2 History Taking of Common Pediatric Cases
2.25 Seizure
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• Acute recurrent throbbing headache suggests a migraine; headache that pres-ents as a band around the head may suggest a tension headache; a thunder-clap headache suggests subarachnoid hemorrhage.
• An acute-onset severe headache needs rapid assessment as it may require a specific and urgent treatment [64].
• A chronic progressive headache requires neuroimaging evaluation since it may suggest an enlarging intracranial lesion.
Key Points 2.23
• Recent headache onset
• First or worst headache
• Occipital location
• Increasing severity or frequency
• Headache causing awakening from sleep
• Neurologic abnormalities or visual changes
• Headache in the morning, associated with vomiting
• Persistent vomiting
• Behavioral changes
Box 2.1: Warning Features (Red Flags) in Childhood
Headache [65]
Table 2.7 Examples of various types of seizures, with a description of each one [66–68]
Type of seizure Description/clinical features Generalized tonic–clonic
seizure – The child falls to the ground unresponsive, with eye deviation or blinking
– The initial generalized stiffness of limbs, body, and head (tonic phase) may be associated with cyanosis
– The tonic phase is followed by arrhythmic jerking movements (clonic)
– There may be salivary frothing and incontinence of urine or stool
– There is a postictal period of decreased responsiveness or weakness
Tonic seizures – These are breif seizures consisting of the sudden sustained contraction of extensor muscles – They are often associated with falls
Myoclonic seizures – These are sudden, brief (usually <50 ms) involuntary contractions of muscles or muscle groups
– The contractions can be singular or repetitive and are often irregular
Atonic seizures or drop
attacks – These are characterized by loss of postural tone and movement, typically lasting for a brief period (1–2 s) and associated with falls that may lead to facial injury Absence seizures – These occur in children aged between 4 and 12 years
– They may be typical, atypical, or absence with special features
– Typical absence seizures are generalized seizures consisting of an abrupt onset of unresponsiveness, loss of awareness, staring, and eye flutter
– Often the only observed behaviors are lip smacking or semi-purposeful-appearing movements of the hands, with no falls
– These are usually brief (2–15 s) and may occur hundreds of times per day
– They may interfere with the child’s activity and learning – They may be precipitated by hyperventilation for 3–5 min – There is no postictal drowsiness
Focal seizures – Simple partial seizure: Consciousness is not impaired, with motor (can be tonic, clonic, myoclonic), sensory (visual, auditory, olfactory, gustatory, vertiginous, somatosensory), autonomic, or mixed symptoms – Complex partial seizure may be associated with impaired
consciousness and automatisms
– Partial seizures with secondarily generalized convulsions Epileptic spasms (the
preferred term over infantile spasms, because these can occur beyond infancy)
– These occur in infants aged between 3 months and 2 years
– They consist of mixed flexion-extension, flexion, or, less commonly, extension of truncal and extremity muscles that is continued for 1–2 s and may associate with a cry – Attacks of epileptic spasm occur numerous times each
day
– They usually occur in clusters, either upon falling asleep or during early waking hours
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Table 2.7 (continued)
Type of seizure Description/clinical features
Febrile seizures – These occur in children between the ages of 6 and 60 months and associate with fever (38 °C or higher) in the absence of CNS infection or any metabolic imbalance – Simple febrile seizures are primary generalized (usually
tonic–clonic) and brief (last less than 15 min) and do not occur more than once within a day. The child with this type of seizure is neurologically and developmentally normal
– Complex febrile seizures are focal, prolonged (last longer than 15 min), and/or repeated in the same illness (occur multiple times in 24 h)
• Identity: Age
• Chief complaint: Abnormal body movement
• History of present illness:
1. Antecedent: What happened in the hours before the spell? Was the child well or ill, feverish, excited or calm, tired or alert?
2. Context: What happened immediately before the spell? What was the child doing? Were there any provoking factors?
3. Onset: How did the spell start? Was there an aura (behavioral change, feel-ing of fear, a cry, epigastric discomfort or pain, irritability, lethargy)?
Were there any warning signs, triggers for the spells (crying, boredom, anger, anxiety, trauma, or fever)? What was the first thing the child or wit-nesses noticed?
4. Can the child tell when an episode will occur?
5. Does the child remember the spells afterward? Can he/she describe what happens?
6. Description of the event: Was the event witnessed? If so, what was noted during the attack? The color of the skin, lips, breathing changes, type of body movements: tonic–clonic movements, stiffness or floppiness, focal movement? What sort and where: limbs, face, mouth? Was saliva pro-duced at the mouth? Eyes: What did the child’s eyes do? Was the seizure associated with loss of consciousness, incontinence of urine or feces? Did the child experience a loss of responsiveness? Did the child speak or vocalize during the spell?
7. How long did the event last (duration)? How did it resolve?
8. Postictal phase: What did the child do after the attack? Postictal (weak-ness or paralysis, sleep, headache, confusion, injuries)? How long before getting back to normal?
History Station 2.24: Seizure
Continued on the next page 2.25 Seizure
• Past history:
A—Birth history: Maternal diabetes, complicated birth, prolonged labor with fetal distress, instrumental delivery, birth injury, and prolong resuscitation
B—Past medical and surgical history: Head trauma, meningitis, previous brain damage, metabolic disorders, illnesses, rheumatic fever, hospitaliza-tions, history of febrile seizures, previous episodes of seizure. If there is epilepsy, ask about: When did it begin? What was the age of onset? What is the frequency of episodes? What were the results of electroencephalo-grams, CT scans, etc.?
• Medication history: Recent use of medications (e.g., antidepressants, stimu-lants, immunosuppressants, antibiotics, lithium, hypoglycemic agents, isoni-azid), if the child on antiepileptic drugs (ask about type, dose, frequency of administration, recent modification of the dose, noncompliance with anticon-vulsant medication), drug allergies
• Development history: Developmental delay, school performance
• Immunization history: Recent vaccination, e.g., MMR, diphtheria, tetanus, and acellular pertussis (DTaP)
• Family history: Family history of epilepsy or similar episodes, migraines, tremors, tics, streptococcal infection, rheumatic fever, sleep disturbance, Tourette syndrome, metabolic disorders, or liver disease
• Social history: Alcohol, drug addiction, lead exposure, impact of epilepsy on child’s life
• Review of Systems: Diarrhea, vomiting, jaundice, pallor, weight loss, poor appetite, skin rash, hearing impairment, dyspnea, cyanosis, joint pain
• Seizure in a neonate should always raise the concern for an underlying cause.
• Seizure in a febrile child aged between 6 and 60 months may suggest febrile seizure [66].
• A focal seizure may suggest localized intracranial lesions.
• Early onset of seizures, vomiting, and lethargy may suggest a metabolic disorder.
• Seizure associated with a recent headache, vomiting, lethargy, weakness, or alteration in gait may suggest central nervous system (CNS) pathology, or space-occupying lesions [68].
Key Points 2.24
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