What are the key components of a physical exam for a patient presenting with seizures?

Key Components of Physical Examination for Seizure Patients

The essential components of a physical examination for patients presenting with seizures include vital sign assessment, neurological examination focusing on mental status and focal deficits, signs of trauma, and evaluation for underlying medical causes, as recommended by the American College of Emergency Physicians. 1

Initial Assessment

• Vital Signs:

  • Temperature (fever may indicate infection/meningitis)
  • Blood pressure (hypertension may suggest hypertensive encephalopathy)
  • Heart rate and respiratory rate
  • Oxygen saturation

• General Appearance:

  • Level of consciousness and orientation
  • Signs of trauma (especially head trauma)
  • Evidence of tongue biting or urinary incontinence
  • Skin examination for rashes (meningococcemia), petechiae, or signs of drug use

Neurological Examination

• Mental Status:

  • Orientation to person, place, time
  • Attention and concentration
  • Memory assessment
  • Speech patterns (post-ictal aphasia)

• Cranial Nerve Examination:

  • Pupillary size, symmetry, and reactivity
  • Extraocular movements
  • Facial symmetry
  • Tongue deviation

• Motor Examination:

  • Strength assessment in all extremities (focal weakness may indicate Todd's paralysis or structural lesion)
  • Pronator drift
  • Asymmetric reflexes
  • Abnormal tone (spasticity or rigidity)

• Sensory Examination:

  • Response to tactile and painful stimuli
  • Sensory deficits that might indicate focal lesions

• Coordination and Gait:

  • Finger-to-nose testing
  • Heel-to-shin testing
  • Gait assessment if patient is able to ambulate

Signs of Specific Etiologies

• Meningeal Signs:

  • Nuchal rigidity
  • Kernig's sign
  • Brudzinski's sign

• Signs of Increased Intracranial Pressure:

  • Papilledema on fundoscopic examination
  • Hypertension with bradycardia (Cushing's triad)
  • Altered mental status

• Evidence of Systemic Disease:

  • Hepatomegaly (liver disease)
  • Cardiac murmurs (endocarditis with emboli)
  • Signs of alcohol withdrawal (tremor, tachycardia, diaphoresis)
  • Evidence of trauma or head injury

Common Pitfalls to Avoid

1. Failure to identify non-convulsive status epilepticus: Patients with altered mental status without obvious convulsions may be in non-convulsive status epilepticus, which requires EEG for diagnosis 1

2. Missing signs of alcohol withdrawal: Alcohol withdrawal seizures should be a diagnosis of exclusion, as other serious conditions may coexist 1

3. Overlooking subtle focal neurological deficits: These may indicate a structural lesion requiring urgent neuroimaging 2, 1

4. Inadequate assessment for trauma: Patients may have sustained injuries during seizure activity that require treatment

5. Neglecting to check for rhabdomyolysis: Physical signs like muscle tenderness should prompt CK level testing, especially after generalized tonic-clonic seizures 2, 1

The physical examination findings should guide the subsequent diagnostic workup, including laboratory tests and neuroimaging. Patients with focal neurological deficits, persistent altered mental status, fever, recent trauma, persistent headache, history of cancer, anticoagulation, or suspected HIV infection require urgent neuroimaging 2, 1.