Physical Exam Tips: Types of seizures and how to tell if they are NOT "real" by tfeldman

View this thread on: hive.blog | peakd.com | ecency.com

health · @tfeldman · Feb 17 '17 (edited)

$2.21

Physical Exam Tips: Types of seizures and how to tell if they are NOT "real"

<html>
<h1><strong>Introduction&nbsp;</strong></h1>
<p><br></p>
<p><img src="https://i.imgsafe.org/66b9ae13f3.jpg" width="640" height="451"/></p>
<p><a href="https://pixabay.com/en/epilepsy-seizure-stroke-headache-623346/">See link here&nbsp;</a></p>
<h3>Seizures can be quiet frightening to see, especially if a loved one is having one. The overall risk of epilepsy by the age of 75 is 3.4% in males and 2.8% in women <a href="http://emedicine.medscape.com/article/1184846-overview#a5">(1)</a>. Having true epileptic seizures changes a person’s life. They must remain without seizures to drive a car, and they are put on medications that can have many side effects. For instance, a patient I just saw today loved the drug Topamax and had not had a seizure for many years, but she is likely having lots of kidney stones due to this medication. Although death from a seizure disorder is rare, sudden death among these individuals is about 2.3 times higher than the general population <a href="http://emedicine.medscape.com/article/1184846-overview#a5">(1)</a>.</h3>
<p><br></p>
<p><br></p>
<p>Seizure diagnosis and management is a long topic so I will not bore you with the complexity of these guidelines. I previously wrote a post entitled “The Art of the Physical Examenation,” which can be found at the link provided <a href="https://steemit.com/health/@tfeldman/the-art-of-the-physical-examination">here</a>. In that post, I went into the basic components of the physical exam and how it is more than science; it’s an art. Finding disease is an important part of a physician’s job, but knowing when there is not organic (“true," pathologic) disease is essential as well!&nbsp;</p>
<p><br></p>
<p><br></p>
<p>Before going into exam clues of “fake seizures,” (aka pseudo-seizure…the most politically correct, casual term is probably “stress seizure”) it is important to take Steemians through the symptoms of a true seizure. I have witnessed this multiple times, and even one of my family members experienced true seizures.&nbsp;</p>
<p><br></p>
<p><br></p>
<h1><strong>Signs of a True “Organic" Seizure:&nbsp;</strong></h1>
<p><br></p>
<p><img src="https://i.imgsafe.org/66c53641d5.png" width="487" height="640"/></p>
<p><a href="https://pixabay.com/en/epilepsy-seizure-stroke-apoplexia-156105/">See link here&nbsp;</a></p>
<p><br></p>
<p><strong>History, History, and more History!!! </strong>By far the most important part. What did the patient experience before the event? Was there a warning symptom? Were there potential triggers ( examples...opiate/alcohol withdrawal, hypoglycemia, and medications)? Any prior history of documented seizures?&nbsp;</p>
<p><br></p>
<p><br>
<strong>The best history will come from an observer because often the victim will have no recall of the event. </strong>Some clues that an actual seizure occurred include eyes open during the event (often rolled back), incontinence (urinated on oneself), complaints of muscle pain, and very often a postictal state (confusion, “sluggishness,” temporary neurologic deficits) after the event.&nbsp;&nbsp;</p>
<p><br></p>
<p>As one can see, these “signs” often will be gone by the time they reach the emergency department... so the history is crucial!&nbsp;</p>
<p><br></p>
<p><br>
The physical exam would include much of what one tired to find out in the history. For instance, one may see bite marks or bleeding on the tongue, one may find “wet” pants if they urinated, and the patient may still be in a postictal state. Before going into more physical exam findings, it is important to give a brief classification system for seizures.<br>
</p>
<h1><strong>General Type of Seizures:&nbsp;&nbsp;</strong></h1>
<p><img src="https://upload.wikimedia.org/wikipedia/commons/thumb/c/c6/PET-image.jpg/425px-PET-image.jpg" width="425" height="480"/></p>
<p><a href="https://commons.wikimedia.org/wiki/Brain#/media/File:PET-image.jpg">See Link here (this image is not representing seizure activity)</a></p>
<h2>Focal-Onset Seizures:&nbsp;<br>
&nbsp;</h2>
<h3><strong>1) Simple Focal:&nbsp;</strong></h3>
<p>A seizure affecting one area of the brain while the patient is conscious. For instance, a person could have a motor/visual/other sensory component, which is called an “aura.” This by definition is a simple-focal seizure. Usually lasts seconds to a few minutes <a href="http://emedicine.medscape.com/article/1184846-clinical#b5">(2)</a>.&nbsp;</p>
<p><br></p>
<p>During history taking, this can be difficult to diagnose, but rather easy to exclude. In other words, if the patient doesn’t remember the seizure, then they didn’t have this type of seizure…or a least there was another seizure component.<br>
&nbsp;</p>
<h3><strong>2) Complex Focal:&nbsp;</strong></h3>
<p>Focal &nbsp;in one area of the brain but complex in that the patient does not remain fully conscious. They may have experienced an aura (simple-focal) but then are not &nbsp;aware that they had a sensory phenomenon. An example could be a mom seeing her son not responding and smacking his lips. When he is conscious again, he may not realize anything happened. Often, there is a postictal state of generalized fatigue.&nbsp;</p>
<p><br></p>
<p><strong>It is important to note that a focal onset seizure can turn into a generalized seizure, which is explained below.&nbsp;<br>
</strong>&nbsp;</p>
<h2><strong>Generalized-Onset Seizure<br>
</strong>&nbsp;</h2>
<p><img src="https://upload.wikimedia.org/wikipedia/commons/thumb/4/41/Gehirn_lobi_seitlich.png/640px-Gehirn_lobi_seitlich.png" width="640" height="387"/></p>
<p><a href="https://commons.wikimedia.org/wiki/Category:Epilepsy#/media/File:Gehirn_lobi_seitlich.png">See link here</a></p>
<h3><strong>1) Absence Seizure:&nbsp;</strong></h3>
<p>Seen in children and is often disregarded by teachers as not paying attention. These kids will have “staring spells.” There will likely be blinking and then the patient comes back with no recollection of the event. Clues that this is occurring are teacher/parent observations and poor school performance. It is often missed because the patient will not remember anything while missing important information in class.&nbsp;</p>
<p>A classic special test for this is to hyperventilate the patient until they have one of these events. It is a generalized because it occurs globally in the brain and the patient is not aware of what is occurring. An EEG can clinch this diagnosis <a href=" http://emedicine.medscape.com/article/1184846-clinical#b5">(2)</a>.<br>
&nbsp;</p>
<h3><strong>2) Myoclonic Seizures:&nbsp;</strong></h3>
<p>Jerking-motor movement that lasts seconds. This is often not a seizure and occurs in many people. &nbsp;For example, many people while starting to sleep (phase 1) will jerk. Kind of like when someone is sleeping in class and you see them jerk when waking up. This is normal. In the seizure type they may not be conscious during the event <a href="http://emedicine.medscape.com/article/1184846-clinical#b5 ">(2)</a>.</p>
<h3><strong>3) Clonic:&nbsp;</strong></h3>
<p>Like a myoclonic but a rhythmic jerking that is more repetitive</p>
<p><br></p>
<h3><strong>4) Tonic:&nbsp;</strong></h3>
<p>Flexion or extension of trunk/extremities. This is often seen with&nbsp;other neurologic issues.&nbsp;</p>
<p><br></p>
<h3><strong>5) Primary Generalized Tonic-Clonic Seizures (grand mal seizures) &nbsp;</strong></h3>
<p><img src="https://upload.wikimedia.org/wikipedia/commons/thumb/0/03/Sir_Charles_Bell%2C_Essays_on_Expression_Wellcome_L0021919.jpg/640px-Sir_Charles_Bell%2C_Essays_on_Expression_Wellcome_L0021919.jpg" width="640" height="372"/></p>
<p><a href="https://commons.wikimedia.org/wiki/File:Patient_in_a_convulsion,_1824_Wellcome_L0001716.jpg#/media/File:Sir_Charles_Bell,_Essays_on_Expression_Wellcome_L0021919.jpg">See Link Here&nbsp;</a></p>
<p><br></p>
<p>This is the stereotypical seizure! If they had an aura before the seizure, it started focal and then became generalized. So in primary, there is no aura preceding the event. <strong>It is a global seizure, which includes an extended/flexed trunk/extremities and rhythmic/jerking movement of the arms and legs.</strong> The symptoms I mentioned at the beginning of this post correlate with this type. This is a very common type of seizure.&nbsp;&nbsp;</p>
<p><br>
<strong>When people are are having “pseudo-seizures” they also often mimic this one.&nbsp;&nbsp;</strong></p>
<p><br></p>
<p>As one can see, due to so many different types of seizures, not only is it hard to categorize them, but it is also hard to know if someone actually had a seizure. If someone remembers the event or just had on arm jerking, it still could be a real seizure! This is why even if suspicions are high for a “fake seizure” it is important to get tests such as an EEG to make sure these are not truly occurring.</p>
<h2>&nbsp;<br>
<strong>Pseudo-Seizures: Medically termed “Psychogenic Non-Epileptic Seizures (PNES)”&nbsp;</strong></h2>
<p><br></p>
<p><img src="https://upload.wikimedia.org/wikipedia/commons/thumb/4/47/Sir_Charles_Bell%2C_Essays_on_Expression_Wellcome_L0021920.jpg/604px-Sir_Charles_Bell%2C_Essays_on_Expression_Wellcome_L0021920.jpg" width="604" height="480"/></p>
<p><a href="https://commons.wikimedia.org/wiki/File:Patient_in_a_convulsion,_1824_Wellcome_L0001716.jpg#/media/File:Sir_Charles_Bell,_Essays_on_Expression_Wellcome_L0021920.jpg">See Link Here</a></p>
<p><br>
<strong>It is estimated that 2 to 33/100,000 people have this condition </strong><a href="http://www.uptodate.com/contents/psychogenic-nonepileptic-seizures"><strong>(3)</strong></a><strong>.</strong> It is psychologic in nature. It is felt that calling them “fake” or “pseudo” is wrong because the psychiatric condition is made to seem like it is always intentional. While I think that a majority might be doing it for some benefit (get out of work) or unknown benefit (attention), this does not mean that all the cases are due to this. <strong>One study series found that 66%-99% of cases were in women </strong><a href="http://www.uptodate.com/contents/psychogenic-nonepileptic-seizures"><strong>(3)</strong></a><strong>. One thing for sure—it occurs in women more than men.&nbsp;</strong></p>
<p><br></p>
<h2>&nbsp;<strong>Historical/Physical Clues: Pseudo vs Real&nbsp;</strong></h2>
<p><br>
In a pseudo seizure, <strong>THE EYES are usually closed</strong>. This is due to the fact that the patient is often actively/voluntarily closing their eyelids. In a real seizure, voluntary control does not exist and the eyes remain open! If a physician is witnessing a pseudo-type, they can try to open the eyes during the “event.” <strong>If it is hard to open their eyes, they are most likely actively closing them (in other words….consciously keeping them closed!).</strong>&nbsp;&nbsp;</p>
<p><br></p>
<p><br>
In addition, the movements are important. For instance, in a pseudo-type the movements will usually be very unorganized or exaggerated. In a true tonic-clonic seizure, the movement should be more rhythmic and increase in intensity <a href="http://www.uptodate.com/contents/psychogenic-nonepileptic-seizures">(3)</a>.</p>
<p><br></p>
<p>&nbsp;<br>
Vocalization is an interesting finding. <strong>In a true seizure, you may hear sound because the diaphragm may be “jerking as well.” However, it will be more of a single tone guttural utterance </strong><a href="http://www.uptodate.com/contents/psychogenic-nonepileptic-seizures"><strong>(3)</strong></a><strong>.</strong> Things such as crying/moaning suggest more complex voluntary vocal cord tones and more suggestive a pseudo seizure. One should be careful on this one because my family member did have vocalization, but it was not a voluntary vocalization…..almost a single, monotone moan from this “guttural utterance.”&nbsp;</p>
<p><br></p>
<p><br>
<strong>Other signs of pseudo-type: if the patient has not bitten his or her tongue, no incontinence, no complaints of headache (be careful not to ask right away…most with a true seizure have pretty bad headaches…my family member held his head and complained of a terrible headache).&nbsp;</strong></p>
<p><br></p>
<p><img src="https://i.imgsafe.org/672d49ed66.jpg" width="452" height="640"/><strong>&nbsp;</strong>&nbsp;</p>
<p><a href="https://pixabay.com/en/headache-business-man-failure-1899227/">See Link Here&nbsp;</a></p>
<p><br>
Other historical signs: Do the seizures only occur when someone else is there? Have they ever had a seizure while sleeping? Have they ever had one while driving? <strong>Typically in pseudo-types they only occur where another would notice them</strong>….basically, use common sense….be a detective! For example, if they “fell down” did they slowly go down before having the seizure? If there are no injuries from the fall, it is less likely real.&nbsp;&nbsp;</p>
<p><br></p>
<p><br>
While these signs can clue one into thinking that a pseudo-event occurred, it is important to rule out organic pathology even when in doubt. <strong>Basically, think of this as a diagnosis of exclusion.</strong> If there is some doubt in the diagnosis, make sure you resolve that doubt!&nbsp;&nbsp;</p>
<p><br></p>
<h2><br>
<strong>Conclusion: True story of witnessing a pseudo-seizure in the ED</strong></h2>
<p><br></p>
<p><img src="https://i.imgsafe.org/675068911a.jpg" width="640" height="426"/></p>
<p><a href="https://pixabay.com/en/doctor-hospital-bed-delivery-labor-840127/">See Link Here</a></p>
<p><br></p>
<p>&nbsp;<br>
<strong>Throughout my two years of clinical rotations, I have met a handful of patients with histories that were consistent with pseudo seizures. One time, I actually witnessed one.</strong>&nbsp;</p>
<p><br></p>
<p>Last year during an ER rotation, I took a history on a woman who had multiple “seizures” that day. She had past workups but never found a reason why she had them (<strong>another big clue... but it is important to note that many seizures are idiopathic</strong>). <strong>Many family members were worried about her and were there to comfort and support her.&nbsp;</strong></p>
<p><br></p>
<p>As I finished the history that was very inconsistent (she claimed that she fell and had a seizure while the family said she slowly went to the ground and had a seizure), <strong>I started her neurologic exam and another “event” occurred! She closed her eyes tightly and began shaking her whole body.</strong> <strong>To me, the movements seemed inconsistent and the eyes closing were all suspicious to me.&nbsp;&nbsp;</strong></p>
<p><br></p>
<p><br>
<strong>The family looked really worried as I got the attending physician.</strong> <strong>I told the ER doc that I believed the seizure was “pseudo” in nature.</strong> <strong>As I went back to the room with the ER doc, the patient had another one with inconsistent movements from her last one and eyes still closed.</strong> <strong>The ER doc went up to her and said “GET AHOLD OF YOURSELF!!!!” and she stopped this “event” immediately!</strong> <strong>It may seem obvious to the reader, but one does not stop by command! This was essentially a diagnosis “caught-in-the-act.”&nbsp;</strong></p>
<p><br></p>
<p><br>
I do not think I will ever know the reasons why some people have pseudo-events. I believe many do it for attention. <strong>It was sad for me to see her family so concerned when there was nothing organically wrong with her.</strong> However, I still will not be quick to judge this individual. <strong>In psych cases, sometimes these things are not as “voluntary” as one would believe. Although these situations can be frustrating, it is important to give patients the benefit of the doubt.&nbsp;&nbsp;</strong></p>
<p><br></p>
<p><br>
I hope that this post gave you guys a more clear perspective of true seizure types and ways to start considering if one is truly having a seizure. It is not the easiest task by any means! <strong>The physical exam and the important historical clues will give you most of the answers. Since medicine is also an art, questions must be asked in a way that does not give the patient clues on what to say!</strong> <strong>A good doctor treats the patient with respect, belief, and the desire to help; however, a doctor should still be a good detective!&nbsp;<br>
</strong>&nbsp;</p>
<p><br></p>
<h1><strong>Thanks for reading! Feel free to follow me for more posts on medicine/science/music!</strong></h1>
<p><br></p>
<h3><strong>I am currently in my last few months of medical school and am taking neurology this month!&nbsp;</strong></h3>
<p><br></p>
<p><br></p>
<p><strong>Sources:</strong></p>
<p>*3rd source is not accessible without payment for uptodate website</p>
<p>http://emedicine.medscape.com/article/1184846-overview (1)</p>
<p>http://emedicine.medscape.com/article/1184846-clinical#b5 (2)</p>
<p>http://www.uptodate.com/contents/psychogenic-nonepileptic-seizures (3)</p>
<p><strong>Image Sources&nbsp;</strong></p>
<p>See links below images. No sources were needed, only added for simplicity.&nbsp;</p>
</html>

👍 riverhead, steemaccess, dimimp, benjojo, wackou, craig-grant, shenanigator, neptun, michaeldodridge, justtryme90, summon, vcelier, anyx, kenny-crane, pkattera, bue, lemouth, fyrstikken, fiveboringgames, hilarski, araki, steemstem, good-karma, theyeti, cmp2020, tfeldman, steemservices, leesmoketree, jamtaylor, steemsports, crazymumzysa, bola, remlaps1, sunscape, arcange, cub1, furion, dreemit, strangerarray, cgame, soushi888, steemprentice, brich, gamer00, pheonike, bue-witness, pairmike, bestofreddit, kurtbeil, boy, sethlinson, sqube, elyaque, virtualgrowth, patrice, steem-meme, sjennon, mini, karenmckersie, richardcrill, irawandedy, randyclemens, giantbear, thebatchman, and 65 others

properties (23)

`author`	tfeldman
`permlink`	physical-exam-tips-types-of-seizures-and-how-to-tell-if-they-are-not-real
`category`	health
`json_metadata`	"{"tags":["health","science","life","medicine"],"image":["https://i.imgsafe.org/66b9ae13f3.jpg","https://i.imgsafe.org/66c53641d5.png","https://upload.wikimedia.org/wikipedia/commons/thumb/c/c6/PET-image.jpg/425px-PET-image.jpg","https://upload.wikimedia.org/wikipedia/commons/thumb/4/41/Gehirn_lobi_seitlich.png/640px-Gehirn_lobi_seitlich.png","https://upload.wikimedia.org/wikipedia/commons/thumb/0/03/Sir_Charles_Bell%2C_Essays_on_Expression_Wellcome_L0021919.jpg/640px-Sir_Charles_Bell%2C_Essays_on_Expression_Wellcome_L0021919.jpg","https://upload.wikimedia.org/wikipedia/commons/thumb/4/47/Sir_Charles_Bell%2C_Essays_on_Expression_Wellcome_L0021920.jpg/604px-Sir_Charles_Bell%2C_Essays_on_Expression_Wellcome_L0021920.jpg","https://i.imgsafe.org/672d49ed66.jpg","https://i.imgsafe.org/675068911a.jpg"],"links":["https://pixabay.com/en/epilepsy-seizure-stroke-headache-623346/","http://emedicine.medscape.com/article/1184846-overview#a5","https://steemit.com/health/@tfeldman/the-art-of-the-physical-examination","https://pixabay.com/en/epilepsy-seizure-stroke-apoplexia-156105/","https://commons.wikimedia.org/wiki/Brain#/media/File:PET-image.jpg","http://emedicine.medscape.com/article/1184846-clinical#b5","https://commons.wikimedia.org/wiki/Category:Epilepsy#/media/File:Gehirn_lobi_seitlich.png"," http://emedicine.medscape.com/article/1184846-clinical#b5","http://emedicine.medscape.com/article/1184846-clinical#b5 ","https://commons.wikimedia.org/wiki/File:Patient_in_a_convulsion,_1824_Wellcome_L0001716.jpg#/media/File:Sir_Charles_Bell,_Essays_on_Expression_Wellcome_L0021919.jpg","https://commons.wikimedia.org/wiki/File:Patient_in_a_convulsion,_1824_Wellcome_L0001716.jpg#/media/File:Sir_Charles_Bell,_Essays_on_Expression_Wellcome_L0021920.jpg","http://www.uptodate.com/contents/psychogenic-nonepileptic-seizures","https://pixabay.com/en/headache-business-man-failure-1899227/","https://pixabay.com/en/doctor-hospital-bed-delivery-labor-840127/","http://emedicine.medscape.com/article/1184846-overview"],"app":"steemit/0.1","format":"html"}"
`created`	2017-02-17 04:01:54
`last_update`	2017-02-17 23:18:48
`depth`	0
`children`	13
`last_payout`	2017-03-20 05:17:24
`cashout_time`	1969-12-31 23:59:59
`total_payout_value`	1.730 HBD
`curator_payout_value`	0.479 HBD
`pending_payout_value`	0.000 HBD
`promoted`	0.000 HBD
`body_length`	17,012
`author_reputation`	33,524,616,231,758
`root_title`	"Physical Exam Tips: Types of seizures and how to tell if they are NOT "real""
`beneficiaries`	`[]`
`max_accepted_payout`	1,000,000.000 HBD
`percent_hbd`	10,000
`post_id`	2,527,701
`net_rshares`	16,327,948,943,074
`author_curate_reward`	""

vote details (129)

voter	rshares	pct
summon	228,221,141,039	3%
riverhead	6,733,735,406,298	100%
wackou	1,302,998,598,078	28%
boy	3,194,305,608	100%
bue-witness	3,891,321,949	100%
bunny	586,708,997	100%
bue	61,946,984,539	100%
steemservices	23,679,400,513	2%
mini	1,708,716,609	100%
moon	217,691,350	100%
benjojo	1,386,081,165,819	100%
pairmike	3,712,358,470	1%
pheonike	3,941,072,149	1.68%
proctologic	1,120,428,759	1%
healthcare	638,716,233	100%
daniel.pan	1,008,919,811	100%
konelectric	912,220,229	1%
patrice	2,288,185,053	28%
helen.tan	292,910,189	100%
craig-grant	589,628,358,138	100%
jamtaylor	18,086,364,458	28%
dimimp	1,405,420,957,964	100%
forrestwillie	645,983,100	1%
brich	4,440,809,666	28%
justtryme90	244,433,267,021	100%
applecrisp	450,376,644	30%
kenny-crane	114,755,254,870	100%
andrei	255,684,829	1%
proglobyte	104,306,829	1%
fyrstikken	56,537,674,868	1%
grey580	373,460,385	1%
thebatchman	1,120,903,314	3%
good-karma	29,694,148,078	12%
elyaque	2,925,439,283	1%
furion	8,259,793,784	2%
strangerarray	6,349,887,378	28%
anyx	119,751,455,838	28%
thebatchman1	69,196,920	3%
karenmckersie	1,669,373,940	1%
pkattera	94,536,129,937	28%
arcange	9,201,330,891	28%
fiveboringgames	45,837,723,039	50%
ubg	586,802,464	1%
bola	13,606,453,457	40%
sokal	625,665,640	28%
crazymumzysa	14,530,838,674	100%
mysteem	451,039,163	12%
michaeldodridge	315,590,009,291	100%
proglobyte-m1	105,740,594	1%
craigslist	432,853,330	100%
tingaling	104,304,421	1%
cmp2020	27,736,018,173	63%
toxichan	324,408,470	19.6%
timelapse	462,354,381	1%
kurtbeil	3,224,070,463	1%
tannukas6	62,908,666	1%
randyclemens	1,180,172,855	28%
darthnava	354,838,704	1%
kpine	58,042,089	100%
zentat	109,508,039	1%
virtualgrowth	2,465,102,284	8.4%
lemouth	57,343,189,851	100%
neptun	351,639,969,389	100%
sethlinson	3,024,188,364	20%
hilarski	40,150,328,004	20%
shadowspub	555,125,532	1%
leesmoketree	22,812,787,499	85%
steembriefing	104,372,343	1%
barrydutton	1,063,815,911	1%
shenanigator	426,498,367,125	100%
steemitguide	545,736,007	1%
richardcrill	1,434,835,771	1%
tfeldman	23,911,160,838	100%
jacobts	228,910,603	1%
finleyexp	113,149,834	12%
patelincho	111,967,030	1%
bestofreddit	3,674,712,958	90%
thegame	207,904,784	2.8%
steembets	211,137,106	2.8%
remlaps1	9,993,177,686	100%
zoee	172,028,328	28%
sjennon	1,772,925,710	12%
steemitawards	62,646,014	1%
thesteemawards	424,469,779	20%
steemint	104,616,102	1%
cub1	8,987,188,578	90%
gamer00	4,434,178,266	1%
steemsports	17,866,649,361	1%
steem-meme	1,924,995,424	20%
revostrike	163,238,669	28%
sunscape	9,991,955,625	20%
giantbear	1,174,812,151	1%
stray	417,505,253	1%
steemstem	35,936,930,875	100%
steemspeak	232,929,924	1%
fyrst-witness	394,752,020	1%
steemaccess	2,177,302,741,041	100%
daisyd	216,520,284	1%
steemland.com	210,685,798	2.8%
sqube	2,962,076,398	1%
whatageek	627,410,358	1%
yadamaniart	571,521,313	1%
steemprentice	4,554,374,825	8.4%
reisman	968,865,454	30%
irawandedy	1,332,830,859	28%
seablue	325,378,896	1%
vcelier	126,179,885,847	28%
araki	36,605,819,345	70%
dreemit	6,841,096,782	14%
soushi888	5,380,675,993	100%
meysam	472,700,312	1%
jphenderson	104,425,133	8.4%
love-you	53,746,286	100%
driptorchpress	66,273,293	1%
remlaps2	78,289,773	100%
rahul.stan	505,226,105	100%
free2play	53,690,105	1%
fisteganos	548,574,848	5%
thedeplorable1	428,701,977	1%
bounties	60,555,499	12%
cgame	5,530,325,125	100%
smalltalk	383,707,877	100%
benjiparler	122,110,155	28%
denmarkguy	120,254,045	1%
theyeti	29,567,838,898	28%
adminpoly	279,242,112	50%
izajusto	357,426,235	100%
suheimi45	364,589,851	100%
selected	349,459,514	100%

@araki · Feb 17 '17

@tfeldman, that is good informative blog
in a disorder like Epilepsy require long term treatment and follow up it is crucial to differentiate between  seizure and pseudo-seizure. To role out Metabolic and other cause of convulsion.
you did great job man

👍 tfeldman

`author`	araki
`permlink`	re-tfeldman-physical-exam-tips-types-of-seizures-and-how-to-tell-if-they-are-not-real-20170217t084012143z
`category`	health
`json_metadata`	{"tags":["health"],"users":["tfeldman"],"app":"steemit/0.1"}
`created`	2017-02-17 08:40:09
`last_update`	2017-02-17 08:40:09
`depth`	1
`children`	1
`last_payout`	2017-03-20 05:17:24
`cashout_time`	1969-12-31 23:59:59
`total_payout_value`	0.000 HBD
`curator_payout_value`	0.000 HBD
`pending_payout_value`	0.000 HBD
`promoted`	0.000 HBD
`body_length`	253
`author_reputation`	18,300,925,590,032
`root_title`	"Physical Exam Tips: Types of seizures and how to tell if they are NOT "real""
`beneficiaries`	`[]`
`max_accepted_payout`	1,000,000.000 HBD
`percent_hbd`	10,000
`post_id`	2,528,856
`net_rshares`	12,434,469,835
`author_curate_reward`	""

properties (23)vote details (1)

voter	weight	wgt%	rshares	pct	time
tfeldman	0 B		12,434,469,835	51%

@tfeldman · Feb 17 '17

Thank you! I enjoyed writing it. Just saw two more likely pseudo-seizures today in the neurology office. Thank you for your input. Your article was great and had been thinking about that same topic recently.

👍 araki

properties (23)vote details (1)

voter	weight	wgt%	rshares	pct	time
araki	0 B		52,294,860,903	100%

@justtryme90 · Feb 17 '17

this is a nice post but for some reason steemit is struggling with its link.

properties (22)

`author`	justtryme90
`permlink`	re-tfeldman-physical-exam-tips-types-of-seizures-and-how-to-tell-if-they-are-not-real-20170217t212946781z
`category`	health
`json_metadata`	{"tags":["health"],"app":"steemit/0.1"}
`created`	2017-02-17 21:29:45
`last_update`	2017-02-17 21:29:45
`depth`	1
`children`	5
`last_payout`	2017-03-20 05:17:24
`cashout_time`	1969-12-31 23:59:59
`total_payout_value`	0.000 HBD
`curator_payout_value`	0.000 HBD
`pending_payout_value`	0.000 HBD
`promoted`	0.000 HBD
`body_length`	76
`author_reputation`	140,118,479,939,905
`root_title`	"Physical Exam Tips: Types of seizures and how to tell if they are NOT "real""
`beneficiaries`	`[]`
`max_accepted_payout`	1,000,000.000 HBD
`percent_hbd`	10,000
`post_id`	2,534,018
`net_rshares`	0

@tfeldman · Feb 17 '17

Thanks for reading! I haven't faced any problems on my end....what is happening to the post?

👍 justtryme90

properties (23)vote details (1)

voter	weight	wgt%	rshares	pct	time
justtryme90	0 B		6,112,660,058	1%

@tfeldman · Feb 17 '17

Oh I see what you are saying. I can get to the post but if I click one of my links and try to go back it does not work. Weird!

properties (22)

@tfeldman · Feb 17 '17 (edited)

Here is a shorter link here: http://steem.link/uNGV1

Edit: didn't work

👍 justtryme90

properties (23)vote details (1)

voter	weight	wgt%	rshares	pct	time
justtryme90	0 B		6,112,660,058	1%

@justtryme90 · Feb 18 '17

Yeah, I am not sure what the situation is with the link to your post. Oh well, I will share your next post on my twitter then :)

👍 tfeldman

`author`	justtryme90
`permlink`	re-tfeldman-re-justtryme90-re-tfeldman-physical-exam-tips-types-of-seizures-and-how-to-tell-if-they-are-not-real-20170218t162405070z
`category`	health
`json_metadata`	{"tags":["health"],"app":"steemit/0.1"}
`created`	2017-02-18 16:24:00
`last_update`	2017-02-18 16:24:00
`depth`	3
`children`	1
`last_payout`	2017-03-20 05:17:24
`cashout_time`	1969-12-31 23:59:59
`total_payout_value`	0.000 HBD
`curator_payout_value`	0.000 HBD
`pending_payout_value`	0.000 HBD
`promoted`	0.000 HBD
`body_length`	128
`author_reputation`	140,118,479,939,905
`root_title`	"Physical Exam Tips: Types of seizures and how to tell if they are NOT "real""
`beneficiaries`	`[]`
`max_accepted_payout`	1,000,000.000 HBD
`percent_hbd`	10,000
`post_id`	2,539,204
`net_rshares`	11,992,685,877
`author_curate_reward`	""

properties (23)vote details (1)

voter	weight	wgt%	rshares	pct	time
tfeldman	0 B		11,992,685,877	51%

1 reply

@patrice · Feb 17 '17

As someone that was misdiagnosed as a child with epilepsy I 100% believe that a correct diagnosis is important. It wasn't until I was in my teens that I had a new doctor that did a thorough history and noted that all but the first seizure I had was documented as being accompanied by a high fever. 

I was severely allergic to tegratol, dilantin, and phenobarbitol.  All three resulted in hives, high fevers, and seizures.  I was then prescribed Depakane the same month it was approved by the FDA in and was on it for 4 horrible years. I was taking more than the normal adult dose prescribed today. 

My parents were never told most of the side effects including ones I suffered from the worst: depression, mood swings, and catatonic reactions. I count my self lucky to have a functioning liver and pancreas. Then there was the withdrawal symptoms even when I was tapered off. 

All for a condition I never had.

properties (22)

`author`	patrice
`permlink`	re-tfeldman-physical-exam-tips-types-of-seizures-and-how-to-tell-if-they-are-not-real-20170217t053235389z
`category`	health
`json_metadata`	{"tags":["health"],"app":"steemit/0.1"}
`created`	2017-02-17 05:32:33
`last_update`	2017-02-17 05:32:33
`depth`	1
`children`	1
`last_payout`	2017-03-20 05:17:24
`cashout_time`	1969-12-31 23:59:59
`total_payout_value`	0.000 HBD
`curator_payout_value`	0.000 HBD
`pending_payout_value`	0.000 HBD
`promoted`	0.000 HBD
`body_length`	911
`author_reputation`	26,522,961,289,339
`root_title`	"Physical Exam Tips: Types of seizures and how to tell if they are NOT "real""
`beneficiaries`	`[]`
`max_accepted_payout`	1,000,000.000 HBD
`percent_hbd`	10,000
`post_id`	2,528,053
`net_rshares`	0

@tfeldman · Feb 17 '17

Sorry to hear about that. Seizures are hard to diagnose but the information you mentioned with high fever seemed to be a pretty big clue. Hopefully, you are doing better now! Thank you for reading my post! Side effects are always a big issue when treating any condition...so it's good to get it right!

👍 patrice, zoee

properties (23)vote details (2)

voter	weight	wgt%	rshares	pct	time
patrice	0 B		915,354,015	10%
zoee	0 B		68,812,164	10%

@suheimi45 · Feb 17 '17

good, your post amazing

👍 suheimi45

`author`	suheimi45
`permlink`	re-tfeldman-physical-exam-tips-types-of-seizures-and-how-to-tell-if-they-are-not-real-20170218t050821754z
`category`	health
`json_metadata`	{"tags":["health"],"app":"steemit/0.1"}
`created`	2017-02-17 04:09:54
`last_update`	2017-02-17 04:09:54
`depth`	1
`children`	2
`last_payout`	2017-03-20 05:17:24
`cashout_time`	1969-12-31 23:59:59
`total_payout_value`	0.000 HBD
`curator_payout_value`	0.000 HBD
`pending_payout_value`	0.000 HBD
`promoted`	0.000 HBD
`body_length`	23
`author_reputation`	941,614,898,530
`root_title`	"Physical Exam Tips: Types of seizures and how to tell if they are NOT "real""
`beneficiaries`	`[]`
`max_accepted_payout`	1,000,000.000 HBD
`percent_hbd`	10,000
`post_id`	2,527,724
`net_rshares`	365,923,068
`author_curate_reward`	""

properties (23)vote details (1)

voter	weight	wgt%	rshares	pct	time
suheimi45	0 B		365,923,068	100%

@tfeldman · Feb 17 '17

Thank you for taking the time to read! Much appreciated.

👍 suheimi45

properties (23)vote details (1)

voter	weight	wgt%	rshares	pct	time
suheimi45	0 B		313,547,272	100%

@suheimi45 · Feb 17 '17

you are welcome @tfeldman

👍 suheimi45

`author`	suheimi45
`permlink`	re-tfeldman-re-suheimi45-re-tfeldman-physical-exam-tips-types-of-seizures-and-how-to-tell-if-they-are-not-real-20170218t054018919z
`category`	health
`json_metadata`	{"tags":["health"],"users":["tfeldman"],"app":"steemit/0.1"}
`created`	2017-02-17 04:41:51
`last_update`	2017-02-17 04:41:51
`depth`	3
`children`	0
`last_payout`	2017-03-20 05:17:24
`cashout_time`	1969-12-31 23:59:59
`total_payout_value`	0.000 HBD
`curator_payout_value`	0.000 HBD
`pending_payout_value`	0.000 HBD
`promoted`	0.000 HBD
`body_length`	25
`author_reputation`	941,614,898,530
`root_title`	"Physical Exam Tips: Types of seizures and how to tell if they are NOT "real""
`beneficiaries`	`[]`
`max_accepted_payout`	1,000,000.000 HBD
`percent_hbd`	10,000
`post_id`	2,527,849
`net_rshares`	365,923,068
`author_curate_reward`	""

properties (23)vote details (1)

voter	weight	wgt%	rshares	pct	time
suheimi45	0 B		365,923,068	100%