Seizures
Seizures: Excerpt from Field Guide to Bedside Diagnosis
Differential Overview
❑ Generalized (grand mal)
❑ Partial (focal)
❑ Complex partial (temporal lobe)
❑ Absence (petit mal)
❑ Vasovagal syncope
❑ Myoclonic
❑ Akinetic (drop attacks)
❑ Psychomotor
❑ Pseudoseizures
Diagnostic Approach
When the patient is found unresponsive, the differential is seizure versus syncope. Interviewing witnesses is crucial to ascertain the diagnosis. Seizures can be distinguished by color (cyanosis in seizure, pallor in syncope), aura, injury from falling, protracted tonic-clonic activity, tongue biting, urinary incontinence, and slow recovery of consciousness (seizure). Confusion, headache, and drowsiness are sequelae of seizure, whereas physical weakness and a clear sensorium occur with syncope. Seizures often have a promontory aura, such as an odor, and syncope has a prodrome of tunnel vision. Seizures are followed by eye closure, rotation of the head side-to-side, and prolonged, motionless unresponsiveness.
General precipitating factors include sleep deprivation, systemic disease such as renal failure, metabolic/electrolyte disorder such as hypoglycemia or hyponatremia, alcohol use, or drug use. Elicit a history of febrile seizures or prior head trauma. Common causes of recurrent seizures in previously controlled patients include alcohol use, intercurrent infection, and missed medication doses.
A neurological examination will indicate whether there is an underlying structural problem as evidenced by mild hemiparesis, reflex asymmetry, or extensor plantar response. Seizures are more common in slowly growing cerebral lesions, such as low-grade glioma or meningioma.
Clinical Findings
Generalized (grand mal) In a tonic-clonic seizure, apnea, plethora, tongue biting, incontinence, and violent, rhythmic muscular contractions occur. These are followed by postictal lethargy and confusion. Systemic causes include high fever, alcohol or drug withdrawal, hyponatremia, metabolic acidosis, and renal or hepatic failure. Local causes include scar from trauma, neoplasm, or vasculitis of the central nervous system.
Partial (focal) Eye deviation occurs away from the side of a frontal focus. A Jacksonian seizure begins with clonic movement in the thumb or corner of the mouth and spreads to adjacent motor groups. If it is unilateral, the patient is awake.
Complex partial Temporal lobe seizures are most often characterized by auras and loss of awareness of the environment with repetitive behaviors or movements. Auras may be hallucinations (olfactory, gustatory, visual, or auditory), spatial distortions, deja vu or jamais vu, or affective changes (anxiety, rage). Repetitive motor acts typically include lip smacking, undressing, or speaking incoherently. Movements are purposeful but poorly coordinated. The seizures can be sensory, vertiginous, autonomic, dysphasic, deja vu, affective, illusionary (macroscopia or microscopia), or structured hallucinations. In a patient with fever and confusion, herpes simplex encephalitis should be considered.
Absence (petit mal) These seizures are characterized by staring or ceasing ongoing behavior for 5 to 10 seconds while fluttering the eyelids or twitching the face. There may be minor automatisms, such as licking the lips or shuffling the feet. These symptoms may be reproduced by the alkalosis of hyperventilation.
Vasovagal syncope Nonsustained (less than 15 seconds) clonic jerking with loss of consciousness may be seen.
Myoclonic Rhythmic motor jerks occur with cerebral anoxic injury or metabolic encephalopathy.
Akinetic (drop attacks) Marked by loss of postural tone with petit mal activity, these seizures are difficult to distinguish from syncope.
Psychomotor These may cause feelings of fear and rage or disturbing dreams.
Pseudoseizures Atypical motor activity, lack of a postictal state, and secondary gain are common clues. Seizures occur in the presence of an audience. Movements are often exaggerated, there is no tongue biting, and plantar reflexes are normal.
Pictures
Book Source Details
- Book Title: Field Guide to Bedside Diagnosis
- Author(s): David S. Smith
- Year of Publication: 2007
- Copyright Details: Field Guide to Bedside Diagnosis, Copyright © 2007 Lippincott Williams & Wilkins.
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Copyright notice for book excerpts: Copyright © 2008 Lippincott Williams & Wilkins. All rights reserved.
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More About This Book:
Title: Field Guide to Bedside Diagnosis
Authors: David S. Smith
Publisher: Lippincott Williams & Wilkins
Copyright: 2007
ISBN: 0-78178-165-5
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Seizures, generalized tonic-clonic (Alarming Signs and Symptoms: Lippincott Manual of Nursing Practice Series)
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