Describing Abnormal Body Movements in a Case Presentation

1. First: Classify the Movement Type (Hyperkinetic vs. Hypokinetic)

• Bradykinesia - slowness of movement, one of the hallmarks of Parkinson's disease (PD) and other parkinsonian disorders
• Akinesia - absence of movement

2. Hyperkinetic Movement Types - Know the Definitions

3. For Each Movement Type, Describe These Features

A. Body Distribution

• Which body part(s): face, jaw, tongue, neck, trunk, upper limb (proximal vs. distal), lower limb
• Unilateral vs. bilateral; symmetric vs. asymmetric
• Focal (one region), segmental (adjacent regions), or generalized
• Example: "pill-rolling tremor of the right thumb and index finger"

B. Activation Condition (Especially for Tremor)

• Rest tremor (3.5-7 Hz): present when the limb is fully supported, disappears with action - cardinal sign of PD
• Postural tremor (6-11 Hz): present while maintaining an antigravity position (e.g., arms outstretched) - seen in essential tremor, drug-induced, physiologic
• Kinetic/Action tremor (3-7 Hz): present during goal-directed movement, worsens as the target is approached (also called intention tremor) - hallmark of cerebellar pathology
• Task-specific tremor: occurs only during a particular activity (e.g., writing tremor)

C. Frequency and Amplitude

• Low frequency (3-5 Hz), moderate (5-8 Hz), high frequency (8-12 Hz)
• Fine (barely visible), moderate, or coarse (large sweeping)
• Example: "coarse, low-frequency resting tremor" vs. "fine, high-frequency postural tremor"

D. Rhythm and Pattern

• Rhythmic (regular) - suggests tremor
• Arrhythmic / random - suggests chorea or myoclonus
• Stereotyped / repetitive - suggests tic or dystonia

E. Temporal Course

• Onset: acute (hours-days), subacute (weeks), or chronic/insidious
• Progression: static, improving, or worsening
• Episodic vs. continuous; paroxysmal vs. persistent
• Duration of each episode (e.g., myoclonus lasts <100 ms; tics last milliseconds to seconds; dystonic spasms can last seconds to minutes)

F. Aggravating and Relieving Factors

• Rest vs. action (critical for tremor classification)
• Mental stress, anxiety, fatigue (worsen most tremors)
• Specific tasks or positions
• Voluntary suppression possible? (tics can be temporarily suppressed; chorea cannot)
• Alcohol - reduces essential tremor
• Sleep - most movement disorders disappear during sleep (except some forms of myoclonus and REM sleep behavior disorder)

4. Specific Descriptive Language by Movement Type

Tremor

"The patient has a 4-5 Hz coarse resting tremor of the right hand with a pill-rolling quality, present at rest and suppressed on voluntary action, worsening with mental distraction."

Chorea

Describe as "rapid, irregular, purposeless, dance-like jerky movements" involving named body parts. Note whether the patient attempts to camouflage them within voluntary movements (a classic sign). Chorea is non-patterned and non-rhythmic. In severe cases, use the phrase "flowing from one body part to another." - Adams and Victor's Principles of Neurology, 12th Ed.

Ballismus

"Large-amplitude, flinging, rotatory movements of the proximal arm/leg" - when unilateral, say hemiballismus, which classically localizes to a contralateral subthalamic nucleus lesion.

Dystonia

Describe as "sustained, repetitive muscle contractions causing a twisting movement or fixed abnormal posture." Name the affected region (e.g., cervical dystonia = torticollis; writer's cramp = task-specific hand dystonia). Note whether it is action-induced or present at rest. - Kaplan & Sadock's Comprehensive Textbook of Psychiatry

Myoclonus

Describe as "sudden, shock-like, brief (<100 ms) jerk." Distinguish:

• Positive myoclonus: sudden muscle contraction
• Negative myoclonus (asterixis): sudden brief lapse in sustained posture (e.g., flapping hand tremor in hepatic encephalopathy) Specify: focal, multifocal, or generalized; spontaneous, action-induced, or stimulus-sensitive - Goldman-Cecil Medicine; Bradley and Daroff's Neurology

Tics

Describe as "stereotyped, rapid, recurrent, non-rhythmic movements (motor tics) or vocalizations (vocal/phonic tics)." Crucially mention: suppressible (patient can hold them back briefly, often with a premonitory urge), and semi-voluntary in nature.

5. Associated Features to Mention

• Consciousness during episodes (preserved or impaired - rules in/out seizure)
• Premonitory urge before the movement (tics)
• Sensory tricks (geste antagoniste) that relieve the movement (dystonia)
• Bradykinesia + rigidity coexisting (parkinsonian syndrome)
• Cognitive/behavioral changes (Huntington's disease)
• Pendular knee jerks (chorea - due to associated hypotonia)
• Functional/psychogenic features to note if suspected: abrupt onset, distractibility, inconsistency, dramatic resolution, rhythmic entrainment

6. Sample Case Presentation Phrases

7. Summary Framework (Use for Every Case)

1. What type of movement is it? (tremor / chorea / myoclonus / dystonia / tic / other)
2. Where does it occur? (body distribution, focal vs. generalized)
3. When does it occur? (rest / action / both; continuous or paroxysmal)
4. How fast is it? (frequency estimate, brief vs. sustained)
5. How big is it? (fine, moderate, coarse/large amplitude)
6. What makes it better or worse?
7. Can the patient control it? (suppressible or not)
8. What else is present? (associated neurologic signs)

• Harrison's Principles of Internal Medicine 22E (2025)
• Adams and Victor's Principles of Neurology, 12th Ed.
• Localization in Clinical Neurology, 8e
• Bradley and Daroff's Neurology in Clinical Practice
• Neuroanatomy through Clinical Cases, 3rd Ed.
• Goldman-Cecil Medicine

Describing Convulsions in a Pediatric Case Presentation

Step 1 - Establish the Setting (Pre-ictal / Prodrome)

• Age of the child - critical, as seizure types vary dramatically by age
• State at onset: awake, asleep, just waking up, playing, feeding
• Precipitants: fever, illness, fasting, sleep deprivation, trauma, medications, flashing lights, startle
• Fever: temperature if known, duration of fever before seizure onset (was the seizure within the first 24 hours of fever?)
• Aura: In older children who can report - did they say anything unusual before collapsing? "Funny feeling in the stomach," visual disturbances, fear, smell, deja vu - these indicate a focal onset
• Cry at onset: a sudden sharp cry at the very beginning suggests generalized onset

Step 2 - Describe the Ictal Phase (The Seizure Itself)

A. Onset - Focal or Generalized?

• Focal onset (limited to networks of one hemisphere) - can have intact awareness or impaired awareness
• Generalized onset (bilaterally distributed networks from the start) - consciousness always impaired
• Unknown onset - when onset is not witnessed or unclear

B. Motor Manifestations - Use Precise Terms

1. Tonic phase (~10-30 seconds): "Sudden loss of consciousness, eyes rolled upward, all four limbs became stiff, back arched, jaw clenched"
2. Clonic phase (~30-60 seconds): "Followed by rhythmic jerking of all four limbs, symmetric, gradually slowing in frequency"
3. Associated features during the ictus: "Frothing at the mouth, tongue biting, urinary/fecal incontinence, cyanosis of the lips"

C. Body Distribution

• Generalized (whole body) vs. focal (one limb, one side)
• Symmetric vs. asymmetric
• Did it start focal and then spread? ("Jerking began in the right hand and within 30 seconds spread to the right arm and then the whole body" - this is a Jacksonian march, indicating focal motor cortex origin, with secondary generalization now called focal to bilateral tonic-clonic)
• Eye involvement: "Eyes deviated to the right" / "eyes rolled upward"
• Face: "facial twitching on the left side" / "jaw clenching" / "perioral cyanosis"

D. Consciousness During the Seizure

• Preserved: Child was aware and could respond during the episode - indicates focal aware seizure
• Impaired / lost: Child was unresponsive, staring blankly, did not respond to voice - indicates focal impaired awareness or generalized
• Staring spell with no motor component: Think absence seizure - "The child suddenly stopped activity, stared blankly for ~10 seconds, then resumed as if nothing happened"

E. Duration

• Exact time in minutes/seconds (parents usually underestimate - ask specifically)
• <15 minutes is a key threshold for simple vs. complex febrile seizures
• >5 minutes is the operational definition of status epilepticus requiring treatment
• >30 minutes = established status epilepticus

Step 3 - Autonomic and Associated Features During the Seizure

• Cyanosis: perioral, generalized - indicates apnea/airway compromise
• Pallor or flushing
• Hypersalivation / frothing at the mouth
• Tongue biting (lateral tongue bite suggests GTC; tip-of-tongue bite can be non-epileptic)
• Urinary or fecal incontinence
• Vomiting
• Apnea / breath holding (common in very young children and neonates)
• Tachycardia, diaphoresis

Step 4 - Postictal Phase

Key distinguishing point: In absence seizures, there is NO postictal phase - the child resumes activity immediately. In GTC seizures, there is always a postictal phase. This distinction alone helps differentiate them.

Step 5 - Febrile Seizure Specific Description

"The child, a 2-year-old male, was noted to have fever of 38.9°C for 6 hours. He was sitting playing when suddenly his eyes rolled upward, both arms and legs stiffened, then developed symmetric rhythmic jerking for approximately 3 minutes. There was perioral cyanosis and frothing at the mouth. He was unresponsive during the event. Post-ictally, he was drowsy and confused for 10 minutes, then returned to his baseline. No focal features were observed. Only one episode occurred in this illness."

Step 6 - Frequency and History of Prior Episodes

• First seizure or known epileptic?
• If recurrent: total number of lifetime seizures, frequency per month, any clustering
• Any previous febrile seizures?
• Seizure-free intervals
• Change in pattern from prior episodes?

Step 7 - Context and Triggers

Step 8 - Age-Specific Seizure Patterns in Children

Summary Framework for Presentation

1. SETTING      → Age, state (awake/asleep), precipitant, aura
2. ONSET        → Focal or generalized, eye/head deviation, cry
3. MOTOR        → Tonic / clonic / tonic-clonic / atonic / spasm / automatisms
4. DISTRIBUTION → Symmetric/asymmetric, which limbs, face
5. CONSCIOUSNESS→ Preserved or lost during the event
6. AUTONOMICS   → Cyanosis, frothing, tongue bite, incontinence
7. DURATION     → Exact time; did it stop spontaneously or require intervention?
8. POSTICTAL    → Duration, Todd's palsy, return to baseline
9. FEVER        → Simple vs. complex febrile classification if applicable
10. FREQUENCY   → First episode or recurrent, prior history

• Harrison's Principles of Internal Medicine 22E (2025) - ILAE 2017 classification
• Bradley and Daroff's Neurology in Clinical Practice - Febrile seizures, focal vs. generalized
• Tintinalli's Emergency Medicine - Simple vs. complex febrile seizure criteria
• Rosen's Emergency Medicine - Pediatric seizure management

Differential Diagnosis of Convulsions in Pediatric Case Presentation

1. Is this truly a seizure? (epileptic vs. non-epileptic mimics)
2. If it is a seizure, what is the cause? (provoked vs. unprovoked, and the underlying etiology)

TIER 1 - Is It a True Epileptic Seizure?

Non-Epileptic Mimics ("Not All That Shakes Is a Seizure")

1. Febrile Seizure (Simple or Complex)

• For simple febrile seizure: No further investigation needed; benign, self-limited
• For complex febrile seizure: Focal features, duration >15 minutes, or recurrence within 24 hours - must investigate further to exclude meningitis, encephalitis, or underlying epilepsy
• Key distinguishing feature: Temperature documented, age range 6 months-6 years, no CNS signs

2. Breath-Holding Spell

• Distinguishes from epileptic seizure: Always has a clear trigger (emotional/painful stimulus), starts with crying, involuntary jerks come AFTER the loss of consciousness from anoxia (not before), full recovery is rapid, EEG is normal, no postictal drowsiness
• Danger of over-diagnosis: Parents and physicians may interpret this as epilepsy; the key is the trigger and the crying-then-apnea sequence

3. Syncope (Vasovagal / Reflex Anoxic)

• Distinguishes from seizure: Pallor and diaphoresis precede the event; occurs while upright; rapid recovery (no postictal confusion); may have prodrome of dizziness, nausea, visual graying; normal EEG and ECG (or bradycardia on ECG)
• Key clue: If the child is laid flat, recovery is almost immediate

4. Absence Seizure vs. Daydreaming / Inattention

• True absence: Cannot be interrupted; hyperventilation for 3 minutes can often provoke a spell in the clinic; EEG shows classic 3 Hz spike-and-wave; no postictal phase
• Distinguishes from complex focal seizure: Absence has no aura, no automatisms (or only brief lip smacking), instantaneous recovery; complex focal seizures have longer duration, more prominent automatisms, and postictal confusion
• Distinguishes from daydreaming: Daydreaming child responds to their name; absence child does not

5. Psychogenic Non-Epileptic Seizure (PNES)

• Key distinguishing features: Eyes typically remain closed (epileptic seizures - eyes usually open); out-of-phase limb movements; lack of postictal state despite apparent severity; normal prolactin levels post-ictally; normal EEG during the event
• Important: Many patients with PNES also have true epilepsy - the two can coexist

6. Hypnic Jerks (Sleep Myoclonus)

• Distinguishes from seizure: Occurs only at sleep onset, child wakes up, no other features, occurs in all ages; no EEG abnormality

7. Tics and Stereotypies

• Distinguishes from seizure: Tics are brief, stereotyped, semi-voluntary, partially suppressible, and consciousness is fully preserved throughout; no postictal phase; often associated with a premonitory urge

8. Benign Paroxysmal Vertigo of Childhood

• Distinguishes from seizure: No loss of consciousness; child is frightened but alert; nystagmus may be present; resolves completely; a migraine variant

9. Shuddering Attacks

• Distinguishes from seizure: No loss of consciousness; very brief; child continues normal activity; EEG is normal; may represent early essential tremor

10. Sandifer Syndrome

• Distinguishes from seizure: Occurs peri-prandially; associated with feeding difficulties, vomiting; improvement with anti-reflux treatment; no EEG abnormality

TIER 2 - If It IS a Seizure: What Is the Cause?

A. PROVOKED (Acute Symptomatic) Seizures

1. Febrile Seizure

• Already described above - the most common provoked seizure

2. Meningitis / Encephalitis

• Bacterial meningitis (Neisseria meningitidis, Streptococcus pneumoniae, Listeria): Rapid deterioration, purpuric rash (meningococcal), bulging fontanelle in infants, toxic appearance
• Viral encephalitis (HSV, enterovirus): Behavioral change, focal neurological signs, CSF pleocytosis
• Tuberculous meningitis: Subacute onset, low-grade fever, cranial nerve palsies, contact history
• Key distinguishing feature from simple febrile seizure: Child does NOT return to normal between or after seizures; persistent altered consciousness; meningeal signs

3. Metabolic Causes

4. Hypoxic-Ischemic Encephalopathy (HIE)

• Clue: Documented intrapartum complication; encephalopathic infant (hypotonia, poor feeding, abnormal cry); seizures may be subtle (lip smacking, eye deviation, bicycling)

5. CNS Infection - Cerebral Abscess / Neurocysticercosis

• Cerebral abscess: Immunocompromised child, cyanotic congenital heart disease (paradoxical emboli), sinusitis, mastoiditis; focal seizures + headache + fever
• Neurocysticercosis: Endemic regions (Asia, Africa, Latin America); calcified cysts visible on CT; common cause of new-onset epilepsy in older children in endemic areas

6. Head Trauma

• Immediate (impact) seizures: Within seconds of head injury
• Early post-traumatic seizures: Within first 7 days - reflect acute brain injury
• Late post-traumatic epilepsy: >7 days after injury - true epileptogenesis; risk is 30-50% with penetrating injury
• Non-accidental injury (NAI): In infants with seizures, always consider subdural haematoma from shaken baby syndrome; look for retinal haemorrhages, unexplained bruising, inconsistent history

7. Toxic Ingestion / Drug Poisoning

• Common culprits: antihistamines, tricyclic antidepressants, theophylline, camphor, organophosphates, isoniazid, cocaine, alcohol
• Clue: Acute onset in a previously well toddler with no fever; pupillary changes, autonomic instability, other toxidrome features

8. Electrolyte Disturbance from Dehydration

• Clue: Preceding diarrhoea/vomiting, signs of dehydration (dry mucosa, sunken fontanelle, reduced skin turgor), electrolytes confirm the diagnosis

B. UNPROVOKED Seizures - Epilepsy Syndromes

C. STRUCTURAL / LESIONAL Causes

• Focal seizures or focal neurological signs
• Seizures refractory to first-line treatment
• Abnormal head circumference (macro/microcephaly)
• Neurocutaneous stigmata on skin examination

Summary Differential Framework for Case Presentation

1. Most Likely (given the clinical features)
   → e.g., "Simple febrile seizure in view of: age 2 years, fever,
     generalized tonic-clonic <15 min, single episode, full recovery"

2. Must Not Miss (dangerous if overlooked)
   → Bacterial meningitis / viral encephalitis
   → Hypoglycemia
   → Non-accidental injury (if infant)
   → Status epilepticus

3. Other Causes to Consider
   → Complex febrile seizure (if focal or prolonged)
   → Metabolic (hyponatremia, hypocalcemia)
   → Epilepsy syndrome (if recurrent or unprovoked)
   → Seizure mimic (breath-holding spell if triggered; PNES if adolescent)

• Harrison's Principles of Internal Medicine 22E (2025) - causes by age, Table 436-4
• Rosen's Emergency Medicine - acute symptomatic causes in children
• Bradley and Daroff's Neurology in Clinical Practice - febrile seizures, epilepsy syndromes
• Tintinalli's Emergency Medicine - simple vs. complex febrile, PNES