History and Physical Examination

Jean Aicardi

David C. Taylor

Introduction

Careful and detailed history taking remains the cornerstone of accurate diagnosis of epilepsy,¹³ the prototype of diseases for which the diagnosis rests entirely on clinical grounds and especially on history—the diagnosis is as good as the history.¹⁶ Therefore, history taking and physical examination should be performed in a comprehensive and methodic manner, although flexibility in their practical modalities is an absolute requirement in the examination of children, especially younger ones. The investigation of any disorder should be scaled in proportion to the severity of the problem. Epilepsy has a tremendous impact on patients’ lives, both physically, because it is a threatening and dangerous condition, and psychosocially, because of its chronicity, the fears it generates, and the still-present prejudice against affected persons. Therefore, patients with a suspected diagnosis of epilepsy should be investigated using all means necessary for making a definitive diagnosis, establishing a prognosis, and planning the proper treatment. The necessary investigations vary with the clinical presentation and need not include much in the way of laboratory or other ancillary examinations. However, the process often requires considerable time and is best completed from onset. A succession of fragmentary assessments that may initially seem to save time often results in delaying the diagnosis, sometimes with disastrous consequences, and usually turns out to represent a considerable waste of time.

Taking a history of a paroxysmal disorder demands a proper technique of medical interrogation and a good knowledge of the protean manifestations of the disorder. The aim is to determine as precisely and reliably as possible the objective characteristics and course of a sudden, brief, and unexpected event that has occurred in a highly emotional context and is only partially recalled, often in a biased manner, by both the patient and witnesses. The objective of physical examination is to look for any evidence of an underlying cause, whether limited to the brain or involving other systems as well, as is the case with neurocutaneous disorders, chromosomal abnormalities, and some systemic illnesses.

History Taking

Background

History taking cannot follow strict rules and has to be adapted to each individual case and person. It is often wiser to take advantage of opportunities that may arise during conversation with the person relating the history than to try to maintain a chronologic and logically constructed questioning.

As previously indicated, history should be scaled in detail in proportion to the seriousness of the illness; therefore, it should be meticulously detailed for epilepsy. In some cases, apparently casual details are of tremendous importance.

Although the basic aims of history taking are fundamentally the same, there may be some variation depending on the position of the person taking the history, and the emphasis may not be the same for primary physicians and those in secondary or tertiary care. More importance may variably be given to clearing previous diagnostic confusion, to assessing overall life situation, or to reviewing treatment. History taking is also the first act of the doctor–patient relationship, with long-lasting consequences for the subsequent development of this relationship.

Some physical conditions of the room in which the history is taken are important. Information cannot be properly exchanged in impossible situations. Seating and lighting arrangements should be meant to favor communication, and disturbing factors, such as telephone calls or the repeated entrance of a secretary or colleagues, should not interfere with the exchange. It is essential that patients have the feeling that their personal history is being listened to and given the importance it deserves. This is one of the reasons that sufficient time should be allowed, even for relatively simple cases, and even if the doctor feels that questioning has been thorough. Time is also essential to gather information about fine details, which may constitute valuable cues. It may take a very long time to disentangle the threads of a history and reweave them into a true likeness to the event.¹⁶ Indeed, more than one session is often necessary. An additional advantage is that both patient and doctor can think again about the case and possibly come up with new questions or newly remembered details.

With children, the history is usually obtained mainly from parents or guardians, and such third-party questioning poses special problems. The child’s account, if any can be given, should be particularly facilitated. Older children and adolescents can contribute information on subjective phenomena that are unobtainable from any other source; such information may prove crucial for the diagnosis and be important to the young patients in coming to terms with their illness. One of the difficulties of third-party questioning is the increasing risk for biased and overrehearsed accounts, with the description of the attacks conforming more and more to a preconceived, once-and-forever established idea of what they are like, without the possibility of rectification on the basis of phenomena personally felt by the patient.

Another risk is to give credence to only one parent’s account, usually the mother’s, and ignore the other’s. Listening to both parents, however, might result in contradictory statements. A decision of which account is more credible must be made, which may be in part arbitrary. For these reasons, a fresh history and not a simple repetition of previously given accounts should be obtained at each new consultation. Accepting previous accounts uncritically is a major source of diagnostic errors. Jeavons¹⁰ emphasized the trap represented by a previous
diagnosis of known epilepsy often based on a history that may not have been properly obtained. Such a diagnosis may nonetheless remain accepted for years, thus delaying the true diagnosis. Doctors’ and nurses’ accounts are potentially of great value. In some cases, however, they can also be misleading because professionals often have a tendency to describe attacks as they should theoretically be rather than as they are. Whoever the witnesses, critical scrutiny of their accounts is essential. A distinction should be drawn between first-hand versus second-hand witnesses and between witnesses who have been able to observe the whole of a seizure and those who saw only a part of it. An assessment of the degree of reliability of the witnesses has to be done. It should not be based only on how articulate they are; attempts at checking the veracity of their accounts (e.g., by gathering details that indicate whether they were really in a position to observe some reported phenomena) are important.

The style of history taking depends on individual patients and physicians. With some patients it may be best to listen first to their own account with minimal interference and later ask precise questions about specific points. With others, more directed questioning may be necessary to avoid garrulous, irrelevant, and interpretative accounts. In such cases, it is useful to formulate direct questions about uninterpreted events that are to be answered as yes or no. The meaning of terms has to be made clear and medical terms avoided as much as possible. It is often helpful to offer patients several simple words that are synonymous with medical terms, among which they can choose. Stephenson gave a useful list of such words.¹⁶ Questioning several witnesses may permit some cross-checking of data, and going back to the history to gain more and finer details can clarify some issues.

Obtaining a description of the paroxysmal events is the most important part of history taking, and it requires a high degree of attention and considerable time. The history, however, is not limited to this description. Such events occur in individual persons who react in their own way and in a given setting. Thus, there are two approaches to history taking—obtaining a history of the complaint and obtaining a history of the person.

History of the Complaint

It is often very useful and always recommended to ask for a description of specific attacks. This should especially include the last attack actually witnessed because it is better remembered. The physician should not forget that there may be two or several types of seizures. In such cases, efforts should be made to obtain a description of the most recent seizures of every type.

A description of the first seizure is also of great interest because it not infrequently differs from subsequent attacks. For example, it may have been a febrile convulsion followed by complex partial seizures. In addition, the impact it had on the patient’s life and the way the patient reacted to the first epileptic event can tell much with regard to later adjustment to the illness.

A description of the worst attack is also to be sought. It provides indications about the capacities for adjustment under maximal stress and about the scale of the clinical problem and the risk to life. The circumstances of occurrence, duration, and possible presence of postictal phenomena, such as Todd’s hemiplegia or aphasia, can give valuable clues to lateralization and localization.

The setting in which the attacks occurred may be of considerable significance. Epileptic attacks or nonepileptic paroxysmal events that simulate seizures are often nonrandom phenomena, and the circumstances of occurrence can be important for differential diagnosis and planning of investigations. Points of particular interest include the temporal relation of events to the sleep–waking cycle; for example, was the patient awake or asleep, and, if asleep, did the attack occur at onset of sleep, before or shortly after awakening, or in the middle of the night? In the case of daytime attacks, the following should be determined: Whether the attacks usually occur at a particular time (morning or evening) or apparently at random; the type of activity in which the patient is engaged at the time of seizures (resting, exercising, in bed, at school, playing, in a bath, eating or fasting, standing or reclining, using a computer, watching television or playing a video game, bored, emotionally disturbed, or engaged in a pleasant occupation); and the patient’s general state of health (concomitant or recent febrile or other systemic disease). In the case of a child taking antiepileptic drugs on a long-term basis, the temporal relationship of fits to drug ingestion, the possible failure to take one or several doses, and events such as vomiting or other digestive disturbances that may have interfered with absorption of ingested drugs should all be noted.

A prodrome is a long-term indication of a forthcoming attack. Prodromes (e.g., changes in behavior, such as irritability, sleepiness, feelings of hunger, sweating, hypothermia, distant feeling, and the like) are mostly absent or of secondary importance. Behavioral changes are more often seen before migraine attacks than before epileptic seizures; hunger and hypothermia can suggest hypoglycemia.

The search for a stimulus regularly associated with the occurrence of attacks is of extreme diagnostic interest and consequently should be systematic and thorough. Identification of the regular association of attacks with an immediate stimulus is often of greater value than even a description of the attacks. The significance of the fit may also be better pointed to by the type of stimulus than by the clinical phenomenology of the paroxysm. The regular precipitation of attacks by such stimuli as the sight of blood, blood letting, or injections, prolonged standing in hot or confined places, holding breath, or pain from minor trauma, such as bumping one’s head, is practically diagnostic of “anoxic seizures,”¹⁵ even when the induced attack is difficult or virtually impossible to differentiate from a convulsive generalized epileptic seizure, as in convulsive syncope.⁷^,¹¹ Conversely, such precipitating factors as flashing lights or startle strongly favor a diagnosis of epilepsy after such rare conditions as hyperekplexia have been excluded.³ Certain maneuvers—for example, Valsalva’s maneuver—can induce attacks that are very difficult to distinguish from seizures but are easily recognizable when the initial phenomena are well described.²

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