First Unprovoked Seizure Evaluation Note

Date/Time: [Date and time of encounter]

Location: [clinic / ED / inpatient]

Clinician: [Clinician name], [Role]

(If information for a critical element cannot be obtained, explicitly document the reason rather than omitting. Do not assign a definitive seizure type or unprovoked/acute symptomatic classification if required screening was not completed.)

Chief Concern

[One-line referral question or presenting concern]

History of Present Illness

Information Sources

Sources: [Patient / family member / eyewitness / EMS / video footage / outside records] (List all that apply; include names and relationships when relevant. State explicitly if no eyewitness account exists.)

Interpreter: [used / not used] (If used, document language and modality.)

History Reliability: [excellent / good / limited due to postictal state / unable to obtain]

Event Narrative

[Concise narrative of the index event] (Include date and time, setting and activity at onset, who observed, baseline state immediately before, onset characteristics, key observed behaviors, estimated duration and how measured, post-event course including confusion/somnolence and time to baseline, injuries sustained, and how/why the patient presented for care.)

Semiology Details

• Prodrome/Aura: [Description / none / unknown] (Note features suggesting syncope such as lightheadedness, palpitations vs focal seizure features such as déjà vu, epigastric rising, unusual smell.)
• Onset: [sudden / gradual / unknown]; [posture at onset]; [identified triggers / none]
• Ictal Features: [awareness changes]; [gaze or head deviation]; [motor activity: stiffening/jerking/automatisms]; [vocalizations]; [cyanosis]; [lateralizing signs] (Describe phenomenologically without premature labeling.)
• Duration: [Estimated duration and method of estimation]
• Postictal Features: [confusion duration]; [somnolence]; [Todd paresis or focal deficits: present / absent]; [headache]; [myalgias]
• Tongue Bite: [present with location / absent / unknown]
• Incontinence: [present / absent / unknown]
• Injuries: [head strike / lacerations / dental injury / other / none] (Include location and severity.)

Prior Events

[Prior suspicious events] (Explicitly document presence, absence, or unknown for: staring spells, myoclonic jerks, nocturnal events, unexplained fainting/syncope, frequent déjà vu episodes. Include childhood febrile seizures. If unknown, state why history is limited.)

Provoking Factors Assessment

• Recent fever or infection: [present / absent / unknown]
• Hypoglycemia or electrolyte disturbance: [present / absent / unknown]
• Alcohol use pattern and withdrawal window: [details / absent / unknown]
• Illicit substances (especially stimulants): [details / absent / unknown]
• Recent medication changes or missed sedative/benzodiazepine/barbiturate doses: [details / absent / unknown]
• Sleep deprivation: [present / absent / unknown]
• Recent head trauma: [present / absent / unknown]
• Pregnancy or postpartum status: [pregnant / postpartum / not applicable / unknown]
• Recent stroke symptoms or severe headache: [present / absent / unknown]

Provoking Factor Summary: [Clear provoking factor identified / No provoking factor identified / Indeterminate pending data] (Brief rationale.)

Red Flags

• Persistent altered mental status: [present / absent]
• New focal neurologic deficit: [present / absent]
• Fever or meningismus: [present / absent]
• Immunocompromise: [present / absent]
• Anticoagulation with head trauma: [present / absent]
• Severe headache concerning for hemorrhage: [present / absent]
• Pregnancy with concern for eclampsia: [present / absent / not applicable]
• Features of status epilepticus: [present / absent]

Relevant Background

Neurologic History

[Prior stroke / TBI / CNS tumor / CNS infection / demyelinating disease / developmental delay / complex migraine / none] (List with dates and residual deficits if relevant.)

Medical History

[Cardiac disease or arrhythmia risk]; [syncope history]; [diabetes with hypoglycemia risk]; [other relevant conditions]

Psychiatric History

[Panic disorder / PTSD / functional neurologic symptoms / other / none] (Relevant to PNES differential.)

Family History

[Epilepsy]; [sudden cardiac death]; [genetic syndromes]; [none] (Specify relation and age of onset if known.)

Medications

[Current medications] (Note recent starts, stops, or dose changes within 4–6 weeks; include missed doses of benzodiazepines/barbiturates; include OTCs and supplements.)

Substances

Alcohol: [quantity, frequency, last drink]
Other substances: [type(s), last use timing]

Allergies

[Drug allergies and reaction types] (Note relevance to potential antiseizure medication selection.)

Review of Systems

(Focused and brief. Avoid exhaustive negative listings.)

• Neurologic: [headache / focal weakness / visual symptoms / other / none]
• Cardiac: [palpitations / chest pain / exertional symptoms / other / none]
• Infectious: [fever / neck stiffness / other / none]
• Sleep: [deprivation / parasomnias / other / none]

Physical Examination

(Document components actually performed. If any component was not assessed, state this explicitly rather than recording a normal exam.)

• Vitals/General: [Temperature]; [Blood pressure]; [Heart rate]; [Respiratory rate]; [Oxygen saturation]. Evidence of trauma: [scalp hematoma / tongue injury / other / none]
• Mental Status: [orientation]; [attention]; [language]; [behavior]. Postictal state: [present / resolved]
• Neurologic Exam: [cranial nerves]; [motor strength]; [sensory exam]; [reflexes]; [coordination]; [gait]. Focal deficits: [present with description / absent]
• Additional Exam Elements: [meningismus assessment] (Include if fever, altered mental status, or headache present.) [cardiovascular exam]; [orthostatics] (Include if syncope is in the differential.)

Diagnostic Data

Records Reviewed

[External sources reviewed: outside ED notes / EMS run sheets / witness video / prior imaging / other / none]

Laboratory Results

[Relevant labs and key results with interpretation] (Note whether results support or argue against a provoking factor. If no labs obtained, document rationale.)

ECG

[Performed / Not performed]. [Summary of findings or rationale for omission] (ECG is indicated to evaluate for cardiac conditions that can mimic seizure.)

EEG

[ordered / pending / completed]. (If ordered, specify type: [routine / sleep-deprived / ambulatory] and timing target. If completed, summarize findings. A normal EEG does not exclude epilepsy.)

Neuroimaging

[Imaging performed or planned]. (MRI brain with epilepsy protocol preferred for structural evaluation; CT head without contrast appropriate for emergent exclusion of hemorrhage or mass effect. Document modality, urgency, and rationale.)

Assessment

Primary Problem: First suspected seizure or seizure-like event

Diagnostic Impression

[consistent with epileptic seizure / possibly epileptic seizure / unlikely epileptic seizure with mimic more likely] (Provide brief supporting reasoning based on history, exam, and available data.)

Classification

• Provocation status: [unprovoked / likely acute symptomatic due to (provoking factor) / indeterminate pending additional information]
• Seizure onset classification (if supportable): [focal / generalized / unknown onset] (For focal, note awareness status: [aware / impaired awareness / awareness unknown] if determinable.)

Recurrence Risk Factors

• Prior brain insult: [present / absent / pending]
• Epileptiform abnormalities on EEG: [present / absent / pending]
• Significant imaging abnormality: [present / absent / pending]
• Nocturnal seizure: [present / absent / unknown]
• Other modifiers: [details / none]

Differential Diagnosis

(Include only if diagnostic uncertainty exists.)

[Alternative diagnoses under consideration with key discriminating features and planned data to clarify] (Consider: syncope, PNES, migraine, sleep disorder, metabolic/toxic cause.)

Plan

Diagnostic Workup

• EEG: [type and timing target]
• Neuroimaging: [modality and urgency with rationale]
• Additional labs/tests: [tests and rationale / none indicated]

Antiseizure Medication Decision

[start ASM now / defer pending EEG/MRI results / defer unless recurrence] (Document shared decision-making: individualized recurrence risk estimate; that immediate treatment reduces early recurrence but may not change long-term remission; potential side effects discussed; patient preferences; pregnancy considerations if applicable. If starting ASM, list medication, initial dose, titration plan, monitoring, and key counseling points.)

Recurrence Risk Counseling

[Counseling summary] (Typical recurrence risk after a first unprovoked seizure is approximately 21–45% within 2 years, higher with risk factors. Note which risk factors apply to this patient and what pending results may refine the estimate.)

Safety Counseling

• Driving: [Restrictions advised; patient counseled to follow state-specific seizure driving laws]
• Water safety: [Shower rather than bath; supervised swimming only; no solo open-water activities]
• Heights/machinery: [Avoid ladders, roofs, heavy machinery until cleared]
• Home safety: [Cooking precautions; childcare supervision for bathing and high-risk activities]
• Seizure first aid: [Education provided to patient/family / not provided] (Include instructions on documenting future events: video, timing, triggers.)

Follow-up

• Neurology follow-up: [timeline and clinic/contact]
• Results communication: [how and when results will be conveyed]
• Contingency instructions: [Actions if recurrence before follow-up; criteria for emergency evaluation: prolonged seizure >5 minutes, repeated seizures without recovery, new focal deficits, fever, or persistent confusion]