Epilepsy

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Greeting

Good day, esteemed Professor Doctor …,

I would now like to present the patient Beate Bauer.

She is 37 years old, one meter seventy-one tall and weighs approximately 73 kg.
The body mass index (BMI) is 22.9 kg/m² and therefore within the normal range.

Current history

The patient presented to us because about three hours ago a generalized tonic-clonic seizure occurred suddenly.

According to her husband, the seizure lasted just under two minutes.
Her husband stated that she was unresponsive during the seizure.
He reported observing an upward gaze deviation of the eyes during the seizure.

(The husband described that the patient initially showed a tonic phase with pronounced contractions and extended extremities, which is considered a tonic phase. This was followed by involuntary, rhythmic muscle jerks, referred to as the clonic phase.)

The following clinical signs were not observed: urinary incontinence or fecal incontinence, jaw clenching, tongue bite, cyanosis, fall/trauma, fever, nausea, emesis, tachycardia, dizziness, palpitations, signs of orthostatic hypotension.

As an aura the patient reported a cephalgia and a feeling of inner restlessness that occurred about 1 minute before the seizure.

She reported postictal fatigue and nervousness.

She stated that last night at a wedding reception she drank a lot of beer and vodka. She also slept only about four hours.

Autonomic history

The autonomic history is unremarkable, aside from stress-related insomnia in the form of difficulty falling asleep due to worries about her son and an alternation between constipation and diarrhea with a known irritable colon, present for five years.

Past medical history

Her known past medical conditions are as follows:

She reported suffering for about five years from an irritable colon with alternating bowel habits between diarrhea and constipation. A colonoscopy and other examinations were unremarkable.

She stated that eight years ago she had a miscarriage in the tenth week of pregnancy, for which no precise cause was determined.

According to her own account, the patient had a febrile seizure at the age of one to two years, which was treated with a suppository.

Since childhood there has been a seborrheic dermatitis behind the ears and on the eyebrows, especially in winter, which is treated with corticosteroid ointment as needed. (I observed the scales during the history taking! 😯)

She reported that six years ago she had a climbing accident from about three meters height, resulting in a left-sided acetabular fracture.
This was treated conservatively with rest and physiotherapy.

She added that at age 20 she was hospitalized for one day due to an alcohol intoxication.

Previous surgeries

The patient reported that following a paragliding accident ten years ago she sustained a fracture of the right patella. She declined the surgical treatment recommended at that time due to anxiety.
Since then she has had load-dependent pain in the right knee.

Gynecology

In the gynecological history the patient stated that her last menstruation occurred ten days ago.
Four years ago she had a spontaneous vaginal delivery.
She currently has no gynecological complaints.

Medications

The patient is currently taking the following prescription medications:

Imodium® melt-in-the-mouth tablets
Voltaren® Dispers 46.5 mg.
She also uses a corticosteroid ointment for exacerbations of seborrheic dermatitis.

Allergies

She reacts to seafood with eyelid edema, tongue edema and a rash on the abdomen.
(This reaction reportedly occurred three years ago during a stay in France, requiring treatment in a practice at that time.)
She also has an allergy to dog hair, presenting with a rash and pruritus.

Substance use

Regarding recreational substances the patient reported being a non-smoker for five years. Previously she smoked about ten cigarettes per day for several years, corresponding to approximately 4.5 pack years.
Occasionally she drinks vodka and beer, at times in excessive amounts.
In the past she occasionally used joints.

Social history

She runs her own web design company and lives with her family in an apartment.
She has a four-year-old son who suffers from an atrial septal defect.

Family history

Her father was diagnosed five years ago with peripheral arterial occlusive disease (pAVK) as a result of long-term smoking. Ten years ago he also suffered from left-sided keratitis, which was treated with keratoplasty.
Her mother suffers from Sudeck’s disease (CRPS) after a distal radius fracture one and a half years ago.

Suspected and differential diagnosis

The anamnestic details, including the aura, loss of consciousness, duration, generalized myoclonus and the postictal phase, are most consistent with an epileptic seizure. It should be distinguished whether this is a primary (unprovoked) or secondary seizure.

As a trigger for the seizure, alcohol consumption and sleep deprivation are possible in this case.

Secondary causes could include hypoglycemia, electrolyte disturbances, infections (e.g., meningitis), tumors, poisonings and drug use.

Differentially, a syncope should also be considered, which usually features rapid recovery and no postictal state.

Additionally, psychogenic non-epileptic seizures (PNES) typically show variable movement patterns.

Diagnostic workup

Because of the risk of another seizure, the patient should be admitted and have two large-bore venous accesses placed. Blood glucose should also be measured to exclude hypoglycemia.

Physical examination

After the history a thorough physical examination is performed. This begins with recording vital signs, including heart rate, blood pressure, respiratory rate, oxygen saturation and body temperature.

This is followed by a focused exam starting with inspection. Postictally the patient may appear tired and confused. Visible injuries from a fall and a lateral tongue bite are possible.

Palpation may reveal signs of a posterior shoulder dislocation — for example following a tonic-clonic seizure — as well as tachycardia.

Percussion has no immediate diagnostic utility in the context of epilepsy diagnostics.

Auscultation, however, can help to exclude syncope as a differential diagnosis, particularly by detecting cardiac arrhythmias or tachycardia.

Assess for neurological abnormalities: A focal neurological deficit after a seizure could be a postictal Todd paralysis, but may also indicate a stroke or CNS lesion.

A neurological examination should follow, especially to assess cranial nerve function (pupillary reaction, eye movements, facial motor function), sensation (e.g., by touch or pressure stimuli) and motor function (muscle tone, active and passive mobility, coordination, reflexes). A fundoscopy is essential to exclude a possible papilledema.

Cranial nerve function in detail:

• N. olfactorius (I): olfactory nerve

• N. opticus (II): optic nerve

• N. oculomotorius (III), N. trochlearis (IV), N. abducens (VI): oculomotor nerves controlling eye movements

• N. trigeminus (V): facial sensation and masticatory muscles

• N. facialis (VII): facial muscles, taste

• N. vestibulocochlearis (VIII): hearing and balance

• N. glossopharyngeus (IX): taste, swallowing reflex

• N. vagus (X): parasympathetic innervation of the viscera

• N. accessorius (XI): shoulder and neck muscles

• N. hypoglossus (XII): tongue movement

A CNS infection (e.g., meningitis/encephalitis) can also trigger seizures and must be considered in the presence of fever, meningismus or altered consciousness.

Laboratory tests

We would determine a complete blood count, blood glucose, electrolyte balance (sodium, potassium), renal function (creatinine, BUN), liver values (ALT, AST, alkaline phosphatase), acid–base status and, if suspected, a urine drug screen.

If meningitis is suspected, a cerebrospinal fluid examination should additionally be performed to confirm the diagnosis.

EEG (electroencephalogram)

An EEG is a test that measures the electrical activity of the brain. Electrodes are attached to the scalp to record the brain’s electrical signals. The patient sits or lies relaxed while the recording takes place. The test is painless and usually lasts 20–60 minutes.

During an epileptic seizure, the EEG shows rhythmic discharges (e.g., spikes or sharp waves) in a localized brain region for focal seizures, which may spread. In a generalized seizure, symmetrical, synchronous discharges occur in both hemispheres, typically as generalized spike-wave or polyspike-wave complexes.

Not to forget, the EEG can often be normal between seizures (interictal).

ECG

ECG to exclude cardiac causes, particularly arrhythmias or syncope with transient loss of consciousness, which can mimic an epileptic seizure.

MRI (magnetic resonance imaging)

An MRI is an imaging procedure that uses magnetic fields and radio waves to create detailed images of organs, tissues and structures in the body. The patient must first remove jewelry and other metallic objects and is then moved into a tunnel-like scanner. The patient must also inform the staff about any implants or a pacemaker before the exam. During the examination, which lasts about 20–60 minutes, the patient must lie still. In some cases contrast agent may be administered to better visualize certain structures. Contrast administration carries a risk of allergic reactions or contrast-induced nephropathy.

After a first unprovoked seizure or in focal seizures, priority should be given to performing an MRI of the skull.

cranial CT

An immediate cranial CT (cCT) is only required if red flags are present that indicate an acutely treatable cause. These include a fall or head trauma as a result of the seizure, prolonged impairment of consciousness or a newly developed focal neurological deficit, as well as risk factors for intracranial bleeding or trauma consequences, for example anticoagulation.

Consultations

Neurology

Treatment

Acute management of an epileptic seizure in the emergency department

Medical orders

• NPO (nothing by mouth) from now on.

• Positioning: recovery position, keep airway clear, remove sources of injury, do not restrain.

• Monitoring: continuous ECG, SpO₂, blood pressure; vigilance checks. Vital signs every 15 minutes until stable, then hourly.

• O₂ via nasal cannula 2–4 L/min (target SpO₂ ≥ 94%; for COPD according to baseline).

• Two large-bore IV accesses (at least 16G).

• Determine blood glucose immediately to exclude hypoglycemia.

• Labs: CBC, electrolytes (Na, K), creatinine/eGFR, urea, liver enzymes (AST/ALT, AP, bilirubin, GGT), blood gas (arterial/venous) including lactate, if applicable β-hCG (in women of childbearing potential), urine drug screen (only if suspected).

• 12-lead ECG.

• Imaging: cranial CT (after stabilization, for first seizure, trauma, focal deficit, anticoagulation, etc.).

• Stage – seizure termination:

• Lorazepam 4 mg IV slowly
(If the seizure continues after 5 to 10 minutes (i.e., has not stopped), the same dose of the medication may be repeated once.)

• Alternatively: midazolam 10 mg IM/buccal/nasal or diazepam 10 mg IV.

• Stage – benzodiazepine-refractory:

• Immediate neurology consult.

Seizure prophylaxis

Initially, the patient should avoid possible trigger factors. If an organic cause is present, it must be treated specifically. The diagnosis of epilepsy is made when at least two unprovoked seizures occur more than 24 hours apart. Anticonvulsants such as levetiracetam, lamotrigine, valproate or carbamazepine may be prescribed.

For focal seizures, carbamazepine, lamotrigine or levetiracetam are used.

For generalized seizures, valproate is considered first-line; alternatively lamotrigine or levetiracetam may be used.

For absence seizures, ethosuximide is the first-line therapy, followed by valproate or lamotrigine.

Complications

Status epilepticus: seizure lasting longer than 5 minutes or multiple seizures without full recovery between them (risk: brain damage, hypoxia)

Injuries

Cognitive impairments: concentration disorders, memory problems

Extra

Names:

Fritz Sauermann, Egon Schiele, Alfons Börk, Mrs. Heinimann, Peter Rosenhagen, Peter Nagelsmann

Professions:

Lawyer, independent photography business, librarian

Details:

The patient was against vaccinations.

The patient reported involuntary loss of urine (urinary incontinence) during the seizure.

10-year company anniversary, the 10th anniversary celebration of his law firm office.

The family doctor recommended psychotherapy due to excessive consumption at parties.

As an aura she named visual blurring (blurred vision).

Status post 2 × cesarean section (without complications).

Current History:
An epileptic patient was in a mountain house, drank alcohol and celebrated with friends. He then suffered a convulsive seizure and injured his head. His friends brought him to the hospital. The patient arrived with severe headache (9 out of 10) after the injury. He had no symptoms prior to this seizure, however a similar incident occurred last year.

After the seizure he noticed dizziness, a strange sensation and fatigue. “What do you mean by strange sensation?” Patient: “I don’t know what it is, it’s not vertigo, not pain.”

Pre-existing conditions:

Long-standing vertigo
Ectopic pregnancy two years ago, status post surgery with salpingo-oophorectomy (removal of fallopian tube and ovary).
Celiac disease
Patellar fracture 5 years ago after a climbing accident, surgically treated. (load-dependent knee pain).
Gonalgia with cruciate ligament rupture
Atopic dermatitis on the elbows and popliteal fossae
Dysphonia (due to dry and cold air in the copy shop), treatment: Neoangin plus – lozenges
Psoriasis
Reflux disease, pantoprazole
Status post endoscopic hernioplasty on the left due to an inguinal hernia 3 years ago, uncomplicated.
Status post lymph node excision in the left axilla 8 years ago. Postoperatively, an edema of the left arm was noted as a complication.
Arterial hypertension – Valsartan 80 mg + Amlodipine 5 mg

Allergies:

Symptoms occurred when his son had a dog; therefore they must give the dog away.
House dust mites: rhinoconjunctivitis
Insect venom allergy (bee and wasp sting) with anamnestic anaphylactic shock. The patient carries an emergency kit (EpiPen®).

Family history:
Twin sister suffers from obesity
Father: cataract, treatment: lens implantation
The father had his aortic valve replaced. The procedure was performed via the groin. This surgical method is called transcatheter aortic valve implantation (TAVI).
The patient’s youngest child, however, suffers from cystic fibrosis.
The father suffered a brain hemorrhage at age 67 due to an aneurysm, which was surgically treated by clipping. He is currently in a hospice and suffers from a hemiparesis.

Questions

1. What is meant by an epileptic seizure?

An epileptic seizure is a sudden, transient dysfunction of the brain caused by uncontrolled electrical discharges of neurons. It manifests, for example, as jerking, loss of consciousness, sensory disturbances or behavioral changes.

2. What are trigger factors in epilepsy, and which ones do you know?

Trigger factors are stimuli or conditions that favor or trigger epileptic seizures. Known trigger factors in epilepsy include: sleep deprivation, stress, flickering light (e.g., during screen work), alcohol, febrile infections, hormonal changes, and certain medications such as tricyclic antidepressants and antipsychotics.

3. What does it mean when the patient is frozen (immobile)?

“The patient is frozen” means that she suddenly became motionless and rigid – often as a sign of a tonic seizure or a psychogenic reaction.

4. What is needed for the neurological examination?

• a tuning fork (for vibration sense)

• a reflex hammer (to test deep tendon reflexes)

• a flashlight (for pupillary reaction)

• a cotton swab or brush (for touch sensation)

• an ophthalmoscope

5. How can sensitivity between two points be tested?

Using a so-called Weber caliper (two-point discriminator), the physician checks whether the patient still perceives two closely adjacent stimuli as separate – this is called two-point discrimination. The examination is performed by placing both tips of the caliper on the skin simultaneously and gradually reducing the distance until the patient feels only one point.

6. In which cases is a CT scan indicated in epilepsy?

• MRI is not immediately available.

• an acute neurological emergency is suspected (e.g., hemorrhage, tumor, cerebral edema).

• a focal neurological finding is present.

7. Would you have blood glucose measured during an epileptic seizure even if the patient is not diabetic? Why?

Yes, because hypoglycemia can trigger a seizure – regardless of whether diabetes is known. It can basically occur in anyone, especially in this patient, since she both drank excessively yesterday at a wedding celebration and had not eaten breakfast. Both factors promote the occurrence of hypoglycemia.

8. What must be considered before a cerebrospinal fluid examination?

Before a lumbar puncture, intracranial pressure must be excluded – e.g., by cranial CT or funduscopic examination – and coagulation status must be checked.

9. What is IBD and which types exist?

IBD stands for inflammatory bowel disease. The two main forms are:

• Crohn’s disease – affects the entire gastrointestinal tract in discontinuous segments

• Ulcerative colitis – affects only the colon, usually starting in the rectum, in a continuous pattern

Both diseases run in flares and typically present with diarrhea, abdominal pain and sometimes weight loss.

Diagnosis is usually made by endoscopy/colonoscopy with biopsy.

10. Is cystic fibrosis hereditary, what is the prognosis and life expectancy, what is the main problem of this disease, where exactly does the viscous secretion form in the lung, and which inflammations occur frequently?

Yes, cystic fibrosis is an autosomal recessive inherited metabolic disease.
The main problem is the production of thick mucus, especially in the lungs and the digestive tract.
The mucus accumulates mainly in the bronchi.
Frequent complications are recurrent bacterial bronchitis and pneumonias.
Prognosis has improved significantly with modern therapies; life expectancy today is over 40 years.

11. In which diseases can symptoms similar to irritable bowel syndrome occur?

Similar symptoms can occur in inflammatory bowel diseases (e.g., Crohn’s disease, ulcerative colitis), food intolerances (e.g., lactose intolerance), celiac disease, bacterial overgrowth, thyroid disorders or tumors in the gastrointestinal tract. Therefore, a thorough evaluation is important.

The shaking palsy is an outdated, colloquial term for Parkinson’s disease.

Notes

BMI

Body mass index (BMI)
The BMI is a simple ratio measure for classifying body weight. It is calculated from body weight in kilograms divided by the square of height in meters. The resulting value is used for rough categorization into underweight, normal weight or overweight.

/m²

Unit /m²
The notation “/m²” means “per square meter” and denotes a reference to the area of one square meter.

generalized tonic-clonic

Generalized tonic-clonic seizure
In this seizure type both cerebral hemispheres are involved and symptoms usually occur in a generalized manner. The tonic phase is characterized by a short-lasting stiffening of the muscles, the subsequent clonic phase shows rhythmic jerking of the musculature. Clinically, loss of consciousness during the seizure and typical motor patterns can occur.

unresponsive

Unresponsive
“Unresponsive” describes the absence of a reaction to verbal or tactile stimuli. In epileptic seizures this can range from a transient unclear responsiveness to lack of consciousness; it is not necessarily identical with permanent loss of consciousness. Observation by relatives (no responsiveness, deviation of gaze) is compatible with a seizure phase.

Urinary incontinence

Urinary incontinence

Definition: Involuntary release of urine due to disturbed bladder function or insufficient sphincter control.

Fecal incontinence

Fecal incontinence

Definition: Uncontrolled loss of intestinal contents due to weakness or damage of the sphincter, impaired sensation or diseases causing fecal incontinence.

Jaw clenching

Jaw clenching

Definition: Persistent, often unconscious pressing together of the teeth due to increased tension of the masticatory muscles.

Consequences: Can lead to tooth damage, muscle tension and temporomandibular joint problems.

Nausea

Nausea

Definition: Subjective, unpleasant sensation in the upper abdomen with the desire or urge to vomit; a symptom that can have many causes.

Emesis

Emesis (vomiting)

Term for the active expulsion of gastric contents through the mouth or nose. Vomiting is a nonspecific symptom that can occur with gastrointestinal disorders, intoxications, vestibular problems or central nervous system diseases. Clinically important are accompanying symptoms such as nausea, fluid loss and the risk of aspiration.

Tachycardia

Tachycardia (rapid heartbeat)

Denotes a pathologically increased heart rate. It can occur acutely or chronically and has various causes, such as physiological reactions (stress, physical exertion), metabolic disturbances, fever or cardiac arrhythmias. In tachycardias, differentiation by origin and assessment of hemodynamics and accompanying symptoms are important.

Palpitation

Palpitation (awareness of heartbeats)

Subjective perception of conspicuous heartbeats, for example as strong pounding, skipping or irregular beating. Palpitations are a symptom and can be triggered by increased heart rate, extrasystoles, arrhythmias, metabolic disturbances or psychological stress. They are to be distinguished from objectively measurable tachycardia.

orthostatic hypotension

orthostatic hypotension

Symptom complex in which upon rising from a supine or seated position temporary circulatory disturbances occur, typically with dizziness or the sensation that one’s vision is “going black.” The cause is inadequate adjustment of blood pressure to the change in position; possible triggers are fluid deficiency, medications or autonomic dysfunction.

Aura

Short description: Early warning signs before neurological events.

What it is: An aura denotes perceivable symptoms that immediately precede a neurological event and usually last only briefly.

Duration and course: Typically the complaints occur for seconds to a few minutes and then subside.

Typical features: Visual disturbances (e.g., light phenomena, scintillations), sensory changes (tingling, numbness), transient speech or smell impressions as well as emotional sensations such as sudden fear or déjà-vu experiences can be part of it.

Cephalgia

Short description: Symptom “headache”.

Definition: Cephalgia is the general term for pain in the head region; intensity, localization and accompanying symptoms can vary greatly.

Clinical classification: Headache can be acute or chronic and have different causes (e.g., primary headache syndromes, secondary causes). In migraine the pain often follows an aura; in epileptic seizures persistent headache is more likely to be seen as an accompanying or subsequent phenomenon.

Fatigue

Short description: Persistent exhaustion symptomatology.

Definition: Fatigue describes a pronounced, often long-lasting and burdensome exhaustion that manifests as reduced performance and increased need for recovery.

Clinical relevance: Fatigue can occur after neurological events, including after a seizure (postictal), and impair subjective well‑being and daily functioning.

Wedding celebration

Short description: Social celebration on the occasion of a marriage.

What it is: A wedding celebration is a culturally shaped event to celebrate a marriage; customs and practices vary regionally and individually.

Beer and vodka

Alcohol consumption (beer and vodka) — possible trigger

four

Trigger factor: sleep deprivation

Insomnia

Insomnia (difficulty initiating sleep)

Constipation

Constipation (Obstipation)
Within the context of an irritable bowel known for five years (Colon irritabile), the patient describes alternating bowel habits with phases of constipation and diarrhea. The constipation phases are part of this long-standing pattern.

Diarrhea

Diarrhea

Definition: Increased frequency and increased fluidity of stool compared with the usual bowel habit. Diarrhea can be either short‑lived or persistent over longer periods.

Colon irritabile

Colon irritabile (Irritable bowel syndrome)

Definition: A functional disorder of the intestine characterized by recurrent abdominal pain and altered bowel habits (e.g., diarrhea, constipation, or alternating both) without demonstrable organic cause.

Diagnosis: Determination is clinical based on typical symptoms; prior investigations serve to exclude organic diseases. Often no pathological findings are seen on imaging or endoscopic examinations.

Therapeutic principles: Treatment is oriented to the predominant complaints and is symptomatic. Measures can include dietary adjustments, behavioral or psychosocial approaches, and, depending on the dominant symptom, targeted pharmacological options (e.g., antidiarrheals for predominant diarrhea).

Colonoscopy

Colonoscopy

Definition and purpose: Colonoscopy is an endoscopic examination of the large intestine for direct assessment of the mucosa. It serves to diagnose inflammatory diseases, polyps, and tumors and to exclude organic causes in unclear bowel complaints.

Indication relevance: In suspected chronic inflammatory disease, alarming symptoms, or to clarify unclear endoscopic or imaging findings, colonoscopy is used. In functional disorders such as irritable bowel syndrome, the examination often remains without specific findings.

Miscarriage

Miscarriage (Abort)

Definition: A miscarriage denotes the premature loss of a pregnancy before fetal viability; many definitions use the threshold before the 24th week of gestation.

Causes and forms: Causes are diverse and can include chromosomal abnormalities of the embryo, infections, hormonal disorders, anatomical peculiarities of the uterus, or immunological factors. Various forms are distinguished, such as spontaneous miscarriage and missed (retained) abortion.

Clinical signs: Typical accompanying signs are vaginal bleeding, lower abdominal pain, and possibly passage of tissue. The exact cause cannot always be determined.

febrile seizure

Brief definition:
A febrile seizure is a sudden, fever‑triggered epileptiform seizure in young children.
Clinical features:
Seizures mostly occur in infancy and toddlerhood and are often generalized tonic‑clonic. Episodes typically last only a few minutes. Many children recover without permanent damage.
Significance and course:
Febrile seizures are frightening for parents but are usually benign and in most cases do not require long‑term antiepileptic therapy. Prolonged, focal, or recurrent seizures should be medically evaluated.

seborrheic dermatitis

Brief description:
Seborrheic dermatitis is a chronic‑recurrent inflammation of the skin favoring sebum‑rich regions.
Clinical picture:
Typical are red, scaly skin areas, often with greasy‑appearing deposits. The scalp, facial areas (e.g., eyebrows, nasolabial folds), chest, and behind the ears are particularly affected. Symptoms can fluctuate seasonally and worsen with stress or other factors.
Causes and therapeutic approaches:
Involvement of skin‑resident yeasts and individual disposition are discussed. Treatment includes topical antifungal products and, during inflammatory flares, short‑term use of low‑potency topical corticosteroids; mild care products also support the skin barrier.

Acetabulum fracture

Brief definition:
An acetabulum fracture refers to a bone fracture of the hip socket, i.e., the bony socket portion of the hip joint.
Causes and clinic:
Such fractures usually result from direct or indirect high‑energy trauma in accidents. Symptoms are pain in the hip region and limited load‑bearing capacity.
Treatment and significance:
Therapy depends on fracture type and displacement; minimally displaced injuries can be treated conservatively with rest and subsequent physiotherapy, while markedly displaced fractures often require surgical management. Long‑term problems can include joint complaints or early osteoarthritis.

Alcohol intoxication

Brief definition:
Alcohol intoxication results from excessive intake of ethanol and can affect the central nervous system, respiration, and circulation.
Clinical spectrum:
Depending on the amount consumed and individual tolerance, symptoms range from unsteady gait, speech disturbances, and disinhibition to impaired consciousness, respiratory depression, and life‑threatening states.
Acute management:
Treatment includes monitoring of vital signs, airway protection and aspiration prevention, fluid and electrolyte replacement if needed, and evaluation for comorbidities; severe cases require intensive care.

Imodium

Active ingredient and class: Loperamide, an antidiarrheal.
Mechanism: Loperamide reduces gut motility by acting on peripheral opioid receptors in the gastrointestinal tract, thereby prolonging intestinal transit time.
Indication: Used for acute, non‑infectious diarrheas for short‑term symptom control.
Important risks: Common adverse effects are constipation and abdominal cramps; if warning signs such as high fever or bloody diarrhea occur, use should be medically evaluated.

Voltaren

Active ingredient and class: Diclofenac, a nonsteroidal anti‑inflammatory drug (NSAID).
Mechanism: Diclofenac inhibits cyclooxygenase enzymes and thus reduces prostaglandin synthesis, producing analgesic and anti‑inflammatory effects.
Indication: For symptomatic treatment of pain and inflammatory complaints.
Important risks: Possible side effects include gastrointestinal complaints (e.g., abdominal pain, nausea), headache, and allergic reactions; with prolonged or high‑dose use, gastric ulcers and impaired kidney function may occur.

Cortisone ointment

Drug class: Topical glucocorticoids (commonly used substances e.g., hydrocortisone, betamethasone, mometasone).
Indication: For treatment of inflammatory skin diseases such as eczema, atopic dermatitis, or seborrheic dermatitis during flares.
Mechanism: When applied locally, they reduce inflammatory reactions, relieve itching, and decrease swelling.
Important risks: With prolonged or large‑area use, skin atrophy, pigment changes, and delayed wound healing can occur; application recommendations and treatment duration should be medically or professionally coordinated.

Seafood

Definition: Seafood includes various edible animals from the sea, typically bivalves and other mollusks, crustaceans such as shrimp and crabs, and cephalopods like squid.
Examples: Mussels, shrimp, crabs, squid.
Clinical note: Seafood are foods that can trigger allergic reactions; such reactions range from skin symptoms to mucosal swelling and systemic manifestations.

Eyelid edema, tongue edema

Eyelid edema and tongue edema

Brief description: Swelling of the eyelids and the tongue, as can occur in angioedema.

Clinical context: The history reports that after consuming seafood about three years ago, a reaction occurred with swelling of the eyelids and tongue and a simultaneous skin rash on the abdomen. This reaction at that time led to treatment in an outpatient clinic.

Rashes

Rash (Exanthem)

Definition: A rash denotes a skin eruption, often diffuse or localized, which can occur with allergic reactions or infections.

Clinical context: In the provided history, a rash on the abdomen occurred simultaneously with swelling after eating seafood. Additionally, an allergy to dog hair is described with a skin rash accompanied by itching.

Pruritus

Pruritus (itch)

Term explanation: Pruritus denotes the subjective sensation of itch on the skin.

Clinical context: The history reports that with an allergy to dog hair, itching occurs together with a skin rash.

Pack‑years

Pack‑years

Explanation: The measure “pack‑years” quantifies cumulative exposure to cigarettes and is calculated as (number of cigarettes smoked per day ÷ 20) × number of smoking years.

Anamnestic classification: The patient stated she used to smoke about ten cigarettes per day and has been a non‑smoker for five years. In the history a burden value of about 4.5 pack‑years is given.

Joints

Short description
Joints are hand‑rolled smoking products in which dried cannabis products such as marijuana or hashish are rolled into paper. Material is often mixed with tobacco.
Use and effects
When inhaled, the active substances contained in cannabis quickly enter the bloodstream and can cause psychological and sensory changes.
Important risks
Mixing with tobacco increases the burden on the airways and the addiction potential. Acute effects can include anxiety or perceptual disturbances; long‑term risks affect the airways and mental health.

Atrial septal defect

Definition
An atrial septal defect (ASD) is a congenital defect of the atrial septum with an open connection between the left and right atrium.
Pathophysiology
Due to the defect, there is typically a left‑to‑right shunt that volumetrically burdens the right heart and the pulmonary circulation.
Clinical presentation
Small ASDs often remain asymptomatic. Larger defects can cause exertional dyspnea, recurrent pulmonary problems or cardiac arrhythmias.
Diagnosis and therapy
Evaluation is mainly by echocardiography. Depending on size and clinical relevance, catheter‑based closure or surgical correction is possible.

pAVK

Definition
Peripheral arterial occlusive disease (pAVK) denotes narrowings or occlusions of the arterial vessels, mostly of the legs, with reduced blood flow.
Causes and risk factors
The main cause is atherosclerotic vascular change. Promoting factors are smoking, arterial hypertension, diabetes mellitus, lipid metabolism disorders and lack of physical activity.
Clinical presentation
A typical symptom is exertional leg pain (claudication), often accompanied by skin changes or impaired wound healing in advanced stages.
Therapy
The goal is risk factor reduction and, depending on severity, possibly interventional or surgical restoration of vascular patency.

Keratitis

Definition
Keratitis is an inflammation of the cornea of the eye.
Causes
Triggers can be infections, mechanical injuries, contact lens use or other irritative/inflammatory processes.
Clinical signs
Typical symptoms are eye pain, redness, photophobia, tearing and impaired visual acuity.
Treatment and prognosis
Therapy depends on the cause; untreated corneal inflammation can lead to scarring and vision loss, but with timely and appropriate treatment the prognosis is significantly better.

Keratoplasty

Keratoplasty

Term and goal: Keratoplasty is a surgical procedure to restore or replace the cornea of the eye. The goal is to eliminate clarity and/or structural defects of the cornea that impair vision or endanger the eye.

Procedures: A distinction is made between full‑thickness transplants, in which the entire corneal layer is replaced, and partial procedures, in which only certain layers are exchanged. The choice of procedure depends on the extent and depth of the corneal damage.

Indications and complications: Possible reasons for keratoplasty are inflammatory changes, scarring after injuries or infections, and degenerative diseases. Follow‑up and possible complications range from rejection reactions to wound healing disorders, which is why regular ophthalmological checkups are important.

Sudeck’s disease (CRPS)

Sudeck’s disease (CRPS)

Definition: Complex regional pain syndrome is a chronic pain disorder that typically occurs after trauma or surgery and causes symptoms beyond the expected extent of the original injury.

Clinical features: The clinical picture includes persistent, often burning pain, swelling, changes in skin color and temperature, as well as restrictions in mobility and muscle strength in the affected region.

Treatment and course: Therapy is multimodal and includes pain‑specific measures, active rehabilitation and physical therapy; in many cases early and comprehensive treatment is crucial for improvement, as chronic courses are possible.

Triggers

Manual review required: The note contains only the term “febrile seizure”, while the highlighted term “Triggers” generally refers to precipitating factors. In this context, alcohol and sleep deprivation are mentioned as possible triggers. The present classification is therefore unclear or inconsistent; therefore no reliable substantive rephrasing can be made.

Poisonings

Poisonings (intoxications)

Term and significance: Poisonings refer to harmful effects from ingestion, inhalation or skin contact with toxic substances. In the clinical context, intoxications can affect multiple organ systems and be acutely life‑threatening.

Relevance for the neurological picture: Poisonings can trigger neurological symptoms including seizures, either through direct neurotoxic effects or secondary metabolic disturbances.

Approach: In suspected intoxication, stabilization of vital functions, targeted diagnostic evaluation and, if necessary, specialized antidotal measures and consultation with a poison control center or toxicology service are primary.

Syncope

Syncope — Definition:
A syncope is a transient loss of consciousness due to an acute, global cerebral hypoperfusion, accompanied by spontaneous and complete recovery.

Classification:
Mainly distinguished are neurocardiogenic (e.g., vasovagal) syncope, orthostatic syncope on position change, and cardiac syncope caused by arrhythmias or structural heart disease.

Clinical clues:
Prodromal symptoms may include dizziness, narrowing of the visual field or cold sweat. Syncopal events often occur when standing up or with sudden changes in exertion. Clues to a cardiac cause are known heart disease, palpitations or sudden onset; typically, prolonged postictal delirium is absent in syncope.

PNES

Psychogenic non‑epileptic seizures (PNES) — Features:
PNES are seizures of psychological origin that must be clinically distinguished from epileptic seizures.

Typical findings:
The movement patterns are often variable, irregular and can appear dramatic; individual events often differ from each other. The eyes are often closed during PNES, and affected persons may actively resist opening them. Consciousness can be preserved or altered, but typically there is no clear, deep epileptic loss of consciousness.

Course:
A longer, variable course and the absence of pronounced postictal confusion point more toward PNES than an epileptic seizure.

Blood pressure

Blood pressure measurement — Device components:
Classic manual blood pressure measurement requires a cuff, a hand pump or other inflator for inflation and a manometer for pressure reading. In the auscultatory method a stethoscope is additionally used to detect Korotkoff sounds.

Respiratory rate

Respiratory rate — Definition and limits:
The respiratory rate is the number of breaths per minute and is a fundamental vital sign.

Classification (adults):
Normal values are typically around 12 to 20 breaths per minute. Values over 20/min are termed tachypnea, values under 12/min bradypnea.

Oxygen saturation

Oxygen saturation

Definition and meaning: Oxygen saturation indicates the proportion of hemoglobin bound with oxygen in arterial blood and is an important vital parameter for assessing oxygenation.

Measurement: It is determined noninvasively by pulse oximetry, typically using a clip sensor on a finger, earlobe or toe. The measurement provides a percentage value as well as the pulse rate.

Limitations: Results can be distorted by poor peripheral perfusion, movement, nail polish, bright ambient light or carbon monoxide poisoning. In unclear cases arterial blood gas analyses are useful for further clarification.

Body temperature

Body temperature

Measurement sites and comparison: The recorded body temperature depends on the measurement site. Rectal measurements are considered the best approximation of central temperature. Orally measured temperatures are usually slightly lower than rectal values; axillary measurements are generally even lower.
Axillary: add +0.5 °C,
Oral: add +0.3–0.5 °C,
Rectal: considered the reference value

Todd paralysis

Todd paralysis

Definition: A Todd paralysis is a transient unilateral weakness or paresis that can occur after a focal (localized) seizure with motor involvement.

Clinical course and differential diagnosis: The paralysis typically develops immediately after the seizure and usually improves spontaneously within minutes to hours. If the deficit persists or the course is atypical, other causes such as ischemic stroke or structural lesions must be considered and further diagnostics initiated.

Touching-

With a cotton swab

Papilledema

Papilledema — sign of increased intracranial pressure

Papilledema describes swelling of the optic disc on fundoscopy and is an important sign of increased intracranial pressure. Common causes are space‑occupying lesions, intracranial hemorrhages, hydrocephalus or disturbances of venous outflow. Fundoscopy is used for detection; the presence of papilledema generally requires further neurological evaluation.

Reflexes

Reflexes — Examination findings and significance

Reflexes are typically tested in the neurological examination with a reflex hammer. A distinction is made between deep tendon reflexes and superficial reflexes, and strength, symmetry and inducibility are assessed. Abnormalities provide clues about the localization of a lesion: increased reflexes or pathological loss suggest central motor disorders, while diminished or absent reflexes indicate peripheral nerve or muscle involvement.

Meningismus

Meningismus — Clinical signs of meningeal irritation

Meningismus refers to clinical symptoms indicating irritation of the meninges. Typical findings are neck stiffness, headache and photophobia; nausea and vomiting often occur as well. Specific examination steps can include checking for typical signs such as Kernig’s or Brudzinski’s phenomenon. Meningismus requires evaluation for possible causes, for example meningitis.

Cerebrospinal fluid examination

Cerebrospinal fluid examination — purpose and procedure

The cerebrospinal fluid examination is performed by a lumbar puncture to obtain cerebrospinal fluid. The puncture is usually performed in the lumbar region (for example between the vertebrae L3/L4 or L4/L5) under sterile conditions and local anesthesia; the patient usually assumes a flexed position. The sample taken is examined in the laboratory for cell count, protein content, glucose, lactate as well as for pathogen detection and, if applicable, tumor cells. Indications include, among others, suspected meningitis or encephalitis, demyelinating diseases, or the detection of blood in the CSF.

Lorazepam

Lorazepam

Pharmacologic group: Benzodiazepine.

Effect and mechanism of action: Enhances the inhibitory effect of the neurotransmitter GABA in the central nervous system via GABA-A receptors, producing sedative, anxiolytic, anticonvulsant and muscle-relaxant effects.

Indications: Short-term treatment of severe anxiety, acute agitation, sleep disturbances and as first-line therapy for acute epileptic seizures or status epilepticus in emergency care.

Important risks and notes: Risk of dependence, tolerance and withdrawal symptoms with prolonged use; marked sedation up to respiratory depression possible, especially in combination with other central nervous system depressants; increased risk of falls and confusion in the elderly. Use with caution in liver insufficiency and during pregnancy/breastfeeding.

Valproat

Valproate (valproic acid)

Pharmacologic group: Broad-spectrum anticonvulsant.

Effect: Multiple anticonvulsive effects that overall reduce the excitability of neuronal networks and thereby suppress seizures.

Indications: Used for various forms of epilepsy, particularly generalized seizures; also used in psychiatry as a mood stabilizer.

Important risks and notes: Side effects may include weight gain, tremor, fatigue and gastrointestinal complaints; relevant risks are hepatotoxicity, thrombocytopenia and hyperammonemia. Valproate carries a high teratogenic risk and can cause severe malformations as well as impairments in the neurological development of the child; use during pregnancy should be considered only after careful benefit–risk assessment and specialist counseling.

Levetiracetam

Levetiracetam

Drug class: anticonvulsant (pyrrolidone derivative).

Mechanism of action: affects synaptic vesicle proteins and thereby modulates neurotransmitter release, reducing neuronal excitability.

Indications: treatment of various seizure types as monotherapy or adjunctive therapy in epilepsy; often used because of good tolerability.

Important risks and notes: common adverse effects are fatigue, dizziness and concentration disturbances; some patients may experience behavioral changes or irritability. In pregnancy the safety profile is more favorable than that of some older anticonvulsants, yet individual risk–benefit assessment and close monitoring are required.

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