Diplopia and Headache as Seizure Aura - Case Study Example

EPISODIC S AND ANALYSIS: Diplopia and Headache as Seizure Aura Part EPISODIC S IDENTIFICATION H.K. Age: 15 years old Gender: Female Race: American Chief complaint: “I am having a double vision accompanied by headache on my forehead.” SUBJECTIVE On the afternoon of September 4, 2008, a 15-year old female teenage American complaints of having a double vision (diplopia) since few hours ago accompanied by headache, frontal region, on the school clinic. Client reports 7/10 pain on the head, no traceable history of any head or body injury, no dizziness, no vomiting and not nauseated. The client denies any history of neurologic illness but admits history of seizure and the last seizure episode was on Thursday. She is on antiseizure medication BID (twice a day) and claims that morning dose had already been taken. Breakfast was taken this morning and been exposed to stressful school work. Client has no parental history of neurologic illness or chronic diseases, has completed childhood immunizations and is not allergic to any drugs or foods. OBJECTIVE The client is an adolescent female American with average body built, awake, alert, and oriented to date, place and person (AAOX3). Vital signs taken and recorded were: BP-126/85 mmHg, T-97.4° F, PR-95 bpm and RR-22 cpm. Examination reveals that eyes are slightly asymmetrical, no redness, no drainage, unable to focus and are sensitive to light. Skin is warm to touch, intact, no cyanosis, no lesions on head and no mass upon palpation. There is clarity of speech. ASSESSMENT With the signs and symptoms presented, the diagnosis for this case is disturbance in visual sensory perception related to diplopia or double vision accompanied by headache as aura secondary to episodic seizure. According to Dr. G.R. Kelly and Dr. S.T. Swierzewski (Epilepsy/Seizures, August 1, 2008), injury or disease process that may produce seizure manifesting double vision and headache are head trauma, infection (e.g. encephalitis, meningitis), and drug intoxication or withdrawal. Also, other conditions that produce symptoms similar to those occurring during seizure that must be ruled out are: (1) Breath-holding spells: bluish tint to the skin (cyanosis), loss of consciousness, loss of muscle tone, (2) Menieres disease: vertigo, visual phenomena, speech impairment, altered consciousness, (3) Migraine: aura, loss of consciousness, nausea, photophobia, muscle weakness, (4) Movement disorder: tics, chorea, tremor and (5) Syncope: sudden loss of muscle tone and posture, loss of consciousness, vertigo, nausea, muscle spasm. PLAN Plan of care for this particular case includes staying with the child while monitoring constantly and maintaining the child’s vital functions and the signs and symptoms presented in order to evaluate the exacerbation of these symptoms while securing the client in a safe environment to avoid further injury. Avoid bright light exposure of the client and instead, provide a dim light environment in order to eliminate precipitating factor; move all dangerous equipment around her and clear the area to lessen the risk for possible injury; provide ample and uninterrupted time for the client to rest well; administer her afternoon antiseizure medication in due time as directed; follow-up with the doctor for reevaluation; call the client’s father to inform him about what had happened to his daughter in school so he can picked her up. Also, gather information from the father about the seizure history of the child as to its severity of episodic attacks, its characteristics, the causative factors that usually trigger to manifest signs and symptoms, the effects of medications to the child, any familiar health history related to seizure, and any childhood injury of the client. Part 2 – ANALYSIS SUBJECTIVE The article entitled Seizure Management written by Dr. Katie Allen and Jacqueline Robinson (December 11, 2006) provides clinical guidelines that incorporate nursing care of children with known seizure (epilepsy). According to this article, for a child with previous history of seizure or epilepsy, full assessment of the type of seizure should have include gathering of information from the parent/carer/child about the number of the different types of seizure (its description, duration and occurrence as to time-early morning, nocturnally, or during sleep), child’s altered behavior during the event, any aura experienced other than (diplopia and headache), any impairment or loss of consciousness, and triggers or precipitating factors to seizure like lack of sleep and fatigue, activity, loud noises. Another scholarly written article use in the analysis of this case is the Guideline for Management of Epilepsy in School Setting Including the Role of Community Child Health Medical and nursing Services by Margaret MacSween (last reviewed on April 1, 2008). According to this article, teacher(s) of the client should have been asked about the child’s behavior inside the class. Also, this article points out that information should have been gathered from the parent/teacher/carer/child about the level of the child’s awareness regarding her seizure illness and the level of management that the child can carry out during episodes of aura and seizure. Also, precipitating factors mentioned in this article that should have been considered are the presence of menstruation, constipation, boredom, and feeling of tiredness due to late nights or sleep deprivation. OBJECTIVE Part of the objective cues in first-mentioned article of Allen and Robinson that should have been taken and recorded is the child’s weight. An assessment of the child’s airway functioning is very integral according to this article and this should have been done and recorded on the original case. For thorough physical examination, this article showed that the following information should have included: facial expressions, eye movement, muscular contractions and other sensory involvement. Analysis of the second article by MacSween showed that gathering of objective cues should have also included physical examination of extremities to assess muscle contractions. Child behaviors like plucking of clothes, picking up and placing things down, wandering around, repeating words, lip smacking, and even undressing should have been observed as these are focal sings of onset of seizure. ASSESSMENT According to Allen and Robinson, it is important to distinguish whether the episode was an epileptic or non-epileptic seizure and this should have been stated on the case as well as identifying if the child is already on seizure episode of just manifesting an aura. Other differential diagnoses for a seizure to occur that should have been listed are tumor, intra-ventricular hemorrhage, electrolyte imbalances and toxic ingestion. On the second article by MacSween, of the presenting signs and symptoms of the child, it is important to assess carefully if the child is on the stage of seizure already or just presenting the aura. Differential diagnosis should have included photosensitive epilepsy and petit mal seizure. PLAN Allen and Robinson mentioned about plan of intercepting the onset of seizure and this should have been included on the case since the child is not yet under seizure attack but only on the stage of presenting seizure aura. In the case that seizure may arise, preparation of oxygen to support the child’s breathing pattern as well as planning to time the duration of seizure and record all observed behaviors and characteristics if episodic event will occur should have been included. In the second article by MacSween, part of the plan that should have been included is seeking help, if possible, from a colleague for errand purposes like making a phone call to the child’s parent/carer so that staying with the child in full time for constant monitoring can be achieved. Also, preparation for emergency medications (rectal diazepam, buccal midazolam, and rectal paraldehyde) in case of seizure attack should have been included. Part of the plan for these medications should have been the securing of its availability if seizure may arise. For long term goals about seizure management in school, MacSween mentioned that it is important that school staffs are made aware about occurrence and management of child seizure, thus this should have been a part of the plan – to educate the school staffs to be keen about the unusual behavior observed in children with history of seizure for early prevention of complications and for provision of early treatment. Works Cited: Allen, K. and Robinson, J. (Decmeber 1, 2006). Seizure Management Clinical Guideline. UCL Institute of Child Heath. Link to online article is available at: Kelly G.R. and Swierzewski, S.J. (August 1, 2008). Epilepsy/Seizures: Diagnosis and Differential Diagnosis. An online article in Neurology Channel available at: MacSween, M. (April 1, 2008). Guideline for Management of Epilepsy in School Setting Including the Role of Community Child Health Medical and nursing Services. Steering Groups for Medicines Administrations in Schools, NHS Highland. Link available at: Read More