Symptom Finder - Seizures
Seizures
Suppose a clinician is called to the emergency department to examine a patient who has just had a grand mal seizure. What does he or she look
for? All readers know that a good history is most important in establishing the diagnosis of a seizure disorder, but important steps in the physical
examination are often overlooked.
First of all, the physician wants to determine if the seizure was real. Look for evidence of trauma, lacerations of the tongue, and incontinence.
Also, look for postictal somnolence and hemiparesis (e.g., positive Babinski sign). Next, rule out causes of symptomatic epilepsy. Is there an
unusual odor to the breath (e.g., from alcohol, diabetic acidosis)? Is there a unilateral dilated pupil or papilledema suggesting a space-occupying
lesion, aneurysm, or herniation?
Are there focal neurologic signs such as hemiparesis, cranial nerve palsies, or mental changes suggesting a stroke or space-occupying lesion?
To further evaluate for a stroke, one must check the carotid artery for bruits and listen to the heart for murmurs of arrhythmias. Is there nuchal
rigidity? If so, consider meningitis or a subarachnoid hemorrhage in the differential diagnosis.
Finally, it is necessary to look for skin lesions such as petechiae (suggesting subacute bacterial endocarditis), adenoma sebaceum
(indicating tuberous sclerosis), fibromas (suggesting neurofibromatosis), or a port wine stain of the face (suggesting Sturge–Weber syndrome).
Suppose a clinician is called to the emergency department to examine a patient who has just had a grand mal seizure. What does he or she look
for? All readers know that a good history is most important in establishing the diagnosis of a seizure disorder, but important steps in the physical
examination are often overlooked.
First of all, the physician wants to determine if the seizure was real. Look for evidence of trauma, lacerations of the tongue, and incontinence.
Also, look for postictal somnolence and hemiparesis (e.g., positive Babinski sign). Next, rule out causes of symptomatic epilepsy. Is there an
unusual odor to the breath (e.g., from alcohol, diabetic acidosis)? Is there a unilateral dilated pupil or papilledema suggesting a space-occupying
lesion, aneurysm, or herniation?
Are there focal neurologic signs such as hemiparesis, cranial nerve palsies, or mental changes suggesting a stroke or space-occupying lesion?
To further evaluate for a stroke, one must check the carotid artery for bruits and listen to the heart for murmurs of arrhythmias. Is there nuchal
rigidity? If so, consider meningitis or a subarachnoid hemorrhage in the differential diagnosis.
Finally, it is necessary to look for skin lesions such as petechiae (suggesting subacute bacterial endocarditis), adenoma sebaceum
(indicating tuberous sclerosis), fibromas (suggesting neurofibromatosis), or a port wine stain of the face (suggesting Sturge–Weber syndrome).
