Name: Abhilash Age: 8 years Sex: Male Address: Gadag DOA: 18/5/26 DOE: 19/5/26 Chief Complaints Involuntary movements of both UL & LL × 4days History of Presenting Illness (HOPI) Patient was apparently alright 9 days back, then he came with episodes of uprolling of eyes associated with involuntary movements of both upper and lower limbs. Episodes were sudden in onset, lasted for about 5 minutes, and occurred multiple times in a span of 2 hours before bringing to hospital. During the episode: No loss of consciousness Frothing from mouth present Clonic movements of all four limbs Uprolling of eyes Clenching of teeth No history of Fever (to rule out febrile seizures) Head trauma (traumatic seizures) Vomiting/headache (↑ ICP) Ear discharge (CNS spread/infection) Focal weakness Drug intake Developmental delay Birth asphyxia

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I now have sufficient information to generate a comprehensive clinical case write-up. Let me compile everything into a structured case analysis.

Case Analysis — Abhilash, 8-year-old Male

Clinical Summary

An 8-year-old boy presents with 4 days of recurrent involuntary movements of all four limbs. Episodes began 9 days ago, characterised by:

Sudden onset clonic movements of all four limbs
Uprolling of eyes (deviation)
Frothing from mouth
Clenching of teeth (trismus)
No loss of consciousness (preserved awareness, though this needs careful re-evaluation)
Duration ~5 minutes per episode; multiple episodes over 2 hours
No fever, no trauma, no vomiting/headache, no ear discharge, no focal deficit, no prior drug intake, no developmental delay, no birth asphyxia

Seizure Classification

Feature	This Patient
Onset	Generalised (bilateral from onset)
Awareness	Apparently preserved (but clenching + frothing may impair recall)
Motor type	Clonic (rhythmic jerking of all 4 limbs)
Autonomic	Frothing (hypersalivation)
Ocular	Uprolling/deviation of eyes
Duration	~5 minutes
Cluster	Multiple episodes over 2 hours → cluster seizures / approaching status epilepticus

Per the ILAE 2017 classification, this is a Generalised Onset Motor Seizure — Clonic type (with features also consistent with Generalised Tonic-Clonic Seizure, as eye uprolling, teeth clenching and frothing indicate tonic phase followed by clonic activity).

Differential Diagnosis

Most Likely

1. New-Onset Generalised Epilepsy (unprovoked)

Age 8, no identifiable provocation, generalised semiology, no developmental delay
Could represent a Generalised Epilepsy Syndrome (e.g., Childhood Absence Epilepsy variant, Genetic Generalised Epilepsy)

To Exclude Urgently

Diagnosis	Reasoning	Excluded By
Febrile seizures	Most common seizure condition in children; but no fever here	No fever → makes this less likely; however, a subtle fever at seizure onset should be re-enquired
Meningitis / Encephalitis	CNS infection can provoke acute symptomatic seizures	No fever, no headache, no neck stiffness noted — but CSF should be considered
Intracranial SOL (tumour, cyst)	Structural epilepsy	No focal deficit, no raised ICP symptoms — MRI will exclude
Metabolic seizures (hypoglycaemia, hyponatraemia, hypocalcaemia)	Common in children	Blood glucose, electrolytes, Ca²⁺
Neurocysticercosis	Endemic in India; most common cause of new-onset epilepsy in an Indian child	MRI brain / CT brain
ADEM / Autoimmune encephalitis	Post-infectious; multiple seizures, possible behavioural change	MRI, CSF, autoimmune antibody panel

⚠️ In an Indian child from Gadag (Karnataka), neurocysticercosis must be ruled out first — it is the leading cause of new-onset seizures in school-age children in the subcontinent.

Investigations Required

Bedside/Emergency

Blood glucose (rule out hypoglycaemia)
SpO₂ / ECG monitoring
IV access secured

Blood Investigations

Test	Purpose
CBC, CRP, ESR	Infection, inflammation
Blood glucose	Metabolic cause
Serum electrolytes (Na⁺, K⁺, Ca²⁺, Mg²⁺, PO₄)	Metabolic seizure
LFT, KFT	Baseline before AED
Serum prolactin (within 20 min of seizure)	Supportive of true seizure vs. pseudoseizure
Cysticercus serology (ELISA)	NCC
Blood culture (if febrile)

Neuroimaging

MRI brain with contrast — investigation of choice for epilepsy workup
- Can detect neurocysticercosis (ring-enhancing lesions, scolices), cortical dysplasia, mesial temporal sclerosis, tumours
- If MRI unavailable urgently: NCCT head to exclude bleed/gross SOL
- CT is more sensitive than MRI for calcified NCC lesions

Electroencephalography (EEG)

Interictal EEG — essential for:
- Confirming epileptiform activity
- Classifying seizure type (generalised vs. focal onset)
- Identifying syndrome (e.g., 3 Hz spike-wave → absence; centrotemporal spikes → BECTS)
Sleep EEG / 24-hour ambulatory EEG may be needed if routine EEG is normal

CSF Analysis (Lumbar Puncture)

Indicated if CNS infection suspected (fever, meningism, altered sensorium)
Not routinely needed in an afebrile child, but consider if MRI suggests encephalitis

Acute Management

During Active Seizure (ABC first)

Position: Left lateral (recovery position) to prevent aspiration
Airway: Clear, suction if needed; O₂ supplementation via mask
IV access and blood glucose immediately

Pharmacological — Step-Up Protocol

Step	Drug	Dose	Route
1st line	Lorazepam 0.1 mg/kg (max 4 mg)	IV over 2 min	IV
(If no IV access)	Diazepam rectal 0.5 mg/kg	PR
2nd line (if seizure continues >5 min after benzodiazepine)	Fosphenytoin 20 mg PE/kg OR Phenobarbitone 20 mg/kg	IV	Slow infusion
Alternative 2nd line	Levetiracetam 20–60 mg/kg IV	IV	15 min infusion
3rd line / RSI	Phenobarbitone (if not already used) / ICU intubation + Propofol or Midazolam infusion	IV	ICU

Since the child had multiple seizures over 2 hours, this constitutes cluster seizures and warrants urgent treatment even if currently interictal.

Maintenance AED (once acute phase controlled)

Valproate (Sodium Valproate) 20–40 mg/kg/day in 2–3 divided doses — drug of choice for generalised epilepsy in children
- Broad spectrum: effective against generalised tonic-clonic, absence, myoclonic
Levetiracetam (Keppra) — alternative; fewer drug interactions, no hepatic monitoring needed
Lamotrigine — slower titration; co-prescribe with valproate requires dose reduction
Do NOT use carbamazepine/oxcarbazepine in generalised epilepsy (may worsen absences/myoclonus)

Likely Diagnosis (Working)

New-onset Generalised Epilepsy — Genetic/Structural, Age 8 years

Most probable specific aetiology given geographic context: Neurocysticercosis-associated epilepsy (until MRI rules it out)

If imaging negative: Genetic Generalised Epilepsy (GGE) / self-limited epilepsy syndrome

Admission Plan

Admit to Paediatric ward with seizure precautions (padded cot rails, O₂ at bedside, suction ready)
NBM until stable, then soft diet
IV access maintained
Continuous pulse oximetry
Load with IV Valproate or Levetiracetam
Urgent MRI brain ± contrast
EEG within 24–48 hours
Paediatric neurology consult
Educate parents: seizure first aid, medications, follow-up

Points Favouring / Against Status Epilepticus

Against Status	Supporting Concern
Individual episodes ~5 min	Multiple episodes in 2 hours (cluster)
No LOC mentioned	Postictal state possible between attacks
4-day history (not 24 h continuous)	Approaching operational threshold of "5 min = treat as status"

Per current ILAE definition, status epilepticus = seizure >5 minutes OR ≥2 seizures without full recovery between them. This child's cluster over 2 hours warrants the same urgency.

Sources: Tintinalli's Emergency Medicine, 9th ed.; Neuroanatomy through Clinical Cases, 3rd ed.; Kaplan & Sadock's Comprehensive Textbook of Psychiatry — Seizures and Epilepsy Syndromes in Children.

Can you give me the proper case format to write this case of paediatrics for my tomorrows clinical postings

Here is the complete paediatric case write-up in proper clinical posting format:

CASE PRESENTATION

Department of Paediatrics

PATIENT IDENTIFICATION


Name	Abhilash
Age	8 years
Sex	Male
Address	Gadag
Date of Admission (DOA)	18/05/2026
Date of Examination (DOE)	19/05/2026
IP No.
Ward	Paediatrics
Informant	Parents (Reliable)

CHIEF COMPLAINTS

Involuntary movements of both upper and lower limbs × 4 days

HISTORY OF PRESENTING ILLNESS

Patient Abhilash, an 8-year-old male child, was apparently normal until 9 days back, after which he developed episodes of involuntary movements of all four limbs associated with uprolling of eyes.

Onset: Sudden

Progression: Multiple episodes occurring over a span of 2 hours before being brought to the hospital

Duration of each episode: Approximately 5 minutes

During the Episode, the Following Were Present:

Uprolling of eyes
Clonic movements of all four limbs (bilateral, symmetrical)
Frothing from mouth
Clenching of teeth (trismus)
No loss of consciousness (child was responsive during episodes as reported by parents)

During the Episode, the Following Were Absent:

Loss of consciousness
Cyanosis
Urinary/fecal incontinence (not reported)
Postictal confusion/drowsiness (to be clarified)

HISTORY OF SIMILAR COMPLAINTS IN THE PAST

No previous episodes of involuntary movements or seizures reported prior to 9 days ago.

PERTINENT NEGATIVE HISTORY

Symptom	Significance of Exclusion
No fever	Rules out febrile seizures and CNS infections
No head trauma	Rules out traumatic / post-traumatic seizures
No vomiting / headache	Rules out raised intracranial pressure
No ear discharge	Rules out otogenic spread / CNS infection
No focal weakness	Rules out focal (structural) brain pathology
No drug intake	Rules out drug-induced / toxic seizures
No developmental delay	Rules out neurodevelopmental disorders
No birth asphyxia	Rules out hypoxic-ischemic encephalopathy sequelae

BIRTH HISTORY

Period of gestation: Term / Preterm (to be elicited)
Mode of delivery: Normal vaginal delivery / LSCS (to be elicited)
Birth cry: Present immediately (to be confirmed)
Birth weight: (to be elicited)
NICU admission: None reported
Antenatal complications: Nil reported

DEVELOPMENTAL HISTORY

Milestone	Age Achieved
Smiled	~2 months (to confirm)
Neck holding	~3–4 months
Sitting without support	~6–8 months
Standing with support	~9 months
Walking	~12–14 months
First words	~12 months
Sentences	~18–24 months

Developmental milestones are appropriate for age — no delay reported by parents.

IMMUNISATION HISTORY

Immunised as per National Immunisation Schedule (NIS) up to date (to be confirmed with vaccination card).

NUTRITIONAL HISTORY

Diet: Mixed (vegetarian/non-vegetarian — to be elicited)
Appetite: Normal
No history of pica, food aversion, or failure to thrive
Dietary assessment: Age-appropriate

FAMILY HISTORY

No family history of seizures / epilepsy
No consanguinity in parents (to be confirmed)
No similar illness in siblings

SOCIOECONOMIC HISTORY

Residence: Gadag (semi-urban / rural)
Socioeconomic status: (to be assessed — Kuppuswamy scale)
Type of house: (pucca / kutcha)
Water source: Tap / well (to be elicited)
Sanitation: (to be elicited)

GENERAL PHYSICAL EXAMINATION

Parameter	Findings
Conscious	Yes
Cooperative	Yes
Oriented	To time, place, person
Built and nourishment	Moderately built and nourished
Pallor	Absent
Icterus	Absent
Cyanosis	Absent
Clubbing	Absent
Lymphadenopathy	Absent
Edema	Absent
Dehydration	Absent

Anthropometry


Weight	___ kg (___th centile)
Height	___ cm (___th centile)
Head circumference	___ cm
BMI	___ kg/m²

Vital Signs


Temperature	Afebrile (___°F)
Pulse	___ bpm, regular, normal volume
Respiratory rate	___ breaths/min
Blood pressure	___/___mmHg
SpO₂	___% on room air

SYSTEMIC EXAMINATION

Central Nervous System (Detailed)

Higher Functions:

Conscious, oriented, speech normal
Memory, attention: Intact for age

Cranial Nerves:

II: Visual acuity grossly normal, pupils equal and reactive to light (PEARL), 3 mm bilaterally
III, IV, VI: Extraocular movements full, no nystagmus
V, VII, IX, X, XI, XII: Intact

Motor System:

	Upper Limb	Lower Limb
Tone	Normal	Normal
Power	5/5	5/5
Deep tendon reflexes	++	++
Plantar response	Flexor bilaterally

Sensory System: No gross deficit

Cerebellar Signs: Finger-nose test normal, tandem walk normal, no dysdiadochokinesia

Meningeal Signs:

Neck rigidity: Absent
Kernig's sign: Negative
Brudzinski's sign: Negative

Cardiovascular System

S1, S2 heard, no murmurs
Peripheral pulses normal

Respiratory System

Air entry bilateral, equal
No added sounds

Abdomen

Soft, non-tender
Liver and spleen not palpable
No organomegaly

Skin

No neurocutaneous markers (no ash-leaf macules, no café-au-lait spots, no port-wine stain, no adenoma sebaceum)

PROVISIONAL DIAGNOSIS

New-onset Generalised Epilepsy in an 8-year-old male child

(Aetiology to be determined — structural vs. genetic)

DIFFERENTIAL DIAGNOSES

Neurocysticercosis — Most common cause of new-onset seizures in Indian school-age children (to rule out with MRI/CT brain)
Genetic Generalised Epilepsy (GGE) — Age-appropriate, no identifiable structural cause
Autoimmune / Post-infectious Encephalitis — Multiple seizures in short span
Febrile Seizure — Less likely (no fever documented)
Metabolic Seizure (hypocalcaemia, hyponatraemia) — To exclude with blood work

INVESTIGATIONS ADVISED

Haematological

Complete Blood Count (CBC)
ESR, CRP

Biochemical

Blood glucose (fasting and random)
Serum electrolytes (Na⁺, K⁺, Cl⁻, HCO₃⁻)
Serum calcium, magnesium, phosphorus
Liver function tests (LFT)
Kidney function tests (KFT)
Serum prolactin (within 20 minutes of seizure — supports diagnosis)

Serological

Cysticercus ELISA (IgG) — for neurocysticercosis

Neuroimaging

MRI Brain with contrast — Investigation of choice (CT brain if MRI not available — better for calcified NCC lesions)

Neurophysiology

EEG (Electroencephalogram) — Interictal EEG to characterise seizure type and guide AED choice

CSF Analysis

Lumbar puncture — only if meningitis/encephalitis is clinically suspected

MANAGEMENT

A. General Measures

Admission to Paediatric ward
Seizure precautions: padded cot rails, lateral positioning
O₂ and suction at bedside
IV access secured; continuous SpO₂ monitoring
NPO until fully stable; then age-appropriate soft diet
Daily monitoring of vitals and seizure diary

B. Acute Seizure Protocol

Step	Drug	Dose	Route
1st line	Lorazepam	0.1 mg/kg IV (max 4 mg)	IV slow push
(No IV access)	Diazepam	0.5 mg/kg rectal	PR
2nd line (if >5 min)	Levetiracetam	20–60 mg/kg	IV over 15 min
OR	Fosphenytoin	20 mg PE/kg	IV slow infusion
3rd line	Phenobarbitone	20 mg/kg	IV; ICU setting

C. Maintenance Anti-Epileptic Drug (AED)

Drug of choice: Sodium Valproate

Dose: 20–40 mg/kg/day in 2–3 divided doses
Broad-spectrum; effective for generalised tonic-clonic, absence, and myoclonic seizures
Monitor LFT periodically

Alternative: Levetiracetam (Keppra)

Dose: 20–60 mg/kg/day in 2 divided doses
Preferred if valproate contraindicated
Fewer drug interactions; no hepatic monitoring required

⚠️ Avoid carbamazepine / oxcarbazepine — contraindicated in generalised epilepsy; may precipitate absence seizures and myoclonus.

D. Specific Treatment (if aetiology confirmed)

Neurocysticercosis: Albendazole 15 mg/kg/day × 8 days + corticosteroids (Dexamethasone) + AED
Autoimmune encephalitis: IV methylprednisolone + IVIG
Metabolic: Correct underlying electrolyte abnormality

COUNSELLING POINTS FOR PARENTS

Explain the diagnosis in simple language — seizures are controllable with medications
Seizure first aid: Place child on side, do not insert anything in mouth, time the episode, call emergency if >5 minutes
Medication compliance — do NOT stop AED without doctor's advice even if seizure-free
Avoid heights, swimming alone, cycling on roads during treatment period
Inform school teachers
Regular follow-up with paediatric neurology
Driving restriction (not relevant at age 8, but counsel parents for future)

PROGNOSIS

Good if structural cause is excluded and epilepsy syndrome is identified correctly
Over 70% of epilepsy cases achieve satisfactory seizure control with appropriate AED
Neurocysticercosis-associated epilepsy — excellent prognosis after successful treatment
Genetic Generalised Epilepsy syndromes — many achieve remission by adolescence

References: Tintinalli's Emergency Medicine; Neuroanatomy through Clinical Cases, 3rd Ed.; Kaplan & Sadock's Comprehensive Textbook of Psychiatry

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