EEG: [Timing relative to event; type (routine / sleep-deprived / continuous); key findings] (If planned: [type and urgency].)

Assessment

Working diagnosis: [Likely epileptic seizure / Possible seizure / Likely mimic] — [Confidence level and reasoning]. (If epileptic seizure: [focal onset / generalized onset / unknown onset]; [motor / non-motor]; [awareness preserved / impaired / unknown].)

Provoked vs unprovoked: [Provoked (acute symptomatic) / Unprovoked / Indeterminate] — [Supporting evidence]

Differential considerations: [Brief discussion of competing diagnoses considered (convulsive syncope, cardiac arrhythmia, functional seizures, metabolic/toxic, other) and evidence for/against.]

Recurrence risk: (Document for unprovoked or indeterminate seizures.) Prior brain insult: [Present / Absent / Unknown]; Epileptiform EEG: [Present / Absent / Pending / Not available]; Significant imaging abnormality: [Present / Absent / Pending / Not available]; Nocturnal seizure: [Yes / No]. Risk assessment: [How findings influenced ASM decision and disposition.]

Plan

Seizure/Spell Evaluation

• Diagnostics: EEG: [type, timing, urgency]; Imaging: [emergent CT / outpatient MRI epilepsy protocol — rationale]; Labs: [targeted studies]; LP: [indicated / not indicated — rationale]
• Treatment: Provoking factors addressed: [details]; ASM decision: [start (drug, dose, rationale) / defer (rationale)]; Rescue medication: [prescribed / not indicated]; Shared decision-making: [discussion documented]
• Disposition: [Admit / Discharge] — [Criteria supporting decision]

Syncope/Cardiac Consideration

(Include if syncope remains in differential.)

• [ECG interpretation]; Telemetry: [indicated / not indicated]; Risk stratification: [summary]; Cardiology: [consult / follow-up / not indicated]

Functional Seizure Consideration

(Include if functional seizures suspected.)

• Video-EEG: [indicated / not indicated]; Psychiatric/psychology referral: [details]; ASM: [avoid unless co-occurring epilepsy confirmed]

Injury Management

(Include if injuries present.)

• [Wound care; trauma imaging; concussion evaluation as applicable]

Safety Counseling

• Driving restriction: [Discussed] — [Local reporting requirements noted; patient driving status/occupation: details]
• Water safety (no unsupervised swimming; shower preferred over bath): [Discussed]
• Heights/machinery avoidance and buddy system: [Discussed]
• Return precautions (recurrent seizure, prolonged seizure >5 min, persistent confusion, new focal deficit, fever): [Discussed]
• Seizure first aid education for family/caregivers: [Discussed]
• Trigger avoidance (sleep hygiene, alcohol moderation, medication adherence): [Discussed]
• Patient/family understanding: [Teach-back completed / Verbalized understanding / Requires reinforcement]

Follow-up

• Neurology: [Timeframe]; [Scheduled / To be scheduled / Established care]
• Primary care: [Timeframe]
• Other referrals: [Cardiology, psychology, other — timeframe]
• Pending results: [Tests pending and responsible party for follow-up; communication plan]
• Activity restrictions: [Work/school/driving restrictions or "None beyond safety counseling above"]

(Meta: For high-stakes elements not obtained—pregnancy status, medication adherence, substance use, anticoagulant use, persistent neurologic deficit—document "Unknown/Not obtained" rather than omitting. Distinguish between confirmed absence and not assessed. Maintain source attribution throughout HPI using Reported/Observed/Inferred labels.)