Typically a common but minor complaint, diminished production or excretion of saliva (dry mouth) usually results from mouth breathing. However, this symptom can also result from salivary duct obstruction, Sjögren’s syndrome, the use of an anticholinergic other drug, and the effects of radiation. It can even result from vigorous exercise or autonomic stimulation—for example, as the result of fear.

Increased salivation is an uncommon symptom that can result from a GI disorder, especially of the mouth. It also accompanies certain systemic disorders and may result from the use of certain drugs or from exposure to toxins. Saliva may also accumulate because of difficulty swallowing. (See “Dysphagia,” page 235.)

Craving salty foods is a compensatory response to the body’s failure to adequately conserve sodium. Normally, the renal tubules reabsorb almost all sodium, allowing less than 1% of it to be excreted in the urine. This reabsorption is regulated by aldosterone, a hormone synthesized in the adrenal gland. However, adrenal dysfunction can reduce aldosterone levels, thereby impairing reabsorption and increasing excretion of sodium.

Sudden or rapidly worsening salt craving may indicate adrenal crisis. Adrenal crisis produces profound weakness, fatigue, nausea, vomiting, hypotension, dehydration and, occasionally, high fever. If untreated, this condition can ultimately lead to vascular collapse, renal shutdown, coma, and death. It requires prompt I.V. bolus administration of hydrocortisone. Later, doses may be given I.M. or may be diluted with dextrose in saline solution and given I.V. until the patient’s condition stabilizes.

A scotoma is an area of partial or complete blindness within an otherwise normal or slightly impaired visual field. Usually located within the central 30-degree area, the defect ranges from absolute blindness to a barely detectable loss of visual acuity. Typically, the patient can pinpoint the scotoma’s location in the visual field. (See Locating scotomas, page 614.)

A scotoma can result from a retinal, choroid, or optic nerve disorder. It can be classified as absolute, relative, or scintillating. An absolute scotoma refers to the total inability to see all sizes of test objects used in mapping the visual field. A relative scotoma, in contrast, refers to the ability to see only large test objects. A scintillating scotoma refers to the flashes or bursts of light commonly seen during a migraine headache.

Scrotal swelling occurs when a condition affecting the testicles, epididymis, or scrotal skin produces edema or a mass; the penis may be involved. Scrotal swelling can affect males of any age. It can be unilateral or bilateral and painful or painless.

The sudden onset of painful scrotal swelling suggests torsion of a testicle or testicular appendages, especially in a prepubescent male. This emergency requires immediate surgery to
untwist and stabilize the spermatic cord or to remove the appendage.

If severe pain accompanies scrotal swelling, ask when the swelling began. Using a Doppler stethoscope, evaluate blood flow to the testicle. If it’s decreased or absent, suspect testicular torsion and prepare the patient for surgery. Withhold food and fluids, insert an I.V. catheter, and apply an ice pack to the scrotum to reduce pain and swelling. An attempt may be made to untwist the cord manually, but even if this is successful, the patient may still require surgery for stabilization.

Absence seizures are benign, generalized seizures thought to originate subcortically. These brief episodes of unconsciousness usually last 3 to 20 seconds and can occur 100 or more times a day, causing periods of inattention. Absence seizures usually begin between ages 4 and 12. Their first sign may be deteriorating school work and behavior. The cause of these seizures is unknown.

Absence seizures occur without warning. The patient suddenly stops all purposeful activity and stares blankly ahead, as if he were daydreaming. Absence seizures may produce automatisms, such as repetitive lip smacking, or mild clonic or myoclonic movements, including mild jerking of the eyelids. The patient may drop an object that he’s holding, and muscle relaxation may cause him to drop his head or arms or to slump. After the attack, the patient resumes activity, typically unaware of the episode.

Absence status, a rare form of absence seizure, occurs as a prolonged absence seizure or as repeated episodes of these seizures. Usually not life-threatening, it occurs most commonly in patients who have previously experienced absence seizures.

A complex partial seizure occurs when a focal seizure begins in the temporal lobe and causes a partial alteration of consciousness—usually confusion. Psychomotor seizures can occur at any age, but incidence usually increases during adolescence and adulthood. Two-thirds of patients also have generalized seizures.

An aura—usually a complex hallucination, illusion, or sensation—typically precedes a psychomotor seizure. The hallucination may be audiovisual (images with sounds), auditory (abnormal or normal sounds or voices from the patient’s past), or olfactory (unpleasant smells, such as rotten eggs or burning materials). Other types of auras include sensations of déjà vu, unfamiliarity with surroundings, or depersonalization. Some patients become fearful or anxious, experience lip smacking, or have an unpleasant feeling in the epigastric region that rises toward the chest and throat. The patient usually recognizes the aura and lies down before losing consciousness.

A period of unresponsiveness follows the aura. The patient may experience automatisms, appear dazed and wander aimlessly, perform inappropriate acts (such as undressing in public), be unresponsive, utter incoherent phrases, or (rarely) go into a rage or tantrum. After the seizure, the patient is confused, drowsy, and doesn’t remember the seizure. Behavioral automatisms rarely last longer than 5 minutes, but postseizure confusion, agitation, and amnesia may persist.

Between attacks, the patient may exhibit slow and rigid thinking, outbursts of anger and aggressiveness, tedious conversation, a preoccupation with naive philosophical ideas, diminished libido, mood swings, and paranoid tendencies.

Like other types of seizures, generalized tonicclonic seizures are caused by the paroxysmal, uncontrolled discharge of central nervous system (CNS) neurons, leading to neurologic dysfunction. Unlike most other types of seizures, however, this cerebral hyperactivity isn’t confined to the original focus or to a localized area but extends to the entire brain.

A generalized tonic-clonic seizure may begin with or without an aura. As seizure activity spreads to the subcortical structures, the patient loses consciousness, falls to the ground, and may utter a loud cry that’s precipitated by air rushing from the lungs through the vocal cords. His body stiffens (tonic phase), then undergoes rapid, synchronous muscle jerking and hyperventilation (clonic phase). Tongue biting, incontinence, diaphoresis, profuse salivation, and signs of respiratory distress may also occur. The seizure usually stops after 2 to 5 minutes. The patient then regains consciousness but displays confusion. He may complain of headache, fatigue, muscle soreness, and arm and leg weakness.

Generalized tonic-clonic seizures usually occur singly. The patient may be asleep or awake and active. (See What happens during a generalized tonic-clonic seizure, page 620.) Possible complications include respiratory arrest due to airway obstruction from secretions, status epilepticus (occurring in 5% to 8% of patients), head or spinal injuries and bruises, Todd’s paralysis and, rarely, cardiac arrest. Lifethreatening status epilepticus is marked by prolonged seizure activity or by rapidly recurring seizures with no intervening periods of recovery. It’s most commonly triggered by abrupt discontinuation of anticonvulsant therapy.

Generalized seizures may be caused by a brain tumor, vascular disorder, head trauma, infection, metabolic defect, drug or alcohol withdrawal syndrome, exposure to toxins, or a genetic defect. Generalized seizures may also result from a focal seizure. With recurring seizures, or epilepsy, the cause may be unknown.

If you witness the beginning of the seizure, first check the patient’s airway, breathing, and circulation, and ensure that the cause isn’t asystole or a blocked airway. Stay with the patient and ensure a patent airway. Focus your care on observing the seizure and protecting the patient. Place a towel under his head to prevent injury, loosen his clothing, and move any sharp or hard objects out of his way. Never try to restrain the patient or force a hard object into his mouth; you might chip his teeth or fracture his jaw. Only at the start of the ictal phase can you safely insert a soft object into his mouth.