MDM - Seizure (Breakthrough)

[##-year-old male/female] presents with history and exam consistent with breakthrough seizure [likely secondary to non-compliance].

Initial considerations in this patient included seizure with known seizure disorder, syncope, non-compliance with anticonvulsant medication, alcohol withdrawal seizure, seizure secondary to metabolic etiologies including hypoglycemia, hyperglycemia, hyponatremia, hypernatremia, hypocalcemia, hypomagnesemia, hepatic failure, and uremia among others, meningitis, encephalitis, complex migraine, and intracranial processes including hemorrhage among others.

Patient presented with [active/reported] seizure consistent with [focal/generalized tonic-clonic seizure] that resolved [spontaneously/after treatment with benzodiazepine by EMS/upon arrival in ED].  Patient noted to have [no] evidence of significant injury to the head [or cervical spine.]  Syncope felt to be unlikely in this patient due to witnessed convulsions with associated [tongue laceration, urinary/fecal incontinence/postictal period] and known history of seizure disorder.  Patient noted to have no evidence of shoulder dislocations or other significant musculoskeletal injuries.  Patient noted to have a history of seizures for which they are prescribed [specify medication] with [reported/suspected compliance/non-compliance].  Labs obtained in the evaluation of this patient to include [basic/complete metabolic panel, complete blood count, and anticonvulsant drug level (phenytoin, carbamazapine, phenobarbital, valproic acid)], which were [noted to be unremarkable/notable for describe electrolyte abnormality/sub-therapeutic level of anticonvulsant].  Patient felt to have [no] indication for acute neuroimaging based on [unremarkable neurologic exam/absence of significant associated head injury/report of fall/significant associated head trauma/fall and noted to be unremarkable].

Patient given [missed/loading] dose of [specify anticonvulsant] in the ED, and we ensured the patient had refills of prescribed anticonvulsant prior to discharge.  Prior to discharge we discussed return precautions, treatment with continued use of [specify anticonvulsant and avoidance of alcohol/other precipitants], and follow up with primary care provider [and Neurology] for further evaluation in [2-3 days/1-2 weeks], and the patient demonstrated understanding and agreement.

Prior to discharge we counseled the patient that they should not drive or operate machinery until [further discussion with their primary care provider/neurologist/until they have been seizure-free for one year and reported them to the department of motor vehicles (DMV) due to state requirement for mandatory reporting of seizure (California, Delaware, Nevada, New Jersey, Oregon and Utah)], and the patient demonstrated understanding and agreement with this plan.

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