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Diagnostic Tests for Grand mal seizures

Contents
  1. Grand mal seizures: Introduction
  2. Symptoms of Grand mal seizures
  3. Diagnosis
  4. Home Diagnostic Testing
  5. Failure to Diagnose
  6. Complications

Grand mal seizures Tests: Book Excerpts

Home Diagnostic Testing

These home medical tests may be relevant to Grand mal seizures:

Grand mal seizures Diagnosis: Book Excerpts

Diagnosis of Grand mal seizures: medical news summaries:

The following medical news items are relevant to diagnosis of Grand mal seizures:

Diagnostic Tests for Grand mal 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 Grand mal seizures.

FACIAL PARALYSIS: DIAGNOSTIC WORKUP
(Algorithmic Diagnosis of Symptoms and Signs)

Immediate referral to a neurologist is indicated. One should do a complete examination of the ear, nose, and throat to determine if there is any rupture of the drum, discharge, evidence of otitis media, etc. Then x-rays of the mastoids and petrous bones should be done along with tomography. A CT scan of the brain with emphasis on the internal auditory foramina should be done if acoustic neuroma is suspected. Culture of the discharge from the ears and blood culture should be done if there are associated signs of an infectious process. Testing for Lyme disease may be indicated. Spinal fluid analysis should be done to look for Guillain-Barré syndrome. If myasthenia gravis is suspected, a Tensilon test may be done. Spinal fluid culture should be done in cases of brain abscess. Carotid scans and a workup for an embolic source should be done in cases of cerebral vascular accident. Of course, when there is a brain tumor or abscess or a cerebral vascular accident is suspected, CT scans of the brain should be done. If these are not helpful or are inconclusive, MRI of the brain can be done. Glucose tolerance testing should be done to rule out diabetic neuropathy. If lead poisoning is suspected, a blood level for lead should be done.

 

» READ BOOK EXCERPT ONLINE »

Source: Algorithmic Diagnosis of Symptoms and Signs, 2003

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

Obtain a thorough history of the patient’s headaches or seizure history, asking him to describe any sensory or motor phenomena that precede each headache or seizure. Find out how long each headache or seizure typically lasts. Does anything make it worse, such as bright lights, noise, or caffeine? Does anything make it better? Ask the patient about drugs he takes for pain relief.

» READ BOOK EXCERPT ONLINE »

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

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

If the patient isn't in distress, obtain a detailed history. Ask about the onset and duration of the spasms and ask for a description of pain they produce. Also ask about related signs and symptoms of hypocalcemia, such as numbness and tingling of the fingertips and feet, other muscle cramps or spasms, and nausea, vomiting, and abdominal pain. Check for previous neck surgery, calcium or magnesium deficiency, tetanus exposure, and hypoparathyroidism.

During the history, form a general impression of the patient's mental status and behavior. If possible, ask family members or friends if they've noticed changes in the patient's behavior. Mental confusion or even personality changes may occur with hypocalcemia.

Inspect the patient's skin and fingernails, noting dryness or scaling and ridged, brittle nails.

» 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

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

If the patient is in no immediate danger, perform a complete neurologic assessment. Start with the history, relying on family members for information if necessary. Ask about the onset, duration, intensity, and progression of paralysis and about the events preceding its development. Focus medical history questions on the incidence of degenerative neurologic or neuromuscular disease, recent infectious illness, sexually transmitted disease, cancer, or recent injury. Explore related signs and symptoms, noting fevers, headaches, vision disturbances, dysphagia, nausea and vomiting, bowel or bladder dysfunction, muscle pain or weakness, and fatigue.

Next, perform a complete neurologic examination, testing cranial nerve (CN), motor, and sensory function and deep tendon reflexes (DTRs). Assess strength in all major muscle groups, and note muscle atrophy. (See Testing muscle strength, pages 418 and 419.) Document all findings to serve as a baseline.

» 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

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

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

After providing emergency care, obtain a thorough history of the patient’s headaches or seizures, asking him to describe any sensory or motor phenomena that precede each headache or seizure. Find out how long each headache or seizure typically lasts. Does anything make it worse, such as bright lights, noise, or caffeine? Does anything make it better? Ask the patient about drugs he takes for pain relief.

» READ BOOK EXCERPT ONLINE »

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

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

If the patient isn’t in distress, obtain a detailed history. Ask about the onset and duration of the spasms and the degree of pain they produce. Also ask about related signs and symptoms of hypocalcemia, such as numbness and tingling of the fingertips and feet, other muscle cramps or spasms, and nausea, vomiting, and abdominal pain. Check for previous neck surgery, calcium or magnesium deficiency, tetanus exposure, and hypoparathyroidism.

During the history, form a general impression of the patient’s mental status and behavior. If possible, ask family members or friends if they’ve noticed changes in the patient’s behavior because hypocalcemia can cause confusion and even personality changes.

Inspect the patient’s skin and fingernails, noting any dryness or scaling and ridged, brittle nails.

» 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

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

If the patient is in no immediate danger, perform a complete neurologic assessment. Start with the history, relying on family members for information if necessary. Ask about the onset, duration, intensity, and progression of paralysis and about the events preceding its development. Focus medical history questions on the incidence of degenerative neurologic or neuromuscular disease, recent infectious illness, sexually transmitted disease, cancer, or recent injury. Explore related signs and symptoms, noting fever, headache, vision disturbances, dysphagia, nausea and vomiting, bowel or bladder dysfunction, muscle pain or weakness, and fatigue.

Next, perform a complete neurologic examination, testing cranial nerve, motor, and sensory function and deep tendon reflexes. Assess strength in all major muscle groups, and note any muscle atrophy. (See Testing muscle strength, pages 530 and 531.) Document all findings to serve as a baseline.

» 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

Chorea [Choreiform movements]: History and physical examination
(Professional Guide to Signs & Symptoms (Fifth Edition))

Ask the patient and his family when they first noticed the choreiform movements. Do the movements disappear when the patient is asleep? Find out if anyone in the patient’s family exhibits the same type of movements, and ask about a family history of such diseases as Huntington’s disease. Also ask which medications the patient is taking. Obtain an occupational history, noting especially prolonged exposure to manganese or other metals. As you obtain the history, observe the patient for excessive restlessness and periodic facial grimaces that may interrupt his speech.

Perform a physical examination to evaluate the severity of the patient’s chorea. Ask him to stick out his tongue and keep it out. Typically, he’ll be unable to do this; instead, his tongue will dart in and out of his mouth. Observe the patient’s arms and legs separately for involuntary jerky movements. Ask him to extend and flex his hand as if halting traffic; the choreiform movements will be extremely evident in this position. Also, check for such related signs as athetosis, rigidity, or tremor.

To assess the patient for choreoathetotic gait, ask him to walk. He may change the position of his trunk and upper body parts with each step and jerk and tilt his head to one side. Because of superimposed involuntary movements and postures, the patient’s legs may move slowly and awkwardly. (An involuntary movement suspending his leg momentarily with each step may give a dancing quality to his gait.)

» 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: 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

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

 A. General. A comprehensive physical examination should be performed on all patients with generalized lymphadenopathy. Focus on those findings consistent with the most frequent causes of generalized lymphadenopathy. Note the patient’s temperature and weight, because fever and weight loss are frequent findings. Examine the skin, mucous membranes, abdominal organs, and joints; specifically, the presence of rash, mucocutaneous ulceration, organomegaly, and arthritis can be a guide to possible causes of the adenopathy. The presence of splenomegaly in a patient with adenopathy implies a systemic illness (e.g., infectious mononucleosis, lymphoma, leukemia, lupus, sarcoidosis, toxoplasmosis, or cat scratch disease) (Chapter 15.4). Additionally, search for other abnormal lymph nodes. Studies have shown that clinicians identified only 17% of those cases of generalized lymphadenopathy when it was present (1).

 B. Nodal examination. The abnormal lymph node groups should be specifically examined.

1. Size. Lymph nodes enlarged up to 1 cm in diameter can be considered normal in size. These have a low malignancy risk and can usually be observed. Lymph nodes greater than 1.5 cm × 1.5 cm in area have been shown to have a 38% risk of cancer involvement and merit further workup (2).

 2. Location. Anterior cervical, submandibular, and inguinal nodes are normally palpable. The presence of supraclavicular adenopathy is always abnormal and carries a 90% cancer risk in those aged more than 40 years. Postocciptal nodes are associated with infectious mononucleosis, scalp lesions, toxoplasmosis, and non-Hodgkin’s lymphoma. Axillary nodes are associated with upper extremity infections, breast cancer, cat scratch disease, and lymphomas. Epitrochlear nodes are associated with pyogenic infections, sarcoidosis, tularemia, and syphilis. Inguinal nodes are associated with lower extremity infections and sexually transmitted diseases.

 3. Pain. The presence or absence of pain is not a reliable indicator of the cause of adenopathy. Capsular swelling from acute infections can cause pain as can necrotic hemorrhage from a malignant lymph node.

 4. Consistency. Rock hard nodes are consistent with metastatic disease (2). Firm rubbery nodes are found with lymphomas. Soft nodes tend to occur with infectious causes; however, this should not be considered diagnostic.

Testing

 A. Primary laboratory test. Initial laboratory testing should include a complete blood count (CBC) and a slide test for infectious mononucleosis (IM) (1). Atypical lymphocytes are suggestive of IM, cytomegalovirus, or toxoplasmosis. Neutropenia is found with viral illness, lupus, brucellosis, and bone marrow replacement. Severe anemia can be seen with malignancy and autoimmune processes. If the initial mononucleosis spot is negative, the test should be repeated at intervals of 1, 2, and 3 weeks, if atypical lymphocytes are present in the CBC.

 B. Secondary testing. If the initial laboratory results are nondiagnostic, order a purified protein derivative (PPD), antinuclear antibody, hepatitis B surface antigen, HIV, rapid plasma reagin, cytomegalovirus serology, and chest X-ray (CXR) study. Although the CXR is seldom positive, it can be helpful in finding tuberculosis (TB), histoplasmosis, lymphoma, or sarcoidosis. Although a PPD will not be diagnostic of TB, it can be helpful in differentiating sarcoid from TB on a node biopsy (2).

 C. Lymph node biopsy. If the aforementioned laboratory testing is nondiagnostic, then lymph node biopsy may be indicated. The largest and most pathologic node should be removed. Axillary and inguinal nodes should be avoided as they often reveal only reactive hyperplasia. Biopsy should be avoided in cases of suspected IM and drug reaction because the histologic picture is easily confused with malignant lymphoma (2). Experienced hematologists or hematopathologists should handle all specimens. The value of fine needle aspiration is controversial, with reasonable arguments both for and against (4).

Diagnostic assessment

Generalized lymphadenopathy merits evaluation beyond mere observation, as a specific systemic illness will be the likely cause. The history and examination should focus on infectious, autoimmune, granulomatous, and malignant causes. If a specific entity is suspected based on the history and physical examination, then that entity should be specifically evaluated. In the event the cause is unclear, first order a CBC and mononucleosis spot. If these are negative, then serologic testing and a CXR are warranted. Consider lymph node biopsy in those cases where the node is rock hard or larger than 1.5 cm × 1.5 cm in size (1). Biopsy should be avoided in those cases where viral causes are clinically suggested.


References

1. Ferrer R. Lymphadenopathy: differential diagnosis and evaluation. Am Fam Physician 1998;58:1313–1320.

2. Pangalis GA, Vassilalopoulos TP, Boussiotis VA, Fessas P. Clinical approach to lymphadenopathy. Semin Oncol 1993;20:570–582.

3. Williamson HA. Lymphadenopathy in a family practice. J Fam Pract 1985;20:
449–452.

4. Henry P, Longo D. Enlargement of lymph nodes and spleen. Harrison’s on line 1999;61. www.harrisonsonline.com/

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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

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

First, perform a full neurologic examination. Then proceed to a complete physical examination to detect systemic disorders. Be aware that the physical assessment may not reveal abnormalities.

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

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

Take the patient’s vital signs. Hypocalcemia may result in hypotension and an irregular heart rhythm. Check for Chvostek’s sign, also an indicator of hypocalcemia. Then proceed to perform a complete physical examination. Inspect the patient’s skin and fingernails, noting any dryness or scaling or ridged, brittle nails caused by hypocalcemia.

» READ BOOK EXCERPT ONLINE »

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

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

Perform a physical examination to evaluate the severity of the patient’s chorea. Ask him to stick out his tongue and keep it out. Typically, he’ll be unable to do this; instead, his tongue will dart in and out of his mouth. Observe the patient’s arms and legs separately for involuntary jerky movements. Ask him to extend and flex his hand as if halting traffic, and note the choreiform movements — they’ll be extremely evident in this position. Also, check for such related signs as athetosis, rigidity, or tremor.

To assess the patient for choreoathetotic gait, ask him to walk. He may change the positions of his trunk and upper body parts with each step and jerk and tilt his head to one side. Because of superimposed involuntary movements and postures, the patient’s legs may move slowly and awkwardly. (An involuntary movement suspending his leg momentarily with each step may give a dancing quality to his gait.)

» READ BOOK EXCERPT ONLINE »

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.

» READ BOOK EXCERPT ONLINE »

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.

» READ BOOK EXCERPT ONLINE »

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

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

Perform a complete neurologic examination, testing cranial nerve, motor, and sensory function and deep tendon reflexes. Assess strength in all major muscle groups, and note any muscle atrophy. Document all findings to serve as a baseline.

» READ BOOK EXCERPT ONLINE »

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.

» READ BOOK EXCERPT ONLINE »

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.

» READ BOOK EXCERPT ONLINE »

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

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.
    • >

    » READ BOOK EXCERPT ONLINE »

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

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

    Obtain a thorough history of the patient's headache or seizure history, asking him to describe any sensory or motor phenomena that precede each headache or seizure. Find out how long each headache or seizure typically lasts. Does anything make it worse, such as bright lights, noise, or caffeine? Does anything make it better? Ask the patient about drugs he takes for pain relief.

    Then perform a complete neurologic examination.

    » READ BOOK EXCERPT ONLINE »

    Source: Nursing: Interpreting Signs and Symptoms, 2007

    Carpopedal spasm: History and physical examination
    (Nursing: Interpreting Signs and Symptoms)

    If the patient isn't in distress, obtain a detailed history. Ask about the onset and duration of the spasms and ask for a description of pain they produce. Also ask about related signs and symptoms of hypocalcemia, such as numbness and tingling of the fingertips and feet, other muscle cramps or spasms, and nausea, vomiting, and abdominal pain. Check for previous neck surgery, calcium or magnesium deficiency, tetanus exposure, and hypoparathyroidism.

    During the history, form a general impression of the patient's mental status and behavior. If possible, ask family members or friends if they've noticed changes in the patient's behavior. Mental confusion or even personality changes may occur with hypocalcemia.

    Inspect the patient's skin and fingernails, noting dryness or scaling and ridged, brittle nails.

    » READ BOOK EXCERPT ONLINE »

    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

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

    If the patient is in no immediate danger, perform a complete neurologic assessment. Start with the history, relying on family members for information if necessary. Ask about the onset, duration, intensity, and progression of paralysis and about the events preceding its development. Focus medical history questions on the incidence of degenerative neurologic or neuromuscular disease, recent infectious illness, sexually transmitted disease, cancer, or recent injury. Explore related signs and symptoms, noting fevers, headaches, vision distur-bances, dysphagia, nausea and vomiting, bowel or bladder dysfunction, muscle pain or weakness, and fatigue.

    Next, perform a complete neurologic examination, testing cranial nerve (CN), motor, and sensory function and deep tendon reflexes (DTRs). Assess strength in all major muscle groups, and note muscle atrophy. (See Testing muscle strength, pages 410 and 411.) Document all findings to serve as a baseline.

    » 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.

    » READ BOOK EXCERPT ONLINE »

    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

    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 - Case 19-3: 8-Month-Old Boy: III. Physical Examination
    (Pediatric Complaints and Diagnostic Dilemmas)

    T, 36.2°C; RR, 20/min; HR, 90 to 110 bpm; BP, 120/55 mm Hg; SpO2, 100% in room air
    Height, 25th percentile; weight, 10th percentile; head circumference, 25th percentile
    On examination, he was thin but playful and interactive. The anterior fontanel was open and flat. His pupils were symmetrically reactive to light. The heart sounds were normal, and the lungs were clear to auscultation. His abdomen was slightly protuberant, with a liver edge that was firm and palpable 6 cm below the right costal margin. The spleen tip was just palpable below the left costal margin. There was no ascites or palpable abdominal mass. The infant was circumcised and had normal male genitalia. The neurological examination was normal. He was able to sit without support and maintained good head control. Deep tendon reflexes were 2+ and symmetric. The gag reflex was intact. There were no hyperpigmented or hypopigmented skin lesions.

    IV. Diagnostic Studies

    Serum chemistry values included sodium, 137 mmol/L; potassium, 5.5 mmol/L; chloride, 100 mmol/L; bicarbonate, 13 mmol/L; calcium, 10.5 mg/dL; phosphorous, 6.5 mg/dL; and serum glucose 20 mg/dL. The cholesterol and triglyceride concentrations were 465 and 4,070 mg/dL, respectively. Hepatic function tests included AST, 125 U/L; ALT, 155 U/L; GGT, 564 U/L; total bilirubin, 0.6 mg/dL; and albumin, 4.0 g/dL. Serum and urinary ketones were present. The WBC count, hemoglobin, and platelet count, as well as prothrombin and partial thromboplastin times, were normal. Blood, urine, and stool cultures were obtained.

    » READ BOOK EXCERPT ONLINE »

    Source: Pediatric Complaints and Diagnostic Dilemmas, 2003


     » Next page: Diagnosis of Grand mal seizures

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