Examination of Patient

Overview of Topics

General Aspects of Examination
Neurological Examination
Neurovascular Examination
Differential Diagnosis
International Classification of Seizures

General

1. Examine head for evidence of injury.
2. Optic discs
3. Odor of breath
4. Temp, BP, resp, pulse
5. W/major vessel - temp. may be elevated and heart rate increased.

Neurologic Examination

1. Important to determine if hemplegia is present.
   1. look at facial muscles for signs of flacidity during respiration.
   2. raise limbs & let fall - paralyzed limbs fall heavily, others will sink gradually to bed.
   3. vigorous stimulation of sole of foot will cause withdrawal in unparalyzed limbs.

2. Cortical lesion - pupils may be unequal in size. (larger one on the side opposite the lesion).

3. Conjugate deviation of the head and eyes together.
   1. deviation toward the side of lesion in cortical abnormalities.
   2. away from it in brain stem abnormalities.

4. Stiffness of the neck - related to the presence of blood in the spinal fluid.

Neurovascular Examination

1. Neck flexion - as above.
2. Palpation -
   1. superficial temporal artery
   2. internal carotid
   3. radial artery
3. Auscultation
4. Opthalmodynamometry

Differential Diagnosis

1. Focal or general neurologic symptoms appear suddenly in a patient with hypertension, arteriosclerosis, or other evidence of vascular disease.

2. Diagnosis is a two-fold process
   1. Determine CVA Vs infections, degeneration, or neoplasm.
   2. Determine form of CV disorder -
      • infarction ,
      • hemorrhage
      • embolus

3. Extradural hemorrhage
   1. symptoms appear immediately following a blow to the head.

4. Subdural hematoma
   1. prompt diagnosis important as operation may be necessary to save patient’s life.
   2. may occur with hypertension.
   3. symptoms may not appear for several weeks.

5. Neoplasm or Abscess
   1. usually slow and progressive development of symptoms.
   2. choked disc
   3. normal blood pressure
   4. clear cerebrospinal fluid
   5. abscess - same except cerebrospinal fluid shows mild to moderate pleocytosis.

6. Cerebral Embolism
   1. sudden onset of neurologic symptoms
   2. acute or chronic endocarditis
      • atrial fibrillation
      • recent myocardial infarction
      • septicemia
      • septic focus

7. Cerebral Hemorrhage
   1. Difficult to distinguish from infarction since both occur in same age group with arteriosclerosis and hypertension.
   2. Cerebral hemorrhage
      • convulsions (twice as frequent as patients with Infarction)
      • severe headache, nausea, vomiting, at onset.
      • Cheyne - Stokes or labored respiration
      • Conjugate deviation of the eyes
      • Stiffness of the neck
      • Quadriplegia
      • Bilateral Babinski
      • Bloody cerebrospinal fluid.

TOP

International Classification of Epileptic Seizures

Old terms such as "grand mal". "petit mal", "jacksonian", and "temporal lobe" have been discarded in favor of more descriptive terms.

I. Partial Seizures
A. Partial seizures with elementary symptomatology (without impairment of consciousness)

1. Motor symptoms (jacksonian included)
2. Special sensory or somatosensory symptoms (visual, auditory, olfactory, vertigenous, abdominal)
3. Autonomic symptoms (nausea, vomiting, flushing, HR changes)
4. Compound forms

B. Partial seizures with complex symptomatology (generally impaired consciousness - includes temporal lobe or psychomotor)

1. With impairment of consciousness only
2. Cognitive symptoms
3. Affective symptoms
4. Psychosensory symptoms
5. Psychomotor (automatism’s)
6. Compound

C. Partial seizures secondarily generalized

II. Generalized Seizures (bilaterally symmetrical and without focal onset/centrencephalic - originate in diencephalon)

1. Absences (petit mal)
2. Bilateral massive epileptic myoclonous
3. Infantile spasms
4. Clonic seizures
5. Tonic seizures
6. Tonic - clonic seizures (grand mal)
7. Atonic seizures
8. Kinetic seizures.

III. Unilateral Seizures (or predominantly)

IV. Unclassified Epileptic Seizures (due to incomplete data)