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Diagnostic Tests for Febrile Seizures

Contents
  1. Febrile Seizures: Introduction
  2. Tests for Febrile Seizures
  3. Symptoms of Febrile Seizures
  4. Diagnosis
  5. Home Diagnostic Testing
  6. Alternative Diagnoses
  7. Misdiagnosis
  8. Complications

Febrile Seizures: Diagnostic Tests

The list of diagnostic tests mentioned in various sources as used in the diagnosis of Febrile Seizures includes:

Febrile Seizures Tests: Book Excerpts

Home Diagnostic Testing

These home medical tests may be relevant to Febrile Seizures:

Febrile Seizures Diagnosis: Book Excerpts

Tests and diagnosis discussion for Febrile Seizures:

Doctors sometimes perform tests to be sure that seizures are not caused by something other than simply the fever itself. The majority of children with febrile seizures have rectal temperatures greater than 102 degrees F. Most febrile seizures occur during the first day of a child's fever. (Source: excerpt from NINDS Febrile Seizures Information Page: NINDS)

Diagnostic Tests for Febrile Seizures: Online Medical Books

16 MEDICAL BOOKS ONLINE! Review excerpts from medical books online, free, without registration, for more information about the diagnostic tests for Febrile Seizures.

FEVER, ACUTE: DIAGNOSTIC WORKUP
(Algorithmic Diagnosis of Symptoms and Signs)

Routine studies include a CBC, sedimentation rate, chemistry panel, urinalysis, chest x-rays, VDRL test, and tuberculin skin test. Serial blood cultures should be done on all patients. Febrile agglutinins usually should be done. An ASO titer or streptozyme test should be done to exclude rheumatic fever. RNA, ANA, and DNA tests should be done to look for lupus and other connective tissue disease. An HIV antibody titer may need to be ordered.

The next step is to culture any discharge or various body fluids that might be suspect. Thus, a urinalysis and urine culture should be done. A nose and throat culture should be done. A sputum smear and culture may need to be done. The next consideration is to do various serologic tests. A heterophile antibody titer should be done in teenagers. Febrile agglutinin tests may need to be done. Acute and convalescent phase sera for viral studies may need to be done.

Next one should do skin testing. Thus, histoplasmin, coccidioidin, and blastomycin skin testing should be done on patients with a cough. Trichinella skin testing may need to be done, as well as brucellin skin testing. A Kveim test might need to be done for suspected sarcoidosis.

The next step is to do plain x-rays of suspected areas. For instance, x-rays of the teeth may disclose an abscessed tooth. X-rays of the long bones may disclose a metastatic carcinoma.

The next step is contrast x-ray studies of various organ systems. An intravenous pyelogram may show a hypernephroma. A cholecystogram may show gallstones. An upper GI series and barium enema may show chronic pancreatitis or diverticulitis. Angiography may disclose periarteritis nodosa, aortitis or giant cell arteritis.

The next step is to do a CT scan of the abdomen and pelvis. If this is negative, consider a CT scan of the chest and mediastinum. Echocardiography may disclose valvular vegetations or an atrial myxoma.

Next, consider biopsying various organ systems. For instances, a lymph node biopsy may disclose a lymphoma or sarcoidosis. A muscle biopsy may disclose periarteritis nodosa, polymyositis, or trichinella.

Next one should do bone scans and gallium scans for possible metastasis, osteomyelitis, or localized abscesses.

If all these procedures fail to turn up a lesion, then an exploratory laparotomy may need to be done. A fibrin test may indicate Mediterranean fever, or urine for etiocholanolone may also indicate a relapsing type of fever. A urine test for porphobilinogen may diagnose porphyria.

The wisest move is to conduct this investigation with the help of an infectious disease specialist or a specialist in the body organ system most likely suspected of harboring the infection.

 

» READ BOOK EXCERPT ONLINE »

Source: Algorithmic Diagnosis of Symptoms and Signs, 2003

FEVER, CHRONIC: DIAGNOSTIC WORKUP
(Algorithmic Diagnosis of Symptoms and Signs)

The diagnostic workup is similar to that for acute fever on page 168 .

 

» READ BOOK EXCERPT ONLINE »

Source: Algorithmic Diagnosis of Symptoms and Signs, 2003

CONVULSIONS: DIAGNOSTIC WORKUP
(Algorithmic Diagnosis of Symptoms and Signs)

All patients should receive a CBC, urinalysis, sedimentation rate, ANA, VDRL test, and chemistry panel. Patients with high-risk behavior should have HIV testing. In older patients, a chest x-ray should be done to look for the possibility of a primary lung tumor. A urine drug screen is useful especially in young adults. All patients also need a wake-and-sleep EEG. Ambulatory EEG monitoring can now be done in the hospital or an outpatient setting with a digitrace device. In the elderly, four-vessel angiography or magnetic resonance angiography may be needed to distinguish transient ischemic attacks from epilepsy. There is some argument over whether a CT scan or MRI should be done on all patients with definite convulsions. The author believes that a CT scan should be done on all patients, even those without focal neurologic signs or papilledema. Isotope brain scans, arteriography, and pneumoencephalography are no longer indicated unless something is found on the CT scan that needs further clarification. A spinal tap should also be done when there is fever or when central nervous system lues or multiple sclerosis are suspected. VEPs and BSEPs may also help diagnose multiple sclerosis. It should be noted that seizures occur in 7% of cases with multiple sclerosis. In patients with frequent attacks, a trial of anticonvulsant drugs may be diagnostic.

A consultation with a neurologic specialist can be done at any point in this workup. Certainly, it would be very important to have it done early if there are focal neurologic signs or papilledema.

 

 

» READ BOOK EXCERPT ONLINE »

Source: Algorithmic Diagnosis of Symptoms and Signs, 2003

Fasciculations: History and physical examination
(Handbook of Signs & Symptoms (Third Edition))

If the patient isn’t in severe distress, find out if he has experienced sensory changes, such as paresthesia, or any difficulty speaking, swallowing, breathing, or controlling bowel or bladder function. Ask him if he’s in pain.

Explore the patient’s medical history for neurologic disorders, cancer, and recent infections. Also, ask him about his lifestyle, especially stress at home, on the job, or at school.

Ask the patient about his dietary habits and for a recall of his food and fluid intake in the recent past because electrolyte imbalances may also cause muscle twitching.

Perform a physical examination, looking for fasciculations while the affected muscle is at rest. Observe and test for motor and sensory abnormalities, particularly muscle atrophy and weakness, and decreased deep tendon reflexes. If you note these signs and symptoms, suspect motor neuron disease, and perform a comprehensive neurologic examination.

» READ BOOK EXCERPT ONLINE »

Source: Handbook of Signs & Symptoms (Third Edition), 2006

Fever: History and physical examination
(Handbook of Signs & Symptoms (Third Edition))

If the patient’s fever is only mild to moderate, ask him when it began and how high his temperature reached. Did the fever disappear, only to reappear later? Did he experience other symptoms, such as chills, fatigue, or pain?

Obtain a complete medical history, noting especially immunosuppressive treatments or disorders, infection, trauma, surgery, diagnostic testing, and the use of anesthesia or other medications. Ask about recent travel because certain diseases are endemic.

Let the history findings direct your physical examination. Because a fever can accompany diverse disorders, the examination may range from a brief evaluation of one body system to a comprehensive review of all systems. (SeeHow fever develops.)

» READ BOOK EXCERPT ONLINE »

Source: Handbook of Signs & Symptoms (Third Edition), 2006

Level of consciousness, decreased: History and physical examination
(Handbook of Signs & Symptoms (Third Edition))

Try to obtain history information from the patient, if he’s lucid, and from his family. Did the patient complain of a headache, dizziness, nausea, vision or hearing disturbances, weakness, fatigue, or other problems before his LOC decreased? Has his family noticed changes in the patient’s behavior, personality, memory, or temperament? Also ask about a history of neurologic disease, cancer, or recent trauma or infections; drug and alcohol use; and the development of other signs and symptoms.

Because a decreased LOC can result from a disorder affecting virtually any body system, tailor the remainder of your evaluation according to the patient’s associated symptoms.

» READ BOOK EXCERPT ONLINE »

Source: Handbook of Signs & Symptoms (Third Edition), 2006

Myoclonus: History and physical examination
(Handbook of Signs & Symptoms (Third Edition))

If the patient is stable, evaluate his level of consciousness (LOC) and mental status. Ask about the frequency, severity, location, and circumstances of myoclonus. Has he ever had a seizure? If so, did myoclonus precede it? Is myoclonus ever precipitated by a sensory stimulus? During the physical examination, check for muscle rigidity and wasting, and test deep tendon reflexes.

» READ BOOK EXCERPT ONLINE »

Source: Handbook of Signs & Symptoms (Third Edition), 2006

Seizures, absence: History and physical examination
(Handbook of Signs & Symptoms (Third Edition))

If you suspect a patient is having an absence seizure, evaluate its occurrence and duration by reciting a series of numbers and then asking him to repeat them after the attack ends. If the patient has had an absence seizure, he can’t do this. Alternatively, if the seizures are occurring within minutes of each other, ask the patient to count for about 5 minutes. He’ll stop counting during a seizure and resume when it’s over. Look for accompanying automatisms. Find out if the family has noticed a change in behavior or deteriorating schoolwork.

» READ BOOK EXCERPT ONLINE »

Source: Handbook of Signs & Symptoms (Third Edition), 2006

Seizures, generalized tonic-clonic: History and physical examination
(Handbook of Signs & Symptoms (Third Edition))

If you didn’t witness the seizure, obtain a description from the patient’s companion. Ask when the seizure started and how long it lasted. Did the patient report unusual sensations before the seizure began? Did the seizure start in one area of the body and spread, or did it affect the entire body right away? Did the patient fall on a hard surface? Did his eyes or head turn? Did he turn blue? Did he lose bladder control? Did he have other seizures before recovering?

If the patient may have sustained a head injury, observe him closely for loss of consciousness, unequal or nonreactive pupils, and focal neurologic signs. Does he complain of a headache and muscle soreness? Is he increasingly difficult to arouse when you check on him at 20-minute intervals? Examine his arms, legs, and face (including tongue) for injury, residual paralysis, or limb weakness.

Next, obtain a history. Has the patient ever had generalized or focal seizures before? If so, do they occur frequently? Do other family members also have them? Is the patient receiving drug therapy? Is he compliant? Also, ask about sleep deprivation and emotional or physical stress at the time the seizure occurred.

» READ BOOK EXCERPT ONLINE »

Source: Handbook of Signs & Symptoms (Third Edition), 2006

Seizures, simple partial: History and physical examination
(Handbook of Signs & Symptoms (Third Edition))

Make sure to record the patient’s seizure activity in detail; your data may be critical in locating the lesion in the brain. Does the patient turn his head and eyes? If so, to what side? Where does movement first start? Does it spread? Because a partial seizure may become generalized, you’ll need to watch closely for loss of consciousness, bilateral tonicity and clonicity, cyanosis, tongue biting, and urinary incontinence. (See “Seizures, generalized tonic-clonic,” page 554.)

After the seizure, ask the patient to describe exactly what he remembers, if anything, about the seizure. Check the patient’s LOC, and test for residual deficits (such as weakness in the involved extremity) and sensory disturbances.

Then obtain a history. Ask the patient what happened before the seizure. Can he describe an aura or did he recognize its onset? If so, how — by a smell, a visual disturbance, or a sound or visceral phenomenon such as an unusual sensation in his stomach? How does this seizure compare with others he has had?

Also, explore fully any history — recent or remote — of head trauma. Check for a history of stroke or recent infection, especially with a fever, headache, or stiff neck.

» READ BOOK EXCERPT ONLINE »

Source: Handbook of Signs & Symptoms (Third Edition), 2006

Fasciculations: History and physical examination
(Professional Guide to Signs & Symptoms (Fifth Edition))

If the patient isn’t in severe distress, find out if he has experienced any sensory changes, such as paresthesia, or any difficulty speaking, swallowing, breathing, or controlling bowel or bladder function. Ask him if he’s in pain.

Explore the patient’s medical history for neurologic disorders, cancer, and recent infections. Also, ask him about his lifestyle, especially stress at home, on the job, or at school.

Ask the patient about his dietary habits and for a recall of his food and fluid intake in the recent past because electrolyte imbalances may also cause muscle twitching.

Perform a physical examination, looking for fasciculations while the affected muscle is at rest. Observe and test for motor and sensory abnormalities, particularly muscle atrophy and weakness, and decreased deep tendon reflexes. If you note these signs and symptoms, suspect motor neuron disease, and perform a comprehensive neurologic examination.

» READ BOOK EXCERPT ONLINE »

Source: Professional Guide to Signs & Symptoms (Fifth Edition), 2006

Level of consciousness, decreased: History and physical examination
(Professional Guide to Signs & Symptoms (Fifth Edition))

Try to obtain history information from the patient, if he’s lucid, and from his family. Did the patient complain of headache, dizziness, nausea, visual or hearing disturbances, weakness, fatigue, or any other problems before his LOC decreased? Has his family noticed any changes in the patient’s behavior, personality, memory, or temperament? Also ask about a history of neurologic disease, cancer, or recent trauma or infections; drug and alcohol use; and the development of other signs and symptoms.

Because decreased LOC can result from a disorder affecting virtually any body system, tailor the remainder of your evaluation according to the patient’s associated symptoms.

» READ BOOK EXCERPT ONLINE »

Source: Professional Guide to Signs & Symptoms (Fifth Edition), 2006

Myoclonus: History and physical examination
(Professional Guide to Signs & Symptoms (Fifth Edition))

If the patient is stable, evaluate level of consciousness and mental status. Ask about the frequency, severity, location, and circumstances of the myoclonus. Has he ever had a seizure? If so, did myoclonus precede it? Is the myoclonus ever precipitated by a sensory stimulus? During the physical examination, check for muscle rigidity and wasting, and test deep tendon reflexes.

» READ BOOK EXCERPT ONLINE »

Source: Professional Guide to Signs & Symptoms (Fifth Edition), 2006

Fever [Pyrexia]: History and physical examination
(Professional Guide to Signs & Symptoms (Fifth Edition))

If the patient’s fever is only mild to moderate, ask him when it began and how high his temperature reached. Did the fever disappear, only to reappear later? Did he experience any other symptoms, such as chills, fatigue, or pain?

Obtain a complete medical history, noting especially immunosuppressive treatments or disorders, infection, trauma, surgery, diagnostic testing, and use of anesthesia or other medications. Ask about recent travel because certain diseases are endemic.

Let the history findings direct your physical examination. (See Differential diagnosis: Fever, pages 338 and 339.) Because fever can accompany diverse disorders, the examination may range from a brief evaluation of one body system to a comprehensive review of all systems. (See How fever develops, page 340.)

» READ BOOK EXCERPT ONLINE »

Source: Professional Guide to Signs & Symptoms (Fifth Edition), 2006

Seizures, absence: History and physical examination
(Professional Guide to Signs & Symptoms (Fifth Edition))

If you suspect a patient is having an absence seizure, evaluate its occurrence and duration by reciting a series of numbers and then asking him to repeat them after the attack ends. If the patient has had an absence seizure, he’ll be unable to do this. Alternatively, if the seizures are occurring within minutes of each other, ask the patient to count for about 5 minutes. He’ll stop counting during a seizure and resume when it’s over. Look for accompanying automatisms. Find out if the family has noticed a change in behavior or deteriorating schoolwork.

» READ BOOK EXCERPT ONLINE »

Source: Professional Guide to Signs & Symptoms (Fifth Edition), 2006

Seizures, complex partial: History and physical examination
(Professional Guide to Signs & Symptoms (Fifth Edition))

If you witness a complex partial seizure, never attempt to restrain the patient. Instead, lead him gently to a safe area. (Exception: Don’t approach him if he’s angry or violent.) Calmly encourage him to sit down, and remain with him until he’s fully alert. After the seizure, ask him if he experienced an aura. Record all observations and findings.

» READ BOOK EXCERPT ONLINE »

Source: Professional Guide to Signs & Symptoms (Fifth Edition), 2006

Seizures, generalized tonic-clonic: History and physical examination
(Professional Guide to Signs & Symptoms (Fifth Edition))

If you didn’t witness the seizure, obtain a description from the patient’s companion. Ask when the seizure started and how long it lasted. Did the patient report any unusual sensations before the seizure began? Did the seizure start in one area of the body and spread, or did it affect the entire body right away? Did the patient fall on a hard surface? Did his eyes or head turn? Did he turn blue? Did he lose bladder control? Did he have any other seizures before recovering?

If the patient may have sustained a head injury, observe him closely for loss of consciousness, unequal or nonreactive pupils, and focal neurologic signs. Does he complain of headache and muscle soreness? Is he increasingly difficult to arouse when you check on him at 20-minute intervals? Examine his arms, legs, and face (including tongue) for injury, residual paralysis, or limb weakness.

Next, obtain a history. Has the patient ever had generalized or focal seizures before? If so, do they occur frequently? Do other family members also have them? Is the patient receiving drug therapy? Is he compliant? Ask about sleep deprivation and emotional or physical stress at the time the seizure occurred.

» READ BOOK EXCERPT ONLINE »

Source: Professional Guide to Signs & Symptoms (Fifth Edition), 2006

Seizures, simple partial: History and physical examination
(Professional Guide to Signs & Symptoms (Fifth Edition))

Be sure to record the patient’s seizure activity in detail; your data may be critical in locating the lesion in the brain. Does the patient turn his head and eyes? If so, to what side? Where does movement first start? Does it spread? Because a partial seizure may become generalized, you’ll need to watch closely for loss of consciousness, bilateral tonicity and clonicity, cyanosis, tongue biting, and urinary incontinence. (See “Seizures, generalized tonic-clonic,” page 708.)

After the seizure, ask the patient to describe exactly what he remembers, if anything, about the seizure. Check the patient’s LOC, and test for residual deficits (such as weakness in the involved extremity) and sensory disturbances.

Then obtain a history. Ask the patient what happened before the seizure. Can he describe an aura or did he recognize its onset? If so, how—by a smell, a visual disturbance, or a sound or visceral phenomenon, such as an unusual sensation in his stomach? How does this seizure compare with others he has had?

Explore fully any history, recent or remote, of head trauma. Check for a history of stroke or recent infection, especially with fever, headache, or a stiff neck.

» READ BOOK EXCERPT ONLINE »

Source: Professional Guide to Signs & Symptoms (Fifth Edition), 2006

Fever: Physical examination
(The 10-Minute Diagnosis Manual: Symptoms and Signs in the Time-Limited Encounter)

A. The examination should include the skin, lymph nodes, eyes, nail beds, heart, lungs, abdomen, joints, nervous system, and genitourinary system, including rectal and bimanual pelvic examinations.

B. Infections will increase the pulse rate approximately 10 beats per minute for each 0.5°C (1.0°F) temperature increase.

C. When fever is present, the respiratory rate will frequently increase above the usual 12 to 14 breaths per minute.

D. Infections with Mycoplasma pneumonia, psittacosis, and typhoid fever are often associated with a relative bradycardia.

Testing.

 In cases of a fever in which the cause is unclear, a number of diagnostic tests may be useful, depending on history and physical examination. These include:

 A. Urinalysis with microscopic examination

B. Blood cultures, both aerobic and anaerobic

C. Blood tests: human immunodeficiency virus (HIV), rapid plasma reagent (RPR), antistreptolysin-O (ASO) titer, rheumatoid arthritis (RA) factor, antinuclear antibody (ANA), sedimentation rate, and serum enzymes and chemistries

D. Tuberculosis (TB) skin test

E. Spinal fluid examination

F. Diagnostic imaging: chest film, abdominal ultrasound, abdominal computed tomography (CT), bone scan

G. Biopsies: liver, bone marrow, lymph node, skin, muscle, temporal artery

Diagnostic assessment.

The approach to the febrile patient involves a number of considerations, including the patient’s age, clinical history, risk factors, community illness pattern, and physical presentation. In the family physician’s office, most febrile illnesses are the result of self-limited viral illnesses (e.g., upper respiratory infections). A number of cases of fever will be caused by bacterial infections (e.g., streptococcal pharyngitis or urinary tract infections). The challenge is to select those studies with the highest sensitivity and specificity to increase the probability of a correct diagnosis. When the diagnosis continues to be elusive, repeat the history and the physical examination. Special considerations in specific populations and certain types of fever include:

A. The elderly: 10% of elderly patients will fail to generate a febrile response with pneumonia (1). Fever in the elderly is more likely to indicate a bacterial infection than a fever in younger adults (2).

B. Fever of unknown origin (FUO). An FUO is characterized by the first three criteria listed below:

1. A temperature greater than 38.3°C (101.0°F) on several occasions

2. A duration of 3 weeks

3. Unclear cause after a full physical examination, routine blood tests, cultures, and chest x-ray studies

4. The cause of FUOs will be determined 90% of the time; it will often be a common illness that presents in an unusual manner.

5. Two leading causes of FUO are tuberculosis and infective endocarditis.

6. Other causes include hepatic or subphrenic abscess, neoplasm, and lymphomas such as Hodgkin’s disease.

C. Factitious fever. Factitious fever is a consideration in a patient with a complex emotional disorder. The absence of a normal diurnal pattern, pulse elevation, and diaphoresis may suggest a diagnosis of factitious fever.

D. Drug fever. Drugs are an important cause of noninfectious fever (3).

1. This is a diagnosis of exclusion and requires the fever to coincide with the prescribing of the drug and the resolution of the fever on discontinuing the medication.

2. Drug-associated fevers can be high and take several days to resolve.

3. Among the medications causing a fever are diphenylhydantoin, carbamazepine, histamine-2 (H2) blockers, methyldopa, allopurinol, sulfonamides, cephalosporins, and isoniazid.

E. Postoperative fever. The temporal relationship of the fever to the surgery may provide a clue to the primary source of the infection (4).

1. If fever duration is less than 48 hours, consider atelectasis of the lung.

 2. If duration is more than 3 days, consider urinary tract infection or infected intravascular device.

 3. If fever has been present more than 5 days, consider wound infection, intraabdominal abscess, or empyema.

 F. Hyperthermia. A disruption of thermoregulation can result from excessive heat production, inadequate heat dissipation, or hypothalamus malfunction (5).


References

1. Harper C, Newton P. Clinical aspects of pneumonia in the elderly veterans. J Am Geriatr Soc 1989;37:867–872.

2. Mellors JW, Horwitz RI, Harvey MR, et al. A simple index to identify occult bacterial infection in adults with unexplained fever. Arch Intern Med 1987;147:666–671.

3. Mackowiak PA, ed. Fever: basic mechanisms and management. New York: Raven Press, 1991:239.

4. Mackowiak PA, ed. Fever: basic mechanisms and management. New York: Raven Press, 1991:245.

5. Simon HB. Hyperthermia. N Engl J Med 1993;329(7):483–487.

» READ BOOK EXCERPT ONLINE »

Source: The 10-Minute Diagnosis Manual: Symptoms and Signs in the Time-Limited Encounter, 2000

Seizures: Physical examination (PE)
(The 10-Minute Diagnosis Manual: Symptoms and Signs in the Time-Limited Encounter)

A. Focused neurologic examination. Examine level of consciousness, pupils, fundi, cranial nerves, reflexes, gait, muscle strength, general sensory, coordination, and Romberg’s sign (4). Look for abnormal motor activity and test for abnormal reflexes.

B. Additional PE

 1. Look for signs of systemic illness: cardiac disease (cyanosis, pallor, irregular rhythm, cool extremities) and chronic alcoholism (ascites, jaundice, caput medusae, and bruising).

 2. Look for residual signs of trauma or limb asymmetry.

3. Look for dysmorphic manifestations of heritable disease: vascular malformations (Sturge–Weber), adenoma sebaceum (tuberous sclerosis), or café au lait spots and subcutaneous nodules (neurofibromatosis).

4. Gingival hypertrophy suggests phenytoin therapy.

Testing

A. Clinical laboratory tests. Choice of tests is dictated by the patient’s age, history, physical findings, and type of seizure.

1. In evaluating a child, consider a random glucose, calcium, magnesium, electrolytes, and, possibly, a lead level and an electroencephalogram (EEG). In a child aged less than 5 years with one or two short generalized seizures associated with fever, no neurologic abnormality, and normal bloodwork, no imaging study is generally necessary (5).

2. In adults, obtain glucose, sodium, calcium, and consider thyroid function tests, heavy metal screen, and porphyrins.

3. Obtain a lumbar puncture when acute or chronic infection of subdural is suspected.

4. An abnormal EEG supports the diagnosis of seizure and hints at the cause and classification. A normal EEG does not exclude seizure.

B. Diagnostic imaging

1. In newborns, ultrasound or computerized tomography (CT) imaging may reveal intracerebral hemorrhage or structural abnormality.

2. Adolescents and adults should have a magnetic resonance imaging scan (or CT) to rule out focal and structural lesions.

C. Special studies include prolonged closed-circuit video EEG to distinguish psychogenic seizures or in a patient with continuing seizures and multiple normal EEGs.

Diagnostic assessment.

The key to diagnosis is the history and neurologic examination. A history with a focal component indicates a high likelihood of structural pathology. A recent febrile illness with seizure, headache, change in mental status, or confusion suggests acute CNS infection. A history of headache or change in mental function with seizure and abnormal neurologic examination suggests mass lesion. A clear, focal onset of the event (staring or head turning) may aid in distinguishing seizure from syncope. Emotional lability and a history of psychiatric treatment in a patient whose neurologic workup is negative may suggest a diagnosis of pseudoseizures. A pregnant patient near term who seizes may have pregnancy-induced hypertension or declining drug levels.


References

1. Dichter MA. The epilepsies and convulsive disorders. In: Braunwald E, Fauci AS, Isselbacher DL, et al., ed. Harrison’s principles of internal medicine, 13th ed. New York: McGraw-Hill, 1995:2223.

2. Bradford JC, Kyriakedes CG. Evaluation of the patient with seizures: an evidence based approach. Emerg Med Clin North Am 1999;17(1):203–220, ix–x.

3. Hauser WA. Seizure disorders: the changes with age. Epilepsia 1992;33(4):S6–S14.

4. Roth HL, Drislane FW. Seizures. Neurol Clin 1998;16:257–284.

5. Berg, AT, Shinnar S. The risk of seizure occurrence following a first unprovoked seizure: a quantitative review. Neurology 1991;41:965–972.

» READ BOOK EXCERPT ONLINE »

Source: The 10-Minute Diagnosis Manual: Symptoms and Signs in the Time-Limited Encounter, 2000

Rash Accompanied by Fever: Physical examination
(The 10-Minute Diagnosis Manual: Symptoms and Signs in the Time-Limited Encounter)

A. Examine the lesions and their distribution carefully. Classify the rash as petechial, maculopapular, vesiculobullous, erythematous, or urticarial. Note the distribution of the rash. For instance, rubella and rubeola generally begin on the face and spread to the trunk, whereas RMSF petechiae tend to occur on the ankles and wrists first.

 B. Conduct a general physical examination. Areas of particular concern are:

 1. Head, eyes, ears, nose, and throat. The presence of Koplik’s spots is pathognomic for rubeola. The discovery of a tick lends support to the diagnosis of RMSF. Sinusitis may represent a source for meningococcemia. Pharyngitis in a young adult with diffuse erythema may be caused by C. haemolyticum. Mucous membrane swelling may indicate early anaphylaxis.

 2. Lung examination. Expiratory wheezing, especially in a patient who has recently received medications or contrast dye, can indicate anaphylaxis. Evidence of pneumonia is consistent with psittacosis and mycoplasma.

 3. Cardiac examination. Cardiovascular collapse is associated with meningococcemia and other sepsis. A new murmur (Chapters 7.6 and 7.7) may indicate subacute bacterial endocarditis in a patient with subungual or scleral petechiae.

 4. Genital examination. Purulent urethral drainage or evidence of pelvic inflammatory disease supports consideration of gonorrhea. A chancre would support a diagnosis of syphilis, although palmar lesions often occur well after healing of the initial chancre.

 5. Joint examination and extremities. A petechial rash near the ankles and wrists is suggestive of RMSF. Evidence of joint swelling supports a diagnosis of meningococcemia or gonococcemia. A maculopapular rash may be seen in juvenile rheumatoid arthritis and other rheumatologic conditions as well.

6. Neurologic examination. Evidence of meningitis supports a diagnosis of meningococcemia. Patients with RMSF may also have meningeal signs.

Testing

 should be directed by illnesses suspected, with life-threatening illnesses being tested for on reasonable suspicion. A complete blood count is generally useful, although life-threatening sepsis often presents without significant elevation of white blood count. In general, a blood culture should be obtained in all patients with petechial rashes and in those with signs of cardiovascular collapse.

Diagnostic assessment

Based on history and physical examination, the likelihood of various illnesses can be assessed. Patients who appear toxic should be treated as septic until initial laboratory and culture results can be evaluated (4).


References

1. Schlossberg D. Fever and rash. Infect Dis Clin North Am 1996;10(1):101–110.

2. Drolet BA, Baselga E, Esterly NB. Painful, purpuric plaques in a child with fever. Arch Dermatol 1997;133(12):1500–1501.

3. Anonymous. Fever, nausea, and rash in a 37-year-old man [clinical conference]. Am J Med 1998;104(6):596–601.

4. Dellinger RP. Current therapy for sepsis. Infect Dis Clin North Am 1999;13(2):
495–509.

» READ BOOK EXCERPT ONLINE »

Source: The 10-Minute Diagnosis Manual: Symptoms and Signs in the Time-Limited Encounter, 2000

Seizures: Diagnostic Approach
(Field Guide to Bedside Diagnosis)

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.

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Source: Field Guide to Bedside Diagnosis, 2007

Fever of Unknown Origin: Diagnostic Approach
(Field Guide to Bedside Diagnosis)

Fever of unknown origin (FUO), when a fever over 101°F (38.5°C) remains unexplained for longer than 3 weeks, is usually a result of infection (40%), neoplasm (20%), or collagen-vascular disease (20%). It is most commonly caused by an atypical presentation of a common disease. Always document the fever before pursuing the evaluation.

Consider relatively hidden (deep) sites: retroperitoneum (hematoma or infection), bone, dental, sinus, ovary, prostate, subphrenic (following abdominal surgery), renal, spleen, or prostheses. With FUO in a hospitalized patient, consider sequestered sites (e.g., sinuses in intubated patients or implanted hardware), indwelling lines, C. difficile, or drug reactions. With FUO in a neutropenic patient, consider catheters, perianal infections, Candida, and Aspergillus. Cardinal signs may be absent, e.g., meningitis with opportunistic pathogens without meningismus in 63%, and pneumonia without purulent sputum in 92%. Neutropenic fevers are usually due to bacteremia, with fungal organisms becoming predominant after 7 days of unremitting fever. Fever may also be due to the underlying neoplasm, drugs such as antibiotics, or blood products.

Examine for subtle clues:

• Petechial eruptions in meningococcemia and Rocky Mountain Spotted Fever

• Pustular lesions in gonococcemia or staphylococcal sepsis

• Ecthyma gangrenosum in Pseudomonas sepsis

• Splinter hemorrhages, conjunctival hemorrhages, Roth spots, Osler nodes, and Janeway lesions in endocarditis

• Choroidal tubercles in miliary tuberculosis and candidemia

• Splenomegaly in endocarditis, lymphoma, and cirrhosis

• Hepatic bruit or friction rub in subphrenic abscess

• Temporal artery or scalp tenderness or jaw claudication in giant cell arteritis

• Epitrochlear lymphadenopathy in syphilis

Extreme elevations of fever (.40°C) are found in heat stroke, hypothalamic dysfunction, meningitis, midbrain hemorrhage, falciparum malaria, Rocky Mountain Spotted Fever, typhus, sepsis, malignant hyperthermia, and hypernephroma.

Relative bradycardia occurs in salmonellosis (typhoid fever), meningitis with increased intracranial pressure, mycoplasma and legionella pneumonia, factitious fever, tularemia, brucellosis, mumps, hepatitis, and with concomitant beta blockers. Bradycardia in fever may also signal cardiac conduction abnormalities in acute rheumatic fever, Lyme disease, viral myocarditis, or endocarditis with valve ring abscess.

Relapsing fevers (days of fever alternating with days without) occur in brucellosis (fever with physical activity), Hodgkin disease, extrapulmonary tuberculosis, malaria, and Lyme disease. Hectic fever (difference between peak and trough .1.5°C) suggests abscess, pyelonephritis, ascending cholangitis, tuberculosis, lymphoma, and drug reactions. Absence of diurnal variation suggests a central source. Reversal of the diurnal pattern (“typhus inversus”) occurs with disseminated tuberculosis, typhoid fever, polyarteritis nodosa, and salicylate toxicity.

FUO in patients from the developing world include tuberculosis, typhoid, amebic liver abscesses, AIDS, and geographically restricted infections such as malaria, schistosomiasis, brucellosis, kala azar, filariasis, or Lassa fever. They may present after long incubation or latency periods.

When FUO lasts longer than 6 months, consider factitious fever, granulomatous hepatitis, neoplasm, Still disease, infection, collagen-vascular disease, or exaggerated circadian rhythm.

Patients who remain undiagnosed have a good prognosis (83% resolution in 1 year, 4% mortality).

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Source: Field Guide to Bedside Diagnosis, 2007

Fever: Physical assessment
(Signs & Symptoms: A 2-in-1 Reference for Nurses)

Begin by taking your patient’s vital signs. Let the history findings direct your physical examination. Because fever can accompany diverse disorders, the examination may range from a brief evaluation of one body system to a comprehensive review of all systems. (See Taking an accurate temperature.)

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Source: Signs & Symptoms: A 2-in-1 Reference for Nurses, 2007

Level of consciousness, decreased: Physical assessment
(Signs & Symptoms: A 2-in-1 Reference for Nurses)

Decreased LOC can result from a disorder affecting virtually any body system. After performing a complete neurologic examination, let the results of your history guide the rest of your physical assessment.

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Source: Signs & Symptoms: A 2-in-1 Reference for Nurses, 2007

Myoclonus: Physical assessment
(Signs & Symptoms: A 2-in-1 Reference for Nurses)

Check for muscle rigidity and wasting, and test deep tendon reflexes. Then complete the neurologic and musculoskeletal assessments.

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Source: Signs & Symptoms: A 2-in-1 Reference for Nurses, 2007

Seizures, complex partial: Physical assessment
(Signs & Symptoms: A 2-in-1 Reference for Nurses)

If the patient has had a seizure, examine him for injury. Make sure he has a patent airway, and then perform a complete neurologic assessment.

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Source: Signs & Symptoms: A 2-in-1 Reference for Nurses, 2007

Seizures, generalized tonic-clonic: Physical assessment
(Signs & Symptoms: A 2-in-1 Reference for Nurses)

If the patient may have sustained a head injury, observe him closely for loss of consciousness, unequal or nonreactive pupils, and focal neurologic signs. Examine his arms, legs, and face (including tongue) for injury, residual paralysis, or limb weakness. If you haven’t already done so, take the patient’s vital signs. Then complete your neurologic assessment.

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Source: Signs & Symptoms: A 2-in-1 Reference for Nurses, 2007

Seizures, simple partial: Physical assessment
(Signs & Symptoms: A 2-in-1 Reference for Nurses)

Take your patient’s vital signs. Perform a complete physical assessment, focusing on the neurologic assessment. Check the patient’s LOC, and test for residual deficits (such as weakness in the involved extremity) and sensory disturbances.

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Source: Signs & Symptoms: A 2-in-1 Reference for Nurses, 2007

Fever: Diagnostic Approach: Acute Fever
(The Diagnostic Approach to Symptoms and Signs in Pediatrics)

  • Most acutefevers are caused by infection, usually viral or bacterial.
  • Common infections should be consideredbefore less common ones, unless clinical findings suggest otherwise.
  • Best guide to accurate diagnosis ishistory and physical exam.

    • Clinical Findings

  • Age of child,height of fever, compromised host defenses, and associated findings (e.g.,rash, painful extremity, abdominal pain, jaundice, generalized lymphadenopathy,hepatomegaly, or splenomegaly) are important factors in diagnosisof any child who presents with fever.
  • Important historical information includesany history of contact with other ill individuals, foreign travel,previous immunizations, drug exposure, history of pica, and exposureto animals or birds.

  • History of pica suggests toxoplasmosis or toxocariasis(visceral larva migrans).
  • History of tick exposure suggests RockyMountain spotted fever, relapsing fever, or Lyme disease.
  • History of exposure to animals or birdssuggests diseases caused by rats (plague, rat-bite fever, leptospirosis);hamsters (lymphocytic choriomeningitis encephalitis); rabbits (tularemia);cattle, goats, and dogs (brucellosis); cats (cat scratch disease,toxoplasmosis); and birds (psittacosis).

    • Age

  • Risk ofserious bacterial illness (e.g., septicemia and meningitis) varieswith age and is greatest during immediate neonatal period, especiallyin premature infants.
  • Clinical findings may be nonspecific,including poor feeding, decreased activity, fever, or hypothermia.
  • In such infants, CBC with differentialand blood, urine, and spinal fluid cultures should be performed.
  • Gram-stained smear of spinal fluidshould be performed and antigen studies considered.
  • Chest radiograph should be performedwith history of respiratory symptoms.
  • Stool culture should be performed withhistory of diarrhea.

    • Height of Fever

  • In infants,incidence of serious bacterial infection is higher in those withrectal temperature >41°C compared with those withlower temperature.
  • Preschool and school-aged childrenoften have high fever that persists for several days and is notassociated with localizing findings. Such children do not appearvery ill and usually have self-limited viral infections.
  • Continued observation with close follow-upusually clarifies many of these problems.
  • Whatever the height of fever, assessmentof toxicity and level of functioning is crucial in diagnosis andmanagement.

    • Compromised Host Defenses

    Children with impaired host defenses dueto primary or secondary immunodeficiency disorders are at risk fordevelopment of serious infection caused by wide range of infectiveagents, including bacteria (S. aureus, gram-negative enteric organisms),viruses (cytomegalovirus, VZV), protozoa (P. carinii), and fungi(Candida and Aspergillus species).

    Associated Physical Findings

    Fever and Rash

  • Macularor papular rashes occur with viral infection (enteroviruses, herpesvirus6, measles virus, rubella virus, parvovirus B19, Epstein-Barr virus),bacterial infection (scarlet fever, meningococcemia, toxic shocksyndrome, typhoid fever, rat bite fever, leptospirosis), rickettsialinfection (Rocky Mountain spotted fever), Kawasaki disease, anddrug reactions (most commonly penicillins and sulfonamides).
  • Erythematous rashes occur with viralinfection (parvovirus B19), bacterial infection (scarlet fever,toxic shock syndrome, staphylococcal scalded skin syndrome), Kawasakidisease, and reactions to same drugs causing macular or papularrashes.
  • Petechial and purpuric rashes occurwith congenital viral infection (rubella virus, cytomegalovirus),other viral infection (enteroviruses, Epstein-Barr virus, arboviruses),bacterial infection (group A Streptococcus, N. meningitidis, S.pneumoniae, N. gonorrhoeae, S. aureus, H. influenzae type b, P. aeruginosaand other gram-negative enteric bacteria), rickettsial infection(Rocky Mountain spotted fever), and parasitic infection (toxoplasmosis).
  • Vesicular rashes occur with viral infection(herpes simplex virus, varicella-virus infection, enteroviruses)and bacterial infection (bullous impetigo, staphylococcal scaldedskin syndrome).
  • See Chap.60, Skin Lesions and Rashes.

    • Fever and Painful Extremity

  • Infectiousor inflammatory causes

  • Cellulitis
  • Septic arthritis
  • Osteomyelitis
  • Transient synovitis
  • Skin/soft tissue abscess
  • Thrombophlebitis
  • Acute rheumatic fever
  • Vaccine immunization
  • Other causes

  • Neoplasia (leukemia, osteogenic sarcoma,Ewing sarcoma, metastatic neuroblastoma)
  • Collagen vascular disease (juvenilerheumatoid arthritis, systemic lupus erythematosus)
  • Kawasaki disease
  • Serum sickness
  • Arthritis associated with inflammatorybowel disease
  • See Chap.37, Limp.

    • Fever and Abdominal Pain

  • Infectiousand inflammatory causes

  • Nonspecific viral illness
  • Gastroenteritis
  • Urinary tract infection
  • Pneumonia
  • Appendicitis
  • Intraabdominal abscess
  • Hepatitis
  • Peritonitis
  • Cholecystitis
  • Cholangitis
  • IBD
  • Pelvic inflammatory disease
  • Pancreatitis
  • Generalized vasculitis
  • Other causes

  • Neoplasia (leukemia, Hodgkin disease,non-Hodgkin lymphoma, neuroblastoma, hepatic malignancies)
  • Diabetic ketoacidosis
  • Black widow spider bite
  • See Chap.2, Abdominal Pain.

    • Fever and Jaundice

  • Most commoncause of fever and unconjugated hyperbilirubinemia in neonates is septicemia.Causes of fever and conjugated hyperbilirubinemia in neonates include

  • Viral infection(rubella virus, cytomegalovirus, herpes simplex virus, VZV, enteroviruses,hepatitis B virus)
  • Bacterial infection (septicemia, syphilis)
  • In infancy and childhood, fever andconjugated hyperbilirubinemia may be due to

  • Viral infection (hepatitis A, B, C,D, E; enteroviruses; herpes simplex virus; Epstein-Barr virus; cytomegalovirus
  • Bacterial infection (septicemia, cholecystitis,cholangitis, liver abscess, leptospirosis, brucellosis)
  • Rickettsial infection (Q fever)
  • Fungal infection (histoplasmosis)
  • Parasitic infection (amebiasis, malaria,visceral larval migrans)
  • Drug reactions
  • Neoplasia (hepatic malignancies, non-Hodgkinlymphoma)
  • See Chap.36, Jaundice.

    • Fever and Generalized Lymphadenopathy

  • Infectiouscauses

  • Viralinfection (rubella virus, measles virus, Epstein-Barr virus, cytomegalovirus, VZV,hepatitis A virus, HIV)
  • Bacterial infection (pyogenic infectionfrom S. aureus, group A Streptococcus, H. influenzae type b, S.pneumoniae; tuberculosis; brucellosis; tularemia; salmonellosis;leptospirosis; syphilis)
  • Fungal infection (histoplasmosis)
  • Parasitic infection (toxoplasmosis,malaria)
  • Noninfectious causes

  • Neoplasia(leukemia, non-Hodgkin lymphoma, metastatic neuroblastoma)
  • Langerhans histiocytosis
  • Collagen vascular disease (juvenilerheumatoid arthritis, systemic lupus erythematosus)
  • Drug reactions
  • Serum sickness
  • Chronic granulomatous disease
  • Sarcoidosis
  • See Chap.38, Lymphadenopathy.

    • Fever with Hepatomegaly, Splenomegaly, or Hepatosplenomegaly

  • Causes offever and hepatomegaly

  • Hepatitis (A, B, C, D, E)
  • Primary liver abscess
  • Amebiasis
  • Primary liver malignancies
  • Causes of fever and splenomegaly

  • Viral infection(rubella virus, cytomegalovirus, herpes simplex virus, enteroviruses, Epstein-Barrvirus)
  • Bacterial infection (septicemia, endocarditis,tularemia, plague, salmonellosis, splenic abscess)
  • Rickettsial infection (Rocky Mountainspotted fever)
  • Parasitic infection (malaria, toxoplasmosis)
  • Infectious causes of fever and hepatosplenomegaly

  • Viral infection(rubella virus; herpes simplex virus; cytomegalovirus; VZV; enteroviruses;Epstein-Barr virus; hepatitis A, B, C, D, E)
  • Bacterial infection (septicemia, endocarditis,brucellosis, tuberculosis, syphilis, leptospirosis, relapsing fever)
  • Fungal infection (histoplasmosis, coccidioidomycosis)
  • Parasitic infection (visceral larvalmigrans, toxoplasmosis, Chagas disease)
  • Other causes of fever and hepatosplenomegaly

  • Neoplasia(leukemia, Hodgkin disease, non-Hodgkin lymphoma, neuroblastoma)
  • Langerhans histiocytosis
  • Collagen vascular disease (juvenilerheumatoid arthritis, systemic lupus erythematosus)
  • See Chap.30, Hepatomegaly and Chap. 62, Splenomegaly.

    • Fever without Localizing Signs

  • Most childrenwith fever and no apparent focus of infection have self-limitedviral infection that resolves without treatment and has no sequelae.
  • Small percentage of children with acuteonset of fever ≥39°C and no localizing signs, especiallyat 3–36 mos, may have urinary tract infection, bacteremia,or meningitis.
  • In infants <1 mo of age, commoncauses of septicemia and meningitis are group B Streptococcus andgram-negative enteric bacteria, commonly E. coli. Much less commonis infection with L. monocytogenes.
  • At 1–3 mos of age, most commoncauses of septicemia and meningitis are S. pneumoniae, group B Streptococcus,and N. meningitidis.
  • In children >3 mos of age,S. pneumoniae, N. meningitidis, and Salmonella species (usually occurringwith gastroenteritis) cause most bacterial infections that occurwithout a focus.
  • Diagnostic and management approachto child with fever without apparent focus of infection dependson age, exposure history, usual pathogens, and severity of illness.
  • See references at end of chapter forfurther information.

    • Lab Findings

  • Lab tests(cultures and radiographs most commonly) are used to confirm diagnostic impressionof infection.
  • WBC and differential may suggest bacterialor viral infection, but they are not diagnostic. WBC count >20,000/mm3 withpredominance of neutrophils (>70%) or <5,000/mm3 withlarge number of band forms (>5%–10%)suggests bacterial infection. Although similar WBC counts sometimeoccur with viral infections, in such cases there is usually predominanceof lymphocytes and few band forms.
    • >>

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    Source: The Diagnostic Approach to Symptoms and Signs in Pediatrics, 2006

    Seizures: Diagnostic Approach
    (The Diagnostic Approach to Symptoms and Signs in Pediatrics)

    Neonatal Seizures

    Phenomena That May Be Confused with Seizures

    Determining whether a seizure has occurredmay be difficult in some neonates. Seizures may consist of clonicmovements, tonic posturing of extremity, repetitive random or suckingmovements, or eye deviation. Recurrent apnea also may occur as amanifestation of a seizure disorder, but it is rarely the only manifestation.Jitteriness and benign myoclonic phenomena must be distinguishedfrom seizures.

    Jitteriness

    Jitteriness is stimulus sensitive and hasa tremulous quality. It ceases when extremity is held.

    Benign Neonatal Sleep Myoclonus

  • Occurs duringdrowsiness and sleep but not during wakefulness.
  • Consists of isolated jerking movementsof arm or leg.
  • Pathologic myoclonic jerks in newbornsare not related to sleep; face and trunk may be involved, and EEGis abnormal.

    • Evaluation

  • Historyand physical exam suggest most likely causes of neonatal seizures.
  • Certain tests should be performed initially:CBC with differential; blood glucose and urea nitrogen; and serumelectrolytes, creatinine, calcium, phosphorus, and magnesium.
  • If meningitis or septicemia is suspected,spinal fluid analysis with appropriate cultures, blood culture,UA, and urine culture should be performed.
  • Imaging of brain with head U/Splus CT or MRI is useful for suspected brain malformations and intracranialhemorrhage.
  • The following tests should be consideredfor suspected metabolic disorders: serum ammonia, lactate, pyruvate,carnitine, liver function tests, amino acids, blood pH, and PCO2;urine for reducing sugars, ketones, and organic acid analysis; andcerebrospinal fluid glycine. Simultaneous video-EEG recording mayclarify whether seizures are occurring and if so, what type theyare.
  • Blood glucose determination confirmspresence of hypoglycemia.

  • With symptomatic hypoglycemia, intravenousglucose should be given, but before glucose is given, blood sampleshould be drawn and held for subsequent tests.
  • Serum insulin level of >10μU/mL in presence of hypoglycemia is evidence forhyperinsulinemia.
  • Serum cortisol level of <10μg/dL suggests adrenal insufficiency. Low serum cortisoland growth hormone levels suggest pituitary disease.
  • Presence of hepatomegaly suggests galactosemia,hereditary fructose intolerance, or glycogen storage disease (typesI, III, VI). Urine positive for reducing sugars occurs with galactosemiaand hereditary fructose intolerance.
  • If diagnosis is uncertain and seizuresdo not respond to therapy, 100–200 mg of intravenous pyridoxinemay be given, while monitoring clinical and EEG responses.

    • Postneonatal Seizures

    Phenomena That May Be Confused with Seizures

    Clinical phenomena that may be confused withseizures are syncope, breath-holding spells, tics, benign paroxysmalvertigo, pseudoseizures, night terrors, migraine, and spasmus nutans.Manifestations of each are briefly described and contrasted withthose of seizures.

    Syncope

  • May be precededby dizziness or nausea. There is loss of postural tone, and individual collapses.Bradycardia and lowered BP occur in neurocardiogenic syncope (commonfaint).
  • History may include evidence of anxiety,hyperventilation, systemic illness, fasting, or prolonged standing,especially in warm weather or in closed quarters.
  • Tonic-clonic movements are uncommon,and urine incontinence is rare.
  • After episode, confusion is uncommonand amnesia does not occur.

    • Breath-Holding Spells

  • Unusualbefore 6 mos of age and usually cease by 6 yrs of age.
  • Pallid breath holding, which is consideredvariant of neurocardiogenic syncope, usually follows acute painor an injury. Infant or child becomes pale and loses consciousness;however, complete recovery occurs in 1–2 mins.
  • More common is cyanotic breath-holdingspell, where infant or child cries, holds breath during expiration,and turns dusky until breathing occurs again. Prolonged episodemay result in tonic-clonic movements and loss of consciousness.

    • Tics

    Recurrent involuntary movements that maymimic seizures. No loss or change in consciousness or postictalphenomena occur. Verbal tics also occur, especially in Tourettesyndrome.

    Benign Paroxysmal Vertigo

  • Usuallydevelops in children 2–6 yrs of age.
  • Sudden episodes are associated withfalling, refusing to walk, nausea, vomiting, and nystagmus. Duringthe episode, ability to communicate and talk is retained.
  • Episodes may last seconds to minutesand can occur daily or every few months.

    • Pseudoseizures (Nonepileptic Events)

  • Typicallyoccur at 10–18 yrs of age and are more common in girls.They may be seen, however, in children as young as 4–6yrs of age.
  • These events represent a form of conversionreaction, sometimes as a result of physical or sexual abuse.
  • Episodes can mimic generalized tonic-clonic,tonic, and complex partial seizures, but they differ from true seizuresin several ways. Onset of movements gradually builds up to paroxysmcompared with sudden onset of epileptic attack. Motor movementsare not true clonic movements but range from quivering to flailingof extremities. Postures and verbalizations are unusual.
  • Afterward, most individuals becomeimmediately responsive and do not experience postictal state.
  • Urination and tongue biting are infrequentbut may occur. Episodes never occur during sleep and only infrequentlywhen child is alone.
  • Ictal EEG shows no paroxysmal discharges.
  • Pseudoseizures also can occur in individualswho have true seizures.

    • Night Terrors

    Common in children 5–7 yrs of age,particularly in boys, and occur during slow-wave sleep. Childrenscream, thrash around, and appear frightened. Seem unaware of theirparents and surroundings. Difficult to console and do not rememberepisode. In contrast, nightmares occur during rapid eye movement sleep,and children can often recall episode.

    Migraine

  • Transientconfusional states and focal neurologic signs may occur during migraine episode.
  • Family history of migraine usuallyexists.
  • Migraine and seizures may occur insame individual, so careful evaluation is important.

    • Spasmus Nutans

    Characterized by triad of head nodding, nystagmus,and torticollis.

    Evaluation

  • Once ithas been established that a seizure has occurred, seizure type andcause must be determined if possible. Direct observation or carefulhistory may permit physician to determine seizure type, but thisis not always possible, and EEG is often helpful.
  • Age of onset, type of seizure, medicalhistory, circumstances in which seizure occurs, and physical examhelp determine whether patient has epileptic syndrome. Importantto recognize particular epileptic syndrome to determine appropriatetherapy and prognosis as well as to assess genetic risk.
  • Child who presents with fever and seizureusually has either febrile seizure or intracranial infection (meningitisor encephalitis).
  • Lumbar puncture should be performedin any child with suspected meningitis or encephalitis.
  • Because clinical exam is more reliablein child >18 mos of age than in younger infant, lumbarpuncture may not be necessary in older child with simple febrileseizure who appears otherwise well and has normal physical exam.
  • With occurrence of nonfebrile seizure,serum sodium, glucose, calcium, magnesium, creatinine, and bloodurea nitrogen should be measured. Approach to hypoglycemia has alreadybeen discussed. EEG should be performed except for child with typicalfebrile seizure.
  • History of head trauma suggests presenceof contusion, skull fracture, or intracranial hemorrhage. Childabuse is frequent cause of head trauma, and other clues (e.g., obviousbruising) may be seen. Shaking injury may produce extensive traumawith no visible evidence of injury.
  • With history of head trauma and seizure,CT should be performed.
  • With evidence of increased intracranialpressure or focal findings including focal seizures, intracranialmass lesion should be suspected and CT or MRI should be performed.MRI is preferred over CT for diagnosis of small hamartomas or othermalformations, neuronal migrational disorders, and mesial temporalsclerosis.
  • Drug or poison ingestion is anotherpossible cause of acute seizure, and history may be diagnostic.Otherwise, urine toxicology screen may confirm diagnosis.
  • Cerebral angiography is useful in thediagnosis of a vascular lesion (e.g., cerebral aneurysm or arteriovenousmalformation).
  • Other tests should be ordered, dependingon presence of other findings (e.g., progressive neurologic syndrome).
  • If uncertain whether seizures are occurring,simultaneous video-EEG recording can be performed. Although EEGis useful to help confirm diagnosis of epilepsy and classify typeof seizures, normal interictal EEG may occur with epilepsy and abnormalEEG does not confirm diagnosis unless seizure has been clinicallyrecognized. EEG should be recorded during wakefulness and sleep,and maneuvers that may activate seizure activity (e.g., hyperventilation,photic stimulation, and sleep deprivation) should be performed.
    • >

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    Source: The Diagnostic Approach to Symptoms and Signs in Pediatrics, 2006

    Fasciculations: History and physical examination
    (Nursing: Interpreting Signs and Symptoms)

    If the patient isn't in severe distress, find out if he has experienced sensory changes, such as paresthesia, or any difficulty speaking, swallowing, breathing, or controlling bowel or bladder function. Ask him if he's in pain.

    Explore the patient's medical history for neurologic disorders, cancer, and recent infections. Also, ask him about his lifestyle, especially stress at home, on the job, or at school.

    Ask the patient about his dietary habits and for a recall of his food and fluid intake in the recent past because electrolyte imbalances may also cause muscle twitching.

    Perform a physical examination, looking for fasciculations while the affected muscle is at rest. Observe and test for motor and sensory abnormalities, particularly muscle atrophy and weakness, and decreased deep tendon reflexes. If you note these signs and symptoms, suspect motor neuron disease, and perform a comprehensive neurologic examination.

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    Source: Nursing: Interpreting Signs and Symptoms, 2007

    Level of consciousness, decreased: History and physical examination
    (Nursing: Interpreting Signs and Symptoms)

    Try to obtain history information from the patient, if he's alert, and from his family. Did the patient complain of a headache, dizziness, nausea, vision or hearing disturbances, weakness, fatigue, or other problems before his LOC decreased? Has his family noticed changes in the patient's behavior, personality, memory, or temperament? Also ask about a history of neurologic disease, cancer, or recent trauma or infections; drug and alcohol use; and the development of other signs and symptoms.

    Because a decreased LOC can result from a disorder affecting any body system, tailor the remainder of your evaluation according to the patient's associated symptoms.

    » READ BOOK EXCERPT ONLINE »

    Source: Nursing: Interpreting Signs and Symptoms, 2007

    Myoclonus: History and physical examination
    (Nursing: Interpreting Signs and Symptoms)

    If the patient is stable, evaluate his level of consciousness (LOC) and mental status. Ask about the frequency, severity, location, and circumstances of myoclonus. Has he ever had a seizure? If so, did myoclonus precede it? Is myoclonus ever precipitated by a sensory stimulus? During the physical examination, check for muscle rigidity and wasting, and test deep tendon reflexes. Then perform a neurologic examination.

    » READ BOOK EXCERPT ONLINE »

    Source: Nursing: Interpreting Signs and Symptoms, 2007

    Fever [Pyrexia]: History and physical examination
    (Nursing: Interpreting Signs and Symptoms)

    If the patient's fever is only mild to moderate, ask him when it began and how high his temperature reached. Did the fever disappear, only to reappear later? Did he experience other symptoms, such as chills, fatigue, or pain?

    Obtain a complete medical history, noting especially immunosuppressive treatments or disorders, infection, trauma, surgery, diagnostic testing, and the use of anesthesia or other medications. Ask about recent travel because certain diseases are endemic.

    Let the history findings direct your physical examination. Because a fever can accompany diverse disorders, the examination may range from a brief evaluation of one body system to a comprehensive review of all systems. (See How fever develops.)

    » READ BOOK EXCERPT ONLINE »

    Source: Nursing: Interpreting Signs and Symptoms, 2007

    Seizures, absence: History and physical examination
    (Nursing: Interpreting Signs and Symptoms)

    If you suspect a patient is having an absence seizure, evaluate its occurrence and duration by reciting a series of numbers and then asking him to repeat them after the attack ends. If the patient has had an absence seizure, he can't do this. Alternatively, if the seizures are occurring within minutes of each other, ask the patient to count for about 5 minutes. He'll stop counting during a seizure and resume when it's over. Look for accompanying automatisms. Find out if the family has noticed a change in behavior or deteriorating schoolwork.

    Next, perform a complete neurologic examination.

    » READ BOOK EXCERPT ONLINE »

    Source: Nursing: Interpreting Signs and Symptoms, 2007

    Seizures, complex partial: History and physical examination
    (Nursing: Interpreting Signs and Symptoms)

    If you witness a complex partial seizure, never attempt to restrain the patient. Instead, lead him gently to a safe area. (Exception: Don't approach him if he's angry or violent.) Calmly encourage him to sit down, and remain with him until he's fully alert. After the seizure, ask him if he experienced an aura. Record all observations and findings. Obtain a history. Has the patient experienced a seizure in the past? Has he had a recent head injury? Has he experienced any fever, headaches, or periods of confusion? Obtain a complete drug history. Take his vital signs and perform a complete neurologic examination.

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    Source: Nursing: Interpreting Signs and Symptoms, 2007

    Seizures, generalized tonic-clonic: History and physical examination
    (Nursing: Interpreting Signs and Symptoms)

    If you didn't witness the patient's seizure, obtain a description from his companion. Ask when the seizure started and how long it lasted. Did the patient report unusual sensations before the seizure began? Did the seizure start in one area of the body and spread, or did it affect the entire body right away? Did the patient fall on a hard surface? Did his eyes or head turn? Did he turn blue? Did he lose bladder control? Did he have other seizures before recovering?

    If the patient may have sustained a head injury, observe him closely for loss of consciousness, unequal or nonreactive pupils, and focal neurologic signs. Does he complain of headache and muscle soreness? Is he increasingly difficult to arouse when you check on him at 20-minute intervals? Examine his arms, legs, and face (including tongue) for injury, residual paralysis, or limb weakness.

    Next, obtain a history. Has the patient ever had generalized or focal seizures before? If so, do they occur frequently? Do other family members also have them? Is the patient receiving drug therapy? Is he compliant? Also, ask about sleep deprivation and emotional or physical stress at the time the seizure occurred.

    Next, assess the patient's level of consciousness (LOC) and proceed with a complete neurologic examination.

    » READ BOOK EXCERPT ONLINE »

    Source: Nursing: Interpreting Signs and Symptoms, 2007

    Seizures, simple partial: History and physical examination
    (Nursing: Interpreting Signs and Symptoms)

    Be sure to record the patient's seizure activity in detail; your data may be critical in locating the lesion in the brain. Does the patient turn his head and eyes? If so, to what side? Where does movement first start? Does it spread? Because a partial seizure may become generalized, you'll need to watch closely for loss of consciousness, bilateral tonicity and clonicity, cyanosis, tongue biting, and urinary incontinence. (See “Seizures, generalized tonic-clonic,” page 552.)

    After the seizure, ask the patient to describe exactly what he remembers, if anything, about the seizure. Check the patient's LOC, and test for residual deficits (such as weakness in the involved extremity) and sensory disturbances.

    Then obtain a history. Ask the patient what happened before the seizure. Can he describe an aura or did he recognize its onset? If so, how—by a smell, a vision disturbance, or a sound or visceral phenomenon such as an unusual sensation in his stomach? How does this seizure compare with others he has had?

    Also, explore fully any history—recent or remote—of head trauma. Check for a history of stroke or recent infection, especially with fever, headache, or stiff neck.

    Perform a complete neurologic examination.

    » READ BOOK EXCERPT ONLINE »

    Source: Nursing: Interpreting Signs and Symptoms, 2007


     » Next page: Diagnosis of Febrile Seizures

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