Adult Patient with a Seizure

History
Physical examination
Exclude

Syncope
Transient ischemic attack
Migraine
Acute psychosis
Other causes of episodic cerebral dysfunction

Syncope
Transient ischemic attack
Migraine
Acute psychosis
Other causes of episodic cerebral dysfunction

Assess: adequacy of antiepileptic therapy

Side effects
Serum levels

Laboratory studies

CBC
Electrolytes, calcium, magnesium
Serum glucose
Liver and renal function tests
Urinalysis
Toxicology screen

Consider

CBC
Electrolytes, calcium, magnesium
Serum glucose
Liver and renal function tests
Urinalysis
Toxicology screen

Treat identifiable metabolic abnormalities
Assess cause of neurologic change

Further work-up

Lumbar puncture
Cultures
Endocrine studies
CT
MRI if focal features present

MRI scan and EEG

Appropriate increase or resumption of dose

Increase antiepileptic therapy to maximum tolerated dose; consider alternative antiepileptic drugs

Treat underlying metabolic abnormality

Focal features of seizures
Focal abnormalities on clinical or lab examination
Other evidence of neurologic dysfunction

Consider: Antiepileptic therapy

Consider: Mass lesion; stroke; CNS infection; trauma; degenerative disease

Idiopathic seizures

Treat underlying disorder

Consider: Antiepileptic therapy

Consider: Antiepileptic therapy

End

Normal

Abnormal or change in neurologic exam

Subtherapeutic antiepileptic levels

Therapeutic antiepileptic levels

Yes

No

History of epilepsy; currently treated with antiepileptics

No history of epilepsy

Positive metabolic screen or symptoms/signs suggesting a metabolic or infectious disorder

Negative metabolic screen