Seizure
Content
Date and Time of Interview: June 8, 2016
Source of Referral: None
Source of Information: Patient
Reliability: 90%
Identifying data:
Pasana, Anna, 26 years old, female, married, Roman Catholic, Filipino,
Housewife, currently residing at Babatngon, Leyte. Admitted multiple times at
EVRMC.
Chief Complaint:
Seizure
History of Present Illness:
Patient is known to have a seizure disorder.
1 week PTA, patient had tonic clonic seizure that started from facial twitching
and rolling of eyeballs upward then flexion of right arm then became generalized.
No loss of consciousness but forgets anything that occurred during the seizure
attack and with incontinence. Seizure lasted for 1-2 minutes. Patient was cyanotic
during the event. Patient claimed that before having seizure she experiences
headache first. No consultation done. No medications given.
Night PTA, patient had another seizure but now with dyspnea and abdominal
pain. Patient also had sleeping disturbance hence sought consult at our center and
was admitted.
Past Medical History:
Childhood Illnesses: Had mumps, chicken pox, and measles, no congenital
heart anomalies, no polio myelitis, and no history of tonsillitis nor rheumatic
fever.
Adult Illnesses:
Medical: seizure disorder started when she was 16 years old. She was
admitted more or less 3 times per year. She claims to have no maintenance
medication for seizure. Her seizure usually occurs once per month in the
evening.
Last admission: August 2013- stayed for 5 days. Claimed to have no
home medications.
Surgical: No previous surgical operations
Psychiatric: The patient has no history of psychiatric illness.
Immunizations: could not recall
No known allergies to food or drugs
Family History:
- Father, deceased due to a lung problem
- Mother, deceased due to ulcer.
- Youngest among brood of 8. All of which are apparently well except for
second to the eldest which had mild stroke
2 children – all are apparently well.
- No family history of DM, cancer, bronchial asthma, thyroid disease, seizure
disorder, nor mental illness
Personal and Social History:
She was born and raised in Babatngon, Leyte, and was a highschool
graduate.
She and her family lives in a concrete house, they have toilet facilities
located inside the house. They get water for drinking in a nearby spring. They use
wood for fuel in cooking.
She eats 3x a day with usual meal consists of rice, fish and other seafood.
She has no food preferences. She does not have any exercise regimen.
She is not a cigarette smoker. She is an occasional alcoholic beverage
drinker, not a prohibited drug user. She is not active in any civic or religious
organizations.
REVIEW OF SYSTEM:
General: No weight loss, with body malaise, afebrile.
Skin: No rashes, no sores, no itching, no dryness.
Head: with headache, no dizziness, no lightheadedness, no head injury
Eyes: No double vision, no pain, no redness, no excessive tearing, with blurring of
vision.
Ears: No tinnitus, no vertigo, no discharges, no pain, no hearing loss.
Nose: No itching, with colds, no epistaxis, no sinusitis.
Mouth & Throat: no swelling gums, no bleeding, no dryness, no sore throat, no
dysphagia, and no hoarseness of voice.
Neck: No swollen glands, no lumps, no pain, no stiffness.
Breasts: No pain, no lumps, no nipple discharge.
Respiratory: with productive cough, with dyspnea, no hemoptysis.
Cardiovascular: No chest pain, no palpitations, no orthopnea, no paroxysmal
nocturnal dyspnea.
Gastrointestinal: with abdominal pain, no dysphagia, no heartburn, no loss of
appetite, defecates once daily with yellow semiformed stool, no rectal
bleeding, no constipation, no diarrhea, no excessive flatulence, no melena.
Urinary: Urinates approximately 6x times daily, ¾ of glass per urination, yellowish
in color, no polyuria, no nocturia, no hematuria, no dysuria, no incontinence.
Genital: No hernia, no discharge, no itching, no sores, no redness.
Peripheral Vascular: No intermittent claudication, no leg cramps, no varicose veins,
no swelling, no redness.
Musculoskeletal: with joint pains, no swelling, no redness, no backache.
Neurologic: No fainting, with seizures, no numbness, no tingling sensation, no
tremors, no vertigo.
Hematologic: No easy bruising, no active bleeding, no history of blood transfusion.
Endocrine: No heat and cold intolerance, no excessive sweating, no polyuria, no
polydipsia, no polyphagia.
Psychiatric: No nervousness, no tension, no depression, no mood swings.
PHYSICAL EXAMINATION: (6th day of hospitalization)
General Survey: Patient seen lying on bed, conscious and coherent, oriented to
time, place and person, cooperative, fairly groomed, ectomorph, not in cardiorespiratory distress, afebrile and with the following vital signs:
BP- 110/70
Temp- 36.8
PR- 82
RR- 17
Integument:
Skin- Brown complexion, good skin turgor, no hypo nor hyper pigmentation, no
rashes
Nails – Not pale, no clubbing, no ridges, with capillary refill <3 seconds.
Head: Scalp – No engorged veins, no scars, no lesion, no tenderness.
Hair – Long, black, evenly distributed, neither lice nor nits.
Skull – Normocephalic, symmetrical, atraumatic.
Eyes: Eyebrows – Symmetrical evenly distributed and black.
Eyelashes – evenly distributed, oriented outward.
Eyelids – No ptosis, no periorbital edema, no tenderness, no lesion.
Pupils – PERRLA 3mm.
Conjunctiva – Pinkish palpebral conjunctiva.
Cornea- No ulceration, no lesion.
Sclera –anicteric, no lesion, no hemorrhage.
EOM – Intact, full movement.
Ears: Symmetrical, no impacted cerumen, no abnormal discharges, no swelling, no
tenderness, no hearing loss.
Nose and sinuses: No septal deviation, pinkish mucous membrane, no nasal flaring,
no lesion, no sinus tenderness.
Mouth and Throat: Pinkish lips, no sores, no fissures, pinkish buccal mucosa, no
dentures, no bleeding gums, tongue moves freely, no ulceration, uvula at midline,
no enlargement of tonsils.
Neck: No venous engorgements, trachea at midline, no bruit, no limitation of
movement, thyroid not enlarged, no enlarge lymph nodes.
Breasts: Symmetrical, no lumps, no nipple discharge, no tenderness, no masses.
Chest and lungs: Truncal in shape, no bulging, no retraction of subcostal and
intercostal muscles, symmetrical lung expansion. Confirmed symmetrical lung
expansion, no masses. Resonant in all lung fields. Bronchovesicular breath sounds
in all lung fields, no crackles, no wheezing, no pleural friction rub.
Heart: no precordial bulging. PMI palpable at 5 th ICS left MCL, no thrill, no
heaves. Heartbeat is 110 bpm, regular rhythm, tachycardic, synchronous
with the pulse, no murmurs.
Abdomen:
Inspection: Symmetrical, non distended abdomen. No visible peristaltic waves and
pulsations. No bulging flanks or protruding umbilicus. (-) Psoas sign, (-) Obturator
sign
Palpation: soft abdomen, liver, spleen and kidney not palpable, no inta-abdominal
masses. (-) Murphy’s sign, (-) tenderness at McBurney’s point
Percussion: Tympanitic in all regions, No shifting dullness. No fluid wave.
Auscultation: Normoactive bowel sound. No clappotage.
Extremities: full and equal peripheral pulse, No tenderness.
Back and Spine: No abnormal deviation, no bulging. No tenderness, no mass.
Genital: Grossly female, no discharge and lesion, no swelling.
Neurologic Exam:
Mental Status Examination: Conscious, coherent, cooperative. Oriented to time,
place and person. With good judgment, intact short-term and long-term memory.
Cerebellar: No involuntary movements.
Cranial Nerves:
I–
No anosmia
II –
Pupils constrict in 3 mm diameter, pupils reactive to direct and consensual
light and accommodation. Good central and peripheral vision.
III, IV, VI- Moves eyes, downward, upward, medially, and laterally (full and intact
EOM).
V–
Intact sensory function to touch, intact corneal reflex.
VII –
Smiles, able to frown
VIII –
Responsive to verbal stimuli.
IX, X –
Able to swallow.
X –
Able to turn head both sides against resistance, able to lift shoulder
against resistance.
XII –
Able to protrude tongue, no right and left deviation, no atrophy and
fasciculation.
MOTOR FUNCTION:
Can flex and extend both upper and lower extremities without limitation, no
atrophy of muscles, no involuntary movements, no spasticity, no rigidity and no
flaccidity.
SENSORY:
Sensitive to pain, touch and pressure on right and left upper and lower extremities,
seen as arousal, withdrawal of tested extremity to pain, and change in facial
expression.
MUSCLE STRENGTH:
-Able to extend both wrist; grip both hands; abduct and adduct fingers; flex and
extend knees, plantar flexes and dorsiflexes ankles. Grade 3/5.
REFLEXES:
Biceps = 2+
Triceps= 2+
Brachioradialis = 2+
Patellar = 2+
Plantar = 2+
PATHOLOGIC REFLEXES:
(-) babinski
(-) ankle clonus
MENINGEAL SIGNS:
(-) Nuchal rigidity
(-) Brudzinski’s sign
(-) Kernig’s sign
ANS: (-) incontinence, excessive sweating, lacrimation, salivation.
Impression:
Complex
partial
seizure
with
secondary
generalization
Basis:
Seizure started at the eyes then became generalized
Impaired consciousness
Incontinence
With aura
Does not remember events that occurred
Ictus duration ≥ 1 minute
DIFFERENTIAL DIAGNOSIS
DIAGNOSIS
Simple
partial
seizure
Juvenile
Myoclonic
seizure
Metabolic
Seizure
Syncope
RULE-IN
RULE-OUT
No impairment of
consciousness
-
Without loss of
consciousness
-
With aura
-
-
without impairment of
consciousness; may be
motor, sensory, or
autonomic
-
lacks true aura (altho'
patient may describe
feeling unwell w/
diaphoresis, nausea, and
tunneling of vision), motor
manifestation <30 sec
(convulsive activity <10 sec
may occur with transient
cerebral hypoperfusion),
and without postictal
disorientation, muscle
soreness, or sleepiness;
skin pallor & clamminess
support syncope
DIAGNOSIS
1. Electroencephalogram – most important diagnostic procedure for patients with
epilepsy.
2. Cranial MRI or Cranial CT scan – indicated for focal seizures, intractable seizures
and progressive neurologic disease or structural lesions that may warrant surgical
intervention.
3. Lumbar puncture: done if CNS infection is suspected.
Management
AEDs in Epilepsy
Generalized
Valproic acid
Ethosuximide
Partial, secondarily generalized
Carbamazepine
Phenytoin
Clonazepam
Valproic acid
Phenobarbital
Seizure type
1st drug
2nd drug
1. Simple & complex
Carbamazepine
Phenobarbital
partial
Phenytoin
Valproic acid
Carbamazepine
Valproic acid
2. Secondarily generalized
Phenytoin
Phenobarbital
Valproic acid
Clonazepam
3. Absence
Ethosuximide
(typical/atypical)
Valproic acid
Phenytoin
4. Absence + TC
Valproic
acid
Phenytoin
Clonazepam
5. Primary gen.
Valproic
acid
Clonazepam/Topiramat
e
6. Myoclonic
Polypharmacy vs. Monotherapy
- In addition to seizure specificity, one important new concept in epilepsy is
monotherapy
- Advantages:
o Side effects & drug interactions are reduced and/or eliminated
o Better compliance, hence better seizure control
o Cost-effective
o Improved quality of life
Epilepsy Surgery
- When seizures cannot be adequately controlled by 2 or 3 different medications
- If there is an identifiable brain lesion believed to be causing the seizures
1. To remove seizure focus
a. Can be treated successfully w/ surgery
- Focal and secondarily generalized seizures
- Unilateral multifocal epilepsy w/ infantile hemiplegia (Rasmussen’s
encephalitis)
2. To treat underlying conditions
a. Brain tumor
b. Hydrocephalus
Source of Referral: None
Source of Information: Patient
Reliability: 90%
Identifying data:
Pasana, Anna, 26 years old, female, married, Roman Catholic, Filipino,
Housewife, currently residing at Babatngon, Leyte. Admitted multiple times at
EVRMC.
Chief Complaint:
Seizure
History of Present Illness:
Patient is known to have a seizure disorder.
1 week PTA, patient had tonic clonic seizure that started from facial twitching
and rolling of eyeballs upward then flexion of right arm then became generalized.
No loss of consciousness but forgets anything that occurred during the seizure
attack and with incontinence. Seizure lasted for 1-2 minutes. Patient was cyanotic
during the event. Patient claimed that before having seizure she experiences
headache first. No consultation done. No medications given.
Night PTA, patient had another seizure but now with dyspnea and abdominal
pain. Patient also had sleeping disturbance hence sought consult at our center and
was admitted.
Past Medical History:
Childhood Illnesses: Had mumps, chicken pox, and measles, no congenital
heart anomalies, no polio myelitis, and no history of tonsillitis nor rheumatic
fever.
Adult Illnesses:
Medical: seizure disorder started when she was 16 years old. She was
admitted more or less 3 times per year. She claims to have no maintenance
medication for seizure. Her seizure usually occurs once per month in the
evening.
Last admission: August 2013- stayed for 5 days. Claimed to have no
home medications.
Surgical: No previous surgical operations
Psychiatric: The patient has no history of psychiatric illness.
Immunizations: could not recall
No known allergies to food or drugs
Family History:
- Father, deceased due to a lung problem
- Mother, deceased due to ulcer.
- Youngest among brood of 8. All of which are apparently well except for
second to the eldest which had mild stroke
2 children – all are apparently well.
- No family history of DM, cancer, bronchial asthma, thyroid disease, seizure
disorder, nor mental illness
Personal and Social History:
She was born and raised in Babatngon, Leyte, and was a highschool
graduate.
She and her family lives in a concrete house, they have toilet facilities
located inside the house. They get water for drinking in a nearby spring. They use
wood for fuel in cooking.
She eats 3x a day with usual meal consists of rice, fish and other seafood.
She has no food preferences. She does not have any exercise regimen.
She is not a cigarette smoker. She is an occasional alcoholic beverage
drinker, not a prohibited drug user. She is not active in any civic or religious
organizations.
REVIEW OF SYSTEM:
General: No weight loss, with body malaise, afebrile.
Skin: No rashes, no sores, no itching, no dryness.
Head: with headache, no dizziness, no lightheadedness, no head injury
Eyes: No double vision, no pain, no redness, no excessive tearing, with blurring of
vision.
Ears: No tinnitus, no vertigo, no discharges, no pain, no hearing loss.
Nose: No itching, with colds, no epistaxis, no sinusitis.
Mouth & Throat: no swelling gums, no bleeding, no dryness, no sore throat, no
dysphagia, and no hoarseness of voice.
Neck: No swollen glands, no lumps, no pain, no stiffness.
Breasts: No pain, no lumps, no nipple discharge.
Respiratory: with productive cough, with dyspnea, no hemoptysis.
Cardiovascular: No chest pain, no palpitations, no orthopnea, no paroxysmal
nocturnal dyspnea.
Gastrointestinal: with abdominal pain, no dysphagia, no heartburn, no loss of
appetite, defecates once daily with yellow semiformed stool, no rectal
bleeding, no constipation, no diarrhea, no excessive flatulence, no melena.
Urinary: Urinates approximately 6x times daily, ¾ of glass per urination, yellowish
in color, no polyuria, no nocturia, no hematuria, no dysuria, no incontinence.
Genital: No hernia, no discharge, no itching, no sores, no redness.
Peripheral Vascular: No intermittent claudication, no leg cramps, no varicose veins,
no swelling, no redness.
Musculoskeletal: with joint pains, no swelling, no redness, no backache.
Neurologic: No fainting, with seizures, no numbness, no tingling sensation, no
tremors, no vertigo.
Hematologic: No easy bruising, no active bleeding, no history of blood transfusion.
Endocrine: No heat and cold intolerance, no excessive sweating, no polyuria, no
polydipsia, no polyphagia.
Psychiatric: No nervousness, no tension, no depression, no mood swings.
PHYSICAL EXAMINATION: (6th day of hospitalization)
General Survey: Patient seen lying on bed, conscious and coherent, oriented to
time, place and person, cooperative, fairly groomed, ectomorph, not in cardiorespiratory distress, afebrile and with the following vital signs:
BP- 110/70
Temp- 36.8
PR- 82
RR- 17
Integument:
Skin- Brown complexion, good skin turgor, no hypo nor hyper pigmentation, no
rashes
Nails – Not pale, no clubbing, no ridges, with capillary refill <3 seconds.
Head: Scalp – No engorged veins, no scars, no lesion, no tenderness.
Hair – Long, black, evenly distributed, neither lice nor nits.
Skull – Normocephalic, symmetrical, atraumatic.
Eyes: Eyebrows – Symmetrical evenly distributed and black.
Eyelashes – evenly distributed, oriented outward.
Eyelids – No ptosis, no periorbital edema, no tenderness, no lesion.
Pupils – PERRLA 3mm.
Conjunctiva – Pinkish palpebral conjunctiva.
Cornea- No ulceration, no lesion.
Sclera –anicteric, no lesion, no hemorrhage.
EOM – Intact, full movement.
Ears: Symmetrical, no impacted cerumen, no abnormal discharges, no swelling, no
tenderness, no hearing loss.
Nose and sinuses: No septal deviation, pinkish mucous membrane, no nasal flaring,
no lesion, no sinus tenderness.
Mouth and Throat: Pinkish lips, no sores, no fissures, pinkish buccal mucosa, no
dentures, no bleeding gums, tongue moves freely, no ulceration, uvula at midline,
no enlargement of tonsils.
Neck: No venous engorgements, trachea at midline, no bruit, no limitation of
movement, thyroid not enlarged, no enlarge lymph nodes.
Breasts: Symmetrical, no lumps, no nipple discharge, no tenderness, no masses.
Chest and lungs: Truncal in shape, no bulging, no retraction of subcostal and
intercostal muscles, symmetrical lung expansion. Confirmed symmetrical lung
expansion, no masses. Resonant in all lung fields. Bronchovesicular breath sounds
in all lung fields, no crackles, no wheezing, no pleural friction rub.
Heart: no precordial bulging. PMI palpable at 5 th ICS left MCL, no thrill, no
heaves. Heartbeat is 110 bpm, regular rhythm, tachycardic, synchronous
with the pulse, no murmurs.
Abdomen:
Inspection: Symmetrical, non distended abdomen. No visible peristaltic waves and
pulsations. No bulging flanks or protruding umbilicus. (-) Psoas sign, (-) Obturator
sign
Palpation: soft abdomen, liver, spleen and kidney not palpable, no inta-abdominal
masses. (-) Murphy’s sign, (-) tenderness at McBurney’s point
Percussion: Tympanitic in all regions, No shifting dullness. No fluid wave.
Auscultation: Normoactive bowel sound. No clappotage.
Extremities: full and equal peripheral pulse, No tenderness.
Back and Spine: No abnormal deviation, no bulging. No tenderness, no mass.
Genital: Grossly female, no discharge and lesion, no swelling.
Neurologic Exam:
Mental Status Examination: Conscious, coherent, cooperative. Oriented to time,
place and person. With good judgment, intact short-term and long-term memory.
Cerebellar: No involuntary movements.
Cranial Nerves:
I–
No anosmia
II –
Pupils constrict in 3 mm diameter, pupils reactive to direct and consensual
light and accommodation. Good central and peripheral vision.
III, IV, VI- Moves eyes, downward, upward, medially, and laterally (full and intact
EOM).
V–
Intact sensory function to touch, intact corneal reflex.
VII –
Smiles, able to frown
VIII –
Responsive to verbal stimuli.
IX, X –
Able to swallow.
X –
Able to turn head both sides against resistance, able to lift shoulder
against resistance.
XII –
Able to protrude tongue, no right and left deviation, no atrophy and
fasciculation.
MOTOR FUNCTION:
Can flex and extend both upper and lower extremities without limitation, no
atrophy of muscles, no involuntary movements, no spasticity, no rigidity and no
flaccidity.
SENSORY:
Sensitive to pain, touch and pressure on right and left upper and lower extremities,
seen as arousal, withdrawal of tested extremity to pain, and change in facial
expression.
MUSCLE STRENGTH:
-Able to extend both wrist; grip both hands; abduct and adduct fingers; flex and
extend knees, plantar flexes and dorsiflexes ankles. Grade 3/5.
REFLEXES:
Biceps = 2+
Triceps= 2+
Brachioradialis = 2+
Patellar = 2+
Plantar = 2+
PATHOLOGIC REFLEXES:
(-) babinski
(-) ankle clonus
MENINGEAL SIGNS:
(-) Nuchal rigidity
(-) Brudzinski’s sign
(-) Kernig’s sign
ANS: (-) incontinence, excessive sweating, lacrimation, salivation.
Impression:
Complex
partial
seizure
with
secondary
generalization
Basis:
Seizure started at the eyes then became generalized
Impaired consciousness
Incontinence
With aura
Does not remember events that occurred
Ictus duration ≥ 1 minute
DIFFERENTIAL DIAGNOSIS
DIAGNOSIS
Simple
partial
seizure
Juvenile
Myoclonic
seizure
Metabolic
Seizure
Syncope
RULE-IN
RULE-OUT
No impairment of
consciousness
-
Without loss of
consciousness
-
With aura
-
-
without impairment of
consciousness; may be
motor, sensory, or
autonomic
-
lacks true aura (altho'
patient may describe
feeling unwell w/
diaphoresis, nausea, and
tunneling of vision), motor
manifestation <30 sec
(convulsive activity <10 sec
may occur with transient
cerebral hypoperfusion),
and without postictal
disorientation, muscle
soreness, or sleepiness;
skin pallor & clamminess
support syncope
DIAGNOSIS
1. Electroencephalogram – most important diagnostic procedure for patients with
epilepsy.
2. Cranial MRI or Cranial CT scan – indicated for focal seizures, intractable seizures
and progressive neurologic disease or structural lesions that may warrant surgical
intervention.
3. Lumbar puncture: done if CNS infection is suspected.
Management
AEDs in Epilepsy
Generalized
Valproic acid
Ethosuximide
Partial, secondarily generalized
Carbamazepine
Phenytoin
Clonazepam
Valproic acid
Phenobarbital
Seizure type
1st drug
2nd drug
1. Simple & complex
Carbamazepine
Phenobarbital
partial
Phenytoin
Valproic acid
Carbamazepine
Valproic acid
2. Secondarily generalized
Phenytoin
Phenobarbital
Valproic acid
Clonazepam
3. Absence
Ethosuximide
(typical/atypical)
Valproic acid
Phenytoin
4. Absence + TC
Valproic
acid
Phenytoin
Clonazepam
5. Primary gen.
Valproic
acid
Clonazepam/Topiramat
e
6. Myoclonic
Polypharmacy vs. Monotherapy
- In addition to seizure specificity, one important new concept in epilepsy is
monotherapy
- Advantages:
o Side effects & drug interactions are reduced and/or eliminated
o Better compliance, hence better seizure control
o Cost-effective
o Improved quality of life
Epilepsy Surgery
- When seizures cannot be adequately controlled by 2 or 3 different medications
- If there is an identifiable brain lesion believed to be causing the seizures
1. To remove seizure focus
a. Can be treated successfully w/ surgery
- Focal and secondarily generalized seizures
- Unilateral multifocal epilepsy w/ infantile hemiplegia (Rasmussen’s
encephalitis)
2. To treat underlying conditions
a. Brain tumor
b. Hydrocephalus
