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Diseases » Convulsions » Causes
 

Causes of Convulsions

Contents
  1. Convulsions: Introduction
  2. List of Causes
  3. Drugs/substances (765 causes)
  4. Drug interaction (4007 causes)
  5. Hidden causes
  6. Excerpts from book chapters
  7. Complication causes
  8. Causes of symptoms
  9. News
  10. Related cause information

List of causes of Convulsions

Following is a list of causes or underlying conditions (see also Misdiagnosis of underlying causes of Convulsions) that could possibly cause Convulsions includes:

More causes: see full list of causes for Convulsions

Causes of Convulsions (Diseases Database):

The follow list shows some of the possible medical causes of Convulsions that are listed by the Diseases Database:

Source: Diseases Database

Convulsions Causes: Book Excerpts

Convulsions as a complication of other conditions:

Other conditions that might have Convulsions as a complication may, potentially, be an underlying cause of Convulsions. Our database lists the following as having Convulsions as a complication of that condition:

Convulsions as a symptom:

Conditions listing Convulsions as a symptom may also be potential underlying causes of Convulsions. Our database lists the following as having Convulsions as a symptom of that condition:

Medications or substances causing Convulsions:

The following drugs, medications, substances or toxins are some of the possible causes of Convulsions as a symptom. This list is incomplete and various other drugs or substances may cause your symptoms. Always advise your doctor of any medications or treatments you are using, including prescription, over-the-counter, supplements, herbal or alternative treatments.

See full list of 765 medications causing Convulsions


Drug interactions causing Convulsions:

When combined, certain drugs, medications, substances or toxins may react causing Convulsions as a symptom.

The list below is incomplete and various other drugs or substances may cause your symptoms. Always advise your doctor of any medications or treatments you are using, including prescription, over-the-counter, supplements, herbal or alternative treatments.

  • Elavil and monoamine oxidase inhibitor antidepressant interaction
  • Endep and monoamine oxidase inhibitor antidepressant interaction
  • Etrafon and monoamine oxidase inhibitor antidepressant interaction
  • Etrafon-A and monoamine oxidase inhibitor antidepressant interaction
  • Etrafon-Forte and monoamine oxidase inhibitor antidepressant interaction
  • more interactions...»

See full list of 4007 drug interactions causing Convulsions

Medical news summaries relating to Convulsions:

The following medical news items are relevant to causes of Convulsions:

Related information on causes of Convulsions:

As with all medical conditions, there may be many causal factors. Further relevant information on causes of Convulsions may be found in:

Causes of Convulsions: Online Medical Books

16 MEDICAL BOOKS ONLINE! Review excerpts from medical books online, free, without registration, for more information about the causes of Convulsions.

Tremor: Differential Diagnosis
(In a Page: Signs and Symptoms)

Resting tremors

  • Parkinson's disease
    –“Pill-rolling” appearance
    –Associated cog-wheel rigidity, shuffling gait, akinesis, and/or depression
  • Benign familial or essential tremor
    –Especially common with head tremor (e.g., actress Katherine Hepburn)
    –Positive family history
    –No other neurologic findings
  • Drug or toxin-induced tremors (e.g., MPTP)
  • Postural tremors: Elicited when a limb is held up against gravity; caused by metabolic conditions (e.g., thyrotoxicosis)
  • Voluntary movement (hyperkinetic) tremors
  • Wilson's disease
  • Stroke
  • Cerebellar disease
    Movement tremors
  • Intentional tremor: Occurs with movement toward a target; associated with a cerebellar deficit which would inhibit (e.g., multiple sclerosis, midbrain injury or stroke)

    • » READ BOOK EXCERPT ONLINE »

    Source: In a Page: Signs and Symptoms, 2004

    Seizures/Convulsions: Differential Diagnosis
    (In a Page: Signs and Symptoms)

    • Partial seizure (involve only part of the brain)
      –Simple (no altered consciousness)
      –Complex (with altered consciousness)
    • Generalized seizure (involve both hemispheres)
      –Tonic-clonic
      –Atonic
      –Tonic
      –Myoclonic
      –Absence
    • Epilepsy
      –Recurrent unprovoked seizures of any or multiple types, which may be idiopathic or symptomatic
      • Secondary seizure
        –Metabolic abnormalities (e.g., electrolyte disturbances, hypoglycemia)
        –Drug effects, intoxication, or withdrawal
        –Head injury/trauma
        –Febrile seizures in children
        –Structural lesions (e.g., tumor, subdural hematoma)
        –Cerebrovascular etiologies (e.g., cerebral infarct, intracerebral hemorrhage, subarachnoid hemorrhage
        –Hypoxic-ischemic encephalopathy
        –Infection (e.g., meningitis, encephalitis)
        –Hypoxia
      • Nonepileptic seizure
        –Not associated with abnormal electrical activity in the brain
        –Patients with loss of consciousness secondary to cerebral hypoperfusion (fainting, syncope) may occasionally exhibit brief periods of twitching or convulsive movements resembling seizure activity
        –Psychological disturbances (pseudoseizure)
      • Inborn errors of metabolism
        –Disorders of amino acid metabolism
        –Organic acidemias
        –Urea cycle disorders
        –Mitochondrial disorders
        –Peroxisomal disorders
        –Glycogen storage disorders
        –Disorders of sugar metabolism
      • Rasmussen's encephalitis
        –Causes seizures and progressive hemispheric dysfunction in infants

    » READ BOOK EXCERPT ONLINE »

    Source: In a Page: Signs and Symptoms, 2004

    Seizures – Childhood: Differential Diagnosis
    (In A Page: Pediatric Signs and Symptoms)

    • Febrile seizure
    • Cerebral dysgenesis: Disorders of neuronal migration, heterotopias, lissencephaly
    • Epilepsy syndromes
      –Childhood absence
      –Juvenile absence
      –Juvenile myoclonic epilepsy (JME)
      –Benign rolandic epilepsy (BRE)
    • Meningitis/encephalitis (e.g., HSV)
    • Cerebral abscess
    • Postinfectious (e.g., ADEM)
    • Hyponatremia
    • Hypernatremia
    • Hypocalcemia
    • Hypoglycemia
    • Toxins: Ingestions or sedative withdrawal
    • Trauma
    • Pyridoxine deficiency
    • Neoplasm
    • Degenerative
      –Alpers disease
      –Rett syndrome
      –Unterricht-Lundborg disease
      –Lafora disease
      –Neuronal ceroid lipofuscinosis
    • Genetic
      –Angelman syndrome
      –Aicardi syndrome
      • Metabolic
        –Medium chain acyl-CoA dehydrogenase deficiency (MCAD)
        –Myoclonus epilepsy and ragged-red fibers syndrome (MERRF)
        –Sialidosis
        –Glucose transporter deficiency
        –Urea cycle defects
    • Vascular: Stroke, hemorrhage, vasculitis
    • Hashimoto encephalitis
    • Seizure mimics
      –Breath-holding spells
      –Syncope, convulsive syncope
      –Gastroesophageal reflux
      –Cardiac arrhythmia
      –Movement disorder
      –Migraine
      –Benign paroxysmal vertigo
      –Parasomnia
      –Pseudo-seizure
      –Rage attack

    » READ BOOK EXCERPT ONLINE »

    Source: In A Page: Pediatric Signs and Symptoms, 2007

    Seizures – Neonatal: Differential Diagnosis
    (In A Page: Pediatric Signs and Symptoms)

    • Hypoxic ishemic encephalopathy
    • Bacterial meningitis/sepsis
    • Stroke
    • Cerebral dysgenesis
    • Electrolyte disturbances
      –Hypoglycemia
      –Hyponatremia
      –Hypomagnesemia
      –Hypocalcemia
    • Maternal drug use
      –Drug withdrawal after delivery
      –Direct effect of drugs, such as cocaine
    • Congenital infections (TORCH)
      –Toxoplasmosis
      –Syphilis
      –Rubella
      –CMV
      –HSV
    • HSV encephalitis
      • Intracranial hemorrhage
        –Subdural hemorrhage
        –Intraparenchymal hemorrhage
        –Intraventricular hemorrhage in the premature infant
        –Subarachnoid hemorrhage
    • Urea cycle disturbances
    • Smith-Lemli-Opitz syndrome
    • Nonketotic hyperglycinemia
    • Pyridoxine deficiency
    • Fructose dysmetabolism
    • Amino acidurias
      –Maple syrup urine disease
      –Proprionic acidemia
    • Molybdenum cofactor deficiency
    • Mitochondrial encephalopathy
    • Glucose transporter deficiency
      • Benign etiologies
        –Benign idiopathic neonatal seizures (fifth day fits)
        –Benign familial neonatal seizures
    • Movements commonly mistaken for seizures
      –Benign neonatal sleep myoclonus
      –Jitteriness (may be secondary to hypoglycemia, drug withdrawal, or idiopathic)
      –Gastroesophageal reflux (arching, writhing)
      –Breath-holding spell

    » READ BOOK EXCERPT ONLINE »

    Source: In A Page: Pediatric Signs and Symptoms, 2007

    Fasciculations: Medical causes
    (Handbook of Signs & Symptoms (Third Edition))

    Amyotrophic lateral sclerosis

    Coarse fasciculations usually begin in the small muscles of the hands and feet, and then spread to the forearms and legs. Widespread, symmetrical muscle atrophy and weakness may result in dysarthria; difficulty chewing, swallowing, and breathing; and, occasionally, choking and drooling.

    Bulbar palsy

    Fasciculations of the face and tongue commonly appear early. Progressive signs and symptoms include dysarthria, dysphagia, hoarseness, and drooling. Eventually, weakness spreads to the respiratory muscles.

    Poliomyelitis (spinal paralytic)

    Coarse fasciculations, usually transient but occasionally persistent, accompany progressive muscle weakness, spasms, and atrophy. The patient may also exhibit decreased reflexes, paresthesia, coldness and cyanosis in the affected limbs, bladder paralysis, dyspnea, elevated blood pressure, and tachycardia.

    Spinal cord tumors

    Fasciculations may develop along with muscle atrophy and cramps, asymmetrically at first and then bilaterally as cord compression progresses. Motor and sensory changes distal to the tumor include weakness or paralysis, areflexia, paresthesia, and a tightening band of pain. Bowel and bladder control may be lost.

    Other causes

    Pesticide poisoning

    Ingestion of organophosphate or carbamate pesticides commonly produces an acute onset of long, wavelike fasciculations and muscle weakness that rapidly progresses to flaccid paralysis. Other common effects include nausea, vomiting, diarrhea, loss of bowel and bladder control, hyperactive bowel sounds, and abdominal cramping. Cardiopulmonary findings include bradycardia, dyspnea or bradypnea, and pallor or cyanosis. Seizures, visual disturbances (pupillary constriction or blurred vision), and increased secretions (tearing, salivation, pulmonary secretions, or diaphoresis) may also occur.

    » READ BOOK EXCERPT ONLINE »

    Source: Handbook of Signs & Symptoms (Third Edition), 2006

    Myoclonus: Medical causes
    (Handbook of Signs & Symptoms (Third Edition))

    Alzheimer’s disease

    Generalized myoclonus may occur in advanced stages of Alzheimer’s disease, a slowly progressive dementia. Other late findings include mild choreoathetoid movements, muscle rigidity, bowel and bladder incontinence, delusions, and hallucinations.

    Creutzfeldt-Jakob disease

    Diffuse myoclonic jerks appear early in Creutzfeldt-Jakob disease, a rapidly progressive dementia. Initially random, they gradually become more rhythmic and symmetrical, usually occurring in response to sensory stimuli. Associated effects include ataxia, aphasia, hearing loss, muscle rigidity and wasting, fasciculations, hemiplegia, and vision disturbances, or possibly, blindness.

    Encephalitis (viral)

    With viral encephalitis, myoclonus is usually intermittent and either localized or generalized. Associated findings vary, but may include a rapidly decreasing LOC, a fever, a headache, irritability, nuchal rigidity, vomiting, seizures, aphasia, ataxia, hemiparesis, facial muscle weakness, nystagmus, ocular palsies, and dysphagia.

    Encephalopathy

    Hepatic encephalopathy occasionally produces myoclonic jerks in association with asterixis and focal or generalized seizures.

    Hypoxic encephalopathy may produce generalized myoclonus or seizures almost immediately after restoration of cardiopulmonary function. The patient may also have a residual intention myoclonus.

    Uremic encephalopathy commonly produces myoclonic jerks and seizures. Other signs and symptoms include apathy, fatigue, irritability, a headache, confusion, a gradually decreasing LOC, nausea, vomiting, oliguria, edema, and papilledema. The patient may also exhibit elevated blood pressure, dyspnea, arrhythmias, and abnormal respirations.

    Epilepsy

    With idiopathic epilepsy, localized myoclonus is usually confined to an arm or leg and occurs singly or in short bursts, usually upon awakening. It’s usually more frequent and severe during the prodromal stage of a major generalized seizure, after which it diminishes in frequency and intensity.

    Myoclonic jerks are usually the first signs of myoclonic epilepsy, the most common cause of progressive myoclonus. At first, myoclonus is infrequent and localized, but over a period of months, it becomes more frequent and involves the entire body, disrupting voluntary movement (intention myoclonus). As the disease progresses, myoclonus is accompanied by generalized seizures and dementia.

    Other causes

    Drug withdrawal

    Myoclonus may be seen in patients with alcohol, opioid, or sedative withdrawal or delirium tremens.

    Poisoning

    Acute intoxication with methyl bromide, bismuth, or strychnine may produce an acute onset of myoclonus and confusion.

    » READ BOOK EXCERPT ONLINE »

    Source: Handbook of Signs & Symptoms (Third Edition), 2006

    Seizures, absence: Medical causes
    (Handbook of Signs & Symptoms (Third Edition))

    Idiopathic epilepsy

    Some forms of absence seizure are accompanied by learning disabilities.

    » READ BOOK EXCERPT ONLINE »

    Source: Handbook of Signs & Symptoms (Third Edition), 2006

    Seizures, complex partial: Medical causes
    (Handbook of Signs & Symptoms (Third Edition))

    Brain abscess

    If the brain abscess is in the temporal lobe, complex partial seizures commonly occur after the abscess disappears. Related problems may include a headache, nausea, vomiting, generalized seizures, and a decreased level of consciousness (LOC). The patient may also develop central facial weakness, auditory receptive aphasia, hemiparesis, and ocular disturbances.

    Head trauma

    Severe trauma to the temporal lobe (especially from a penetrating injury) can produce complex partial seizures months or years later. The seizures may decrease in frequency and eventually stop. Head trauma also causes generalized seizures and behavior and personality changes.

    Herpes simplex encephalitis

    The herpes simplex virus commonly attacks the temporal lobe, resulting in complex partial seizures. Other features include a fever, a headache, coma, and generalized seizures.

    Temporal lobe tumor

    Complex partial seizures may be the first sign of a temporal lobe tumor. Other signs and symptoms include a headache, pupillary changes, and mental dullness. Increased intracranial pressure may cause a decreased LOC, vomiting and, possibly, papilledema.

    » READ BOOK EXCERPT ONLINE »

    Source: Handbook of Signs & Symptoms (Third Edition), 2006

    Seizures, generalized tonic-clonic: Medical causes
    (Handbook of Signs & Symptoms (Third Edition))

    Brain abscess

    Generalized seizures may occur in the acute stage of abscess formation or after the abscess disappears. Depending on the size and location of the abscess, a decreased level of consciousness (LOC) varies from drowsiness to deep stupor. Early signs and symptoms reflect increased intracranial pressure (ICP) and include a constant headache, nausea, vomiting, and focal seizures. Typical later features include ocular disturbances, such as nystagmus, impaired vision, and unequal pupils. Other findings vary with the abscess, site but may include aphasia, hemiparesis, abnormal behavior, and personality changes.

    Brain tumor

    Generalized seizures may occur, depending on the tumor’s location and type. Other findings include a slowly decreasing LOC, a morning headache, dizziness, confusion, focal seizures, vision loss, motor and sensory disturbances, aphasia, and ataxia. Later findings include papilledema, vomiting, increased systolic blood pressure, widening pulse pressure and, eventually, a decorticate posture.

    Chronic renal failure

    End-stage renal failure produces the rapid onset of twitching, trembling, myoclonic jerks, and generalized seizures. Related signs and symptoms include anuria or oliguria, fatigue, malaise, irritability, decreased mental acuity, muscle cramps, peripheral neuropathies, anorexia, and constipation or diarrhea. Integumentary effects include skin color changes (yellow, brown, or bronze), pruritus, and uremic frost. Other effects include an ammonia breath odor, nausea and vomiting, ecchymoses, petechiae, GI bleeding, mouth and gum ulcers, hypertension, and Kussmaul’s respirations.

    Eclampsia

    Generalized seizures are a hallmark of eclampsia. Related findings include a severe frontal headache, nausea and vomiting, vision disturbances, increased blood pressure, a fever of up to 104° (40° C), peripheral edema, and sudden weight gain. The patient may also exhibit oliguria, irritability, hyperactive deep tendon reflexes (DTRs), and a decreased LOC.

    Encephalitis

    Seizures are an early sign of encephalitis, indicating a poor prognosis; they may also occur after recovery as a result of residual damage. Other findings include a fever, a headache, photophobia, nuchal rigidity, neck pain, vomiting, aphasia, ataxia, hemiparesis, nystagmus, irritability, cranial nerve palsies (causing facial weakness, ptosis, dysphagia), and myoclonic jerks.

    Epilepsy (idiopathic)

    In most cases, the cause of recurrent seizures is unknown.

    Head trauma

    In severe cases, generalized seizures may occur at the time of injury. (Months later, focal seizures may occur.) Severe head trauma may also cause a decreased LOC, leading to coma; soft-tissue injury of the face, head, or neck; clear or bloody drainage from the mouth, nose, or ears; facial edema; bony deformity of the face, head, or neck; Battle’s sign; and a lack of response to oculocephalic and oculovestibular stimulation. Motor and sensory deficits may occur along with altered respirations. Examination may reveal signs of increasing ICP, such as a decreased response to painful stimuli, nonreactive pupils, bradycardia, increased systolic pressure, and widening pulse pressure. If the patient is conscious, he may exhibit visual deficits, behavioral changes, and a headache.

    Hepatic encephalopathy

    Generalized seizures may occur late in hepatic encephalopathy. Associated late-stage findings in the comatose patient include fetor hepaticus, asterixis, hyperactive DTRs, and a positive Babinski’s sign.

    Hypoglycemia

    Generalized seizures usually occur with severe hypoglycemia, accompanied by blurred or double vision, motor weakness, hemiplegia, trembling, excessive diaphoresis, tachycardia, myoclonic twitching, and a decreased LOC.

    Hyponatremia

    Seizures develop when serum sodium levels fall below 125 mEq/L, especially if the decrease is rapid. Hyponatremia also causes orthostatic hypotension, a headache, muscle twitching and weakness, fatigue, oliguria or anuria, cold and clammy skin, decreased skin turgor, irritability, lethargy, confusion, and stupor or coma. Excessive thirst, tachycardia, nausea, vomiting, and abdominal cramps may also occur. Severe hyponatremia may cause cyanosis and vasomotor collapse, with a thready pulse.

    Hypoparathyroidism

    Worsening tetany causes generalized seizures. Chronic hypoparathyroidism produces neuromuscular irritability and hyperactive DTRs.

    Hypoxic encephalopathy

    Besides generalized seizures, hypoxic encephalopathy may produce myoclonic jerks and coma. Later, if the patient has recovered, dementia, visual agnosia, choreoathetosis, and ataxia may occur.

    Neurofibromatosis

    Multiple brain lesions from neurofibromatosis cause focal and generalized seizures. Inspection reveals café-au-lait spots, multiple skin tumors, scoliosis, and kyphoscoliosis. Related findings include dizziness, ataxia, monocular blindness, and nystagmus.

    Stroke

    Seizures (focal more commonly than generalized) may occur within 6 months of an ischemic stroke. Associated signs and symptoms vary with the location and extent of brain damage. They include a decreased LOC, contralateral hemiplegia, dysarthria, dysphagia, ataxia, unilateral sensory loss, apraxia, agnosia, and aphasia. The patient may also develop visual deficits, memory loss, poor judgment, personality changes, emotional lability, urine retention or urinary incontinence, constipation, a headache, and vomiting.

    Other causes

    Arsenic poisoning

    Besides generalized seizures, arsenic poisoning may cause a garlicky breath odor, increased salivation, and generalized pruritus. GI effects include diarrhea, nausea, vomiting, and severe abdominal pain. Related effects include diffuse hyperpigmentation; sharply defined edema of the eyelids, face, and ankles; paresthesia of the extremities; alopecia; irritated mucous membranes; weakness; muscle aches; and peripheral neuropathy.

    Barbiturate withdrawal

    In chronically intoxicated patients, barbiturate withdrawal may produce generalized seizures 2 to 4 days after the last dose. Status epilepticus is possible.

    Diagnostic tests

    Contrast agents used in radiologic tests may cause generalized seizures.

    Drugs

    Toxic blood levels of some drugs, such as theophylline, lidocaine, meperidine, penicillins, and cimetidine, may cause generalized seizures. Phenothiazines, tricyclic antidepressants, amphetamines, isoniazid, and vincristine may cause seizures in patients with preexisting epilepsy.

    » READ BOOK EXCERPT ONLINE »

    Source: Handbook of Signs & Symptoms (Third Edition), 2006

    Seizures, simple partial: Medical causes
    (Handbook of Signs & Symptoms (Third Edition))

    Brain abscess

    Seizures can occur in the acute stage of abscess formation or after resolution of the abscess. A decreased LOC varies from drowsiness to deep stupor. Early signs and symptoms reflect increased intracranial pressure and include a constant, intractable headache; nausea; and vomiting. Later signs and symptoms include ocular disturbances, such as nystagmus, decreased visual acuity, and unequal pupils. Other findings vary according to the abscess site and may include aphasia, hemiparesis, and personality changes.

    Brain tumor

    Focal seizures are commonly the earliest indicators of a brain tumor. The patient may report a morning headache, dizziness, confusion, vision loss, and motor and sensory disturbances. He may also develop aphasia, generalized seizures, ataxia, a decreased LOC, papilledema, vomiting, increased systolic blood pressure, and widening pulse pressure. Eventually, he may assume a decorticate posture.

    Head trauma

    Any head injury can cause seizures, but penetrating wounds are characteristically associated with focal seizures. The seizures usually begin 3 to 15 months after injury, decrease in frequency after several years, and eventually stop. The patient may develop generalized seizures and a decreased LOC that may progress to coma.

    Stroke

    A major cause of seizures in patients older than age 50, a stroke may induce focal seizures up to 6 months after its onset. Related effects depend on the type and extent of the stroke, but may include a decreased LOC, contralateral hemiplegia, dysarthria, dysphagia, ataxia, unilateral sensory loss, apraxia, agnosia, and aphasia. A stroke may also cause visual deficits, memory loss, poor judgment, personality changes, emotional lability, a headache, urinary incontinence or retention, and vomiting. It may result in generalized seizures.

    » READ BOOK EXCERPT ONLINE »

    Source: Handbook of Signs & Symptoms (Third Edition), 2006

    Asterixis [Liver flap, flapping tremor]: Medical causes
    (Handbook of Signs & Symptoms (Third Edition))

    ❑ Hepatic encephalopathy. A life-threatening disorder, hepatic encephalopathy initially causes mild personality changes and a slight tremor. The tremor progresses into asterixis — a hallmark of hepatic encephalopathy — and is accompanied by lethargy, aberrant behavior, and apraxia. Eventually, the patient becomes stuporous and displays hyperventilation. When he slips into a coma, hyperactive reflexes, a positive Babinski’s sign, and fetor hepaticus are characteristic signs. The patient may also experience bradycardia, decreased respirations, and seizures.

    ❑ Severe respiratory insufficiency. Characterized by life-threatening respiratory acidosis, severe respiratory insufficiency initially produces headache, restlessness, confusion, apprehension, and decreased reflexes. Eventually, the patient becomes somnolent and may demonstrate asterixis before slipping into a coma. Associated signs and symptoms of respiratory insufficiency include difficulty breathing and rapid, shallow respirations. The patient may be hypertensive in early disease but hypotensive later.

    ❑ Uremic syndrome. A life-threatening disorder, uremic syndrome initially causes lethargy, somnolence, confusion, disorientation, behavior changes, and irritability. Eventually, signs and symptoms appear in diverse body systems. Asterixis is accompanied by stupor, paresthesia, muscle twitching, fasciculations, and footdrop. Other signs and symptoms include polyuria and nocturia followed by oliguria and, then, anuria; elevated blood pressure; signs of heart failure and pericarditis; deep, gasping respirations (Kussmaul’s respirations); anorexia; nausea; vomiting; diarrhea; GI bleeding; weight loss; ammonia breath odor; and metallic taste (dysgeusia).

    Other causes

    ❑ Drugs. Certain drugs, such as the anticonvulsant phenytoin, may cause asterixis.

    » READ BOOK EXCERPT ONLINE »

    Source: Handbook of Signs & Symptoms (Third Edition), 2006

    Tremors: Medical causes
    (Handbook of Signs & Symptoms (Third Edition))

    Alcohol withdrawal syndrome

    Acute alcohol withdrawal after long-term dependence may first be manifested by resting and intention tremors that appear as soon as 7 hours after the last drink and progressively worsen. Other early signs and symptoms include diaphoresis, tachycardia, elevated blood pressure, anxiety, restlessness, irritability, insomnia, headache, nausea, and vomiting. Severe withdrawal may produce profound tremors, agitation, confusion, hallucinations and, possibly, seizures.

    Alkalosis

    Severe alkalosis may produce a severe intention tremor along with twitching, carpopedal spasms, agitation, diaphoresis, and hyperventilation. The patient may complain of dizziness, tinnitus, palpitations, and peripheral and circumoral paresthesia.

    Benign familial essential tremor

    Benign familial essential tremor, a tremor of early adulthood, produces a bilateral essential tremor that typically begins in the fingers and hands and may spread to the head, jaw, lips, and tongue. Laryngeal involvement may result in a quavering voice.

    Cerebellar tumor

    An intention tremor is a cardinal sign of cerebellar tumor; related findings may include ataxia, nystagmus, incoordination, muscle weakness and atrophy, and hypoactive or absent deep tendon reflexes.

    Graves’ disease

    Fine tremors of the hand, nervousness, weight loss, fatigue, palpitations, dyspnea, and increased heat intolerance are some of the typical signs of Graves’disease. It’s also characterized by an enlarged thyroid (goiter) and exophthalmos.

    Hypercapnia

    Elevated partial pressure of carbon dioxide may result in a rapid, fine intention tremor. Other common findings include headache, fatigue, blurred vision, weakness, lethargy, and decreasing level of consciousness (LOC).

    Hypoglycemia

    Acute hypoglycemia may produce a rapid, fine intention tremor accompanied by confusion, weakness, tachycardia, diaphoresis, and cold, clammy skin. Early patient complaints typically include mild generalized headache, profound hunger, nervousness, and blurred or double vision. The tremor may disappear as hypoglycemia worsens and hypotonia and decreased LOC become evident.

    Multiple sclerosis (MS)

    An intention tremor that waxes and wanes may be an early sign of MS. Commonly, visual and sensory impairments are the earliest findings. Associated effects vary greatly and may include nystagmus, muscle weakness, paralysis, spasticity, hyperreflexia, ataxic gait, dysphagia, and dysarthria. Constipation, urinary frequency and urgency, incontinence, impotence, and emotional lability may also occur.

    Parkinson’s disease

    Tremors, a classic early sign of Parkinson’s disease, usually begin in the fingers and may eventually affect the foot, eyelids, jaw, lips, and tongue. The slow, regular, rhythmic resting tremor takes the form of flexion-extension or abduction-adduction of the fingers or hand, or pronation-supination of the hand. Flexion-extension of the fingers combined with abduction-adduction of the thumb yields the characteristic pill-rolling tremor.

    Leg involvement produces flexion-extension foot movement. Lightly closing the eyelids causes them to flutter. The jaw may move up and down, and the lips may purse. The tongue, when protruded, may move in and out of the mouth in tempo with tremors elsewhere in the body. The rate of the tremor holds constant over time, but its amplitude varies.

    Other characteristic findings include cogwheel or lead-pipe rigidity, bradykinesia, propulsive gait with forward-leaning posture, monotone voice, masklike facies, drooling, dysphagia, dysarthria, and occasionally oculogyric crisis (eyes fix upward, with involuntary tonic movements) or blepharospasm (eyelids close completely).

    Thalamic syndrome

    Central midbrain syndromes are heralded by contralateral ataxic tremors and other abnormal movements, along with Weber’s syndrome (oculomotor palsy with contralateral hemiplegia), paralysis of vertical gaze, and stupor or coma.

    Anteromedial-inferior thalamic syndrome produces varying combinations of tremor, deep sensory loss, and hemiataxia. However, the main effect of this syndrome may be an extrapyramidal dysfunction, such as hemiballismus or hemichoreoathetosis.

    Thyrotoxicosis

    Neuromuscular effects of thyrotoxicosis include a rapid, fine intention tremor of the hands and tongue, along with clonus, hyperreflexia, and Babinski’s reflex. Other common signs and symptoms include tachycardia, cardiac arrhythmias, palpitations, anxiety, dyspnea, diaphoresis, heat intolerance, weight loss despite increased appetite, diarrhea, an enlarged thyroid and, possibly, exophthalmos.

    Wernicke’s disease

    An intention tremor is an early sign of Wernicke’s disease — a thiamine deficiency. Other features include ocular abnormalities (such as gaze paralysis and nystagmus), ataxia, apathy, and confusion. Orthostatic hypotension and tachycardia may also develop.

    West Nile encephalitis

    This brain infection is caused by West Nile virus, a mosquito-borne flavivirus endemic to Africa, the Middle East, western Asia, and the United States. Mild infections are common and include fever, headache, and body aches, commonly accompanied by rash and swollen lymph glands. More severe infections are marked by headache, high fever, neck stiffness, stupor, disorientation, coma, tremors, occasional seizures, paralysis and, rarely, death.

    Other causes

    Drugs

    Phenothiazines (particularly piperazine derivatives such as fluphenazine) and other antipsychotics may cause resting and pill-rolling tremors. Infrequently, metoclopramide and metyrosine also cause these tremors. Lithium toxicity, sympathomimetics (such as terbutaline and pseudoephedrine), amphetamines, and phenytoin can all cause tremors that disappear with dose reduction.

    » READ BOOK EXCERPT ONLINE »

    Source: Handbook of Signs & Symptoms (Third Edition), 2006

    Fasciculations: Medical causes
    (Professional Guide to Signs & Symptoms (Fifth Edition))

    Amyotrophic lateral sclerosis

    In this progressive motor neuron disease, coarse fasciculations usually begin in the small muscles of the hands and feet, and then spread to the forearms and legs. Widespread, symmetrical muscle atrophy and weakness may result in dysarthria; difficulty chewing, swallowing, and breathing; and, occasionally, choking and drooling.

    Bulbar palsy

    Fasciculations of the face and tongue commonly appear early in bulbar palsy. Progressive signs and symptoms include dysarthria, dysphagia, hoarseness, and drooling. Eventually, weakness spreads to the respiratory muscles.

    Guillain-Barré syndrome

    Fasciculations may occur in Gullain-Barré syndrome, but the cardinal neurologic symptom is muscle weakness, which typically begins in the legs and spreads quickly to the arms and face. Other findings include paresthesia, incontinence, footdrop, tachycardia, dysphagia, and respiratory insufficiency.

    Herniated disk

    Fasciculations of the muscles innervated by compressed nerve roots may be widespread and profound, but the hallmark of a herniated disk is severe low back pain that may radiate unilaterally to the leg. Coughing, sneezing, bending, and straining exacerbate the pain. Related effects include muscle weakness, atrophy, and spasms; paresthesia; footdrop; steppage gait; and hypoactive deep tendon reflexes in the leg.

    Poliomyelitis (spinal paralytic)

    Coarse fasciculations, usually transient but occasionally persistent, accompany progressive muscle weakness, spasms, and atrophy in this disorder. The patient may also exhibit decreased reflexes, paresthesia, coldness and cyanosis in the affected limbs, bladder paralysis, dyspnea, elevated blood pressure, and tachycardia.

    Spinal cord tumor

    Fasciculations, muscle atrophy, and cramps may develop asymmetrically at first and then bilaterally as cord compression progresses. Motor and sensory changes distal to the tumor include weakness or paralysis, areflexia, paresthesia, and a tightening band of pain. Bowel and bladder control may be lost.

    Syringomyelia

    In this disorder, fasciculations may occur along with Charcot’s joints, areflexia, muscle atrophy, and deep, aching pain. Additional findings include thoracic scoliosis and loss of pain and temperature sensation over the neck, shoulders, and arms.

    Other causes

    Pesticide poisoning

    Ingestion of organophosphate or carbamate pesticides commonly produces acute onset of long, wavelike fasciculations and muscle weakness that rapidly progresses to flaccid paralysis. Other common effects include nausea, vomiting, diarrhea, loss of bowel and bladder control, hyperactive bowel sounds, and abdominal cramping. Cardiopulmonary findings include bradycardia, dyspnea or bradypnea, and pallor or cyanosis. Seizures, vision disturbances (pupillary constriction or blurred vision), and increased secretions (tearing, salivation, pulmonary secretions, or diaphoresis) may also occur.

    » READ BOOK EXCERPT ONLINE »

    Source: Professional Guide to Signs & Symptoms (Fifth Edition), 2006

    Myoclonus: Medical causes
    (Professional Guide to Signs & Symptoms (Fifth Edition))

    Alzheimer’s disease

    Generalized myoclonus may occur in advanced stages of this slowly progressive dementia. Other late findings include mild choreoathetoid movements, muscle rigidity, bowel and bladder incontinence, delusions, and hallucinations.

    Creutzfeldt-Jakob disease

    Diffuse myoclonic jerks appear early in this rapidly progressive dementia. Initially random, they gradually become more rhythmic and symmetrical, often occurring in response to sensory stimuli. Associated effects include ataxia, aphasia, hearing loss, muscle rigidity and wasting, fasciculations, hemiplegia, and visual disturbance, or possibly, blindness.

    Encephalitis (viral)

    With this disease, myoclonus is usually intermittent and either localized or generalized. Associated findings vary but may include rapidly decreasing level of consciousness, fever, headache, irritability, nuchal rigidity, vomiting, seizures, aphasia, ataxia, hemiparesis, facial muscle weakness, nystagmus, ocular palsies, and dysphagia.

    Encephalopathy

    Hepatic encephalopathy occasionally produces myoclonic jerks in association with asterixis and focal or generalized seizures.

    Hypoxic encephalopathy may produce generalized myoclonus or seizures almost immediately after restoration of cardiopulmonary function. The patient may also have a residual intention myoclonus.

    Uremic encephalopathy commonly produces myoclonic jerks and seizures. Other signs and symptoms include apathy, fatigue, irritability, headache, confusion, gradually decreasing level of consciousness, nausea, vomiting, oliguria, edema, and papilledema. The patient may also exhibit elevated blood pressure, dyspnea, arrhythmias, and abnormal respirations.

    Epilepsy

    With idiopathic epilepsy, localized myoclonus is usually confined to an arm or leg and occurs singly or in short bursts, usually upon awakening. It’s usually more frequent and severe during the prodromal stage of a major generalized seizure, after which it diminishes in frequency and intensity.

    Myoclonic jerks are usually the first signs of myoclonic epilepsy, the most common cause of progressive myoclonus. At first, myoclonus is infrequent and localized, but over a period of months, it becomes more frequent and involves the entire body, disrupting voluntary movement (intention myoclonus). As the disease progresses, myoclonus is accompanied by generalized seizures and dementia.

    Other causes

    Drug withdrawal

    Myoclonus may be seen in patients with alcohol, opioid, or sedative withdrawal, or delirium tremens.

    Poisoning

    Acute intoxication with methyl bromide, bismuth, or strychnine may produce an acute onset of myoclonus and confusion.

    » READ BOOK EXCERPT ONLINE »

    Source: Professional Guide to Signs & Symptoms (Fifth Edition), 2006

    Seizures, absence: Medical causes
    (Professional Guide to Signs & Symptoms (Fifth Edition))

    Idiopathic epilepsy

    Some forms of absence seizure are accompanied by learning disabilities.

    » READ BOOK EXCERPT ONLINE »

    Source: Professional Guide to Signs & Symptoms (Fifth Edition), 2006

    Seizures, complex partial: Medical causes
    (Professional Guide to Signs & Symptoms (Fifth Edition))

    Brain abscess

    If the brain abscess is in the temporal lobe, complex partial seizures commonly occur after the abscess disappears. Related problems may include headache, nausea, vomiting, generalized seizures, and a decreased level of consciousness (LOC). The patient may also develop central facial weakness, auditory receptive aphasia, hemiparesis, and ocular disturbances.

    Head trauma

    Severe trauma to the temporal lobe (especially from a penetrating injury) can produce complex partial seizures months or years later. The seizures may decrease in frequency and eventually stop. Head trauma also causes generalized seizures and behavior and personality changes.

    Herpes simplex encephalitis

    The herpes simplex virus commonly attacks the temporal lobe, resulting in complex partial seizures. Other features include fever, headache, coma, and generalized seizures.

    Temporal lobe tumor

    Complex partial seizures may be the first sign of this disorder. Other signs and symptoms include headache, pupillary changes, and mental dullness. Increased intracranial pressure may cause a decreased LOC, vomiting and, possibly, papilledema.

    » READ BOOK EXCERPT ONLINE »

    Source: Professional Guide to Signs & Symptoms (Fifth Edition), 2006

    Seizures, generalized tonic-clonic: Medical causes
    (Professional Guide to Signs & Symptoms (Fifth Edition))

    Alcohol withdrawal syndrome

    i> Sudden withdrawal from alcohol dependence may cause seizures 7 to 48 hours later as well as status epilepticus. The patient may also be restless and exhibit hallucinations, profuse diaphoresis, and tachycardia.

    Brain abscess

    Generalized seizures may occur in the acute stage of abscess formation or after the abscess disappears. Depending on the size and location of the abscess, decreased level of consciousness (LOC) varies from drowsiness to deep stupor. Early signs and symptoms reflect increased intracranial pressure (ICP) and include constant headache, nausea, vomiting, and focal seizures. Typical later features include ocular disturbances, such as nystagmus, impaired vision, and unequal pupils. Other findings vary with the abscess site but may include aphasia, hemiparesis, abnormal behavior, and personality changes.

    Brain tumor

    Generalized seizures may occur, depending on the tumor’s location and type. Other findings include a slowly decreasing LOC, morning headache, dizziness, confusion, focal seizures, vision loss, motor and sensory disturbances, aphasia, and ataxia. Later findings include papilledema, vomiting, increased systolic blood pressure, widening pulse pressure, and (eventually) decorticate posture.

    Cerebral aneurysm

    Occasionally, generalized seizures may occur with an aneurysmal rupture. Premonitory signs and symptoms may last several days, but onset is typically abrupt with severe headache, nausea, vomiting, and decreased LOC. Depending on the site and amount of bleeding, related signs and symptoms vary but may include nuchal rigidity, irritability, hemiparesis, hemisensory defects, dysphagia, photophobia, diplopia, ptosis, and unilateral pupil dilation.

    Chronic renal failure

    End-stage renal failure produces rapid onset of twitching, trembling, myoclonic jerks, and generalized seizures. Related signs and symptoms include anuria or oliguria, fatigue, malaise, irritability, decreased mental acuity, muscle cramps, peripheral neuropathies, anorexia, and constipation or diarrhea. Integumentary effects include skin color changes (yellow, brown, or bronze), pruritus, and uremic frost. Other effects include ammonia breath odor, nausea and vomiting, ecchymoses, petechiae, GI bleeding, mouth and gum ulcers, hypertension, and Kussmaul’s respirations.

    Eclampsia

    Generalized seizures are a hallmark of this disorder. Related findings include severe frontal headache, nausea and vomiting, vision disturbances, increased blood pressure, fever of up to 104° F (40° C), peripheral edema, and sudden weight gain. The patient may also exhibit oliguria, irritability, hyperactive deep tendon reflexes (DTRs), and decreased LOC.

    Encephalitis

    Seizures are an early sign of this disorder, indicating a poor prognosis; they may also occur after recovery as a result of residual damage. Other findings include fever, headache, photophobia, nuchal rigidity, neck pain, vomiting, aphasia, ataxia, hemiparesis, nystagmus, irritability, cranial nerve palsies (causing facial weakness, ptosis, dysphagia), and myoclonic jerks.

    Epilepsy (idiopathic)

    In most cases, the cause of recurrent seizures is unknown.

    Head trauma

    In severe cases, generalized seizures may occur at the time of injury. (Months later, focal seizures may occur.) Severe head trauma may also cause a decreased LOC, leading to coma; soft-tissue injury of the face, head, or neck; clear or bloody drainage from the mouth, nose, or ears; facial edema; bony deformity of the face, head, or neck; Battle’s sign; and lack of response to oculocephalic and oculovestibular stimulation. Motor and sensory deficits may occur along with altered respirations. Examination may reveal signs of increasing ICP, such as decreased response to painful stimuli, nonreactive pupils, bradycardia, increased systolic pressure, and widening pulse pressure. If the patient is conscious, he may exhibit visual deficits, behavioral changes, and headache.

    Hepatic encephalopathy

    Generalized seizures may occur late in this disorder. Associated late-stage findings in the comatose patient include fetor hepaticus, asterixis, hyperactive DTRs, and a positive Babinski’s sign.

    Hypertensive encephalopathy

    This life-threatening disorder may cause seizures along with severely increased blood pressure, decreased LOC, intense headache, vomiting, transient blindness, paralysis, and (eventually) Cheyne-Stokes respirations.

    Hypoglycemia

    Generalized seizures usually occur with severe hypoglycemia, accompanied by blurred or double vision, motor weakness, hemiplegia, trembling, excessive diaphoresis, tachycardia, myoclonic twitching, and decreased LOC.

    Hyponatremia

    Seizures develop
    when serum sodium levels fall below 125 mEq/L, especially if the decrease is rapid. Hyponatremia also causes orthostatic hypotension, headache, muscle twitching and weakness, fatigue, oliguria or anuria, cold and clammy skin, decreased skin turgor, irritability, lethargy, confusion, and stupor or coma. Excessive thirst, tachycardia, nausea, vomiting, and abdominal cramps may also occur. Severe hyponatremia may cause cyanosis and vasomotor collapse, with a thready pulse.

    Hypoparathyroidism

    Worsening tetany causes generalized seizures. Chronic hypoparathyroidism produces neuromuscular irritability and hyperactive DTRs.

    Hypoxic encephalopathy

    Besides generalized seizures, this disorder may produce myoclonic jerks and coma. Later, if the patient has recovered, dementia, visual agnosia, choreoathetosis, and ataxia may occur.

    Multiple sclerosis

    This disorder rarely produces generalized seizures. Characteristic findings include vision deficits, paresthesia, constipation, muscle weakness, paralysis, spasticity, hyperreflexia, intention tremor, ataxic gait, dysphagia, dysarthria, impotence, and emotional lability. Urinary frequency, urgency, and incontinence may also occur.

    Neurofibromatosis

    Multiple brain lesions from this disorder cause focal and generalized seizures. Inspection reveals café-au-lait spots, multiple skin tumors, scoliosis, and kyphoscoliosis. Related findings include dizziness, ataxia, monocular blindness, and nystagmus.

    Porphyria (intermittent acute)

    Generalized seizures are a late sign of this disorder, indicating severe CNS involvement. Acute porphyria also causes severe abdominal pain, tachycardia, psychotic behavior, muscle weakness, and sensory loss in the trunk.

    Sarcoidosis

    Lesions may affect the brain, causing generalized and focal seizures. Associated findings include a nonproductive cough with dyspnea, substernal pain, malaise, fatigue, arthralgia, myalgia, weight loss, tachypnea, dysphagia, skin lesions, and impaired vision.

    Stroke

    Seizures (focal more often than generalized) may occur within 6 months of an ischemic stroke. Associated signs and symptoms vary with the location and extent of brain damage. They include decreased LOC, contralateral hemiplegia, dysarthria, dysphagia, ataxia, unilateral sensory loss, apraxia, agnosia, and aphasia. The patient may also develop visual deficits, memory loss, poor judgment, personality changes, emotional lability, urine retention or urinary incontinence, constipation, headache, and vomiting.

    Other causes

    Arsenic poisoning

    Besides generalized seizures, arsenic poisoning may cause a garlicky breath odor, increased salivation, and generalized pruritus. GI effects include diarrhea, nausea, vomiting, and severe abdominal pain. Related effects include diffuse hyperpigmentation; sharply defined edema of the eyelids, face, and ankles; paresthesia of the extremities; alopecia; irritated mucous membranes; weakness; muscle aches; and peripheral neuropathy.

    Barbiturate withdrawal

    In chronically intoxicated patients, barbiturate withdrawal may produce generalized seizures 2 to 4 days after the last dose. Status epilepticus is possible.

    Diagnostic tests

    Contrast agents used in radiologic tests may cause generalized seizures.

    Drugs

    Toxic blood levels of some drugs, such as theophylline, lidocaine, meperidine, penicillins, and cimetidine, may cause generalized seizures. Phenothiazines, tricyclic antidepressants, amphetamines, isoniazid, and vincristine may cause seizures in patients with preexisting epilepsy.

    » READ BOOK EXCERPT ONLINE »

    Source: Professional Guide to Signs & Symptoms (Fifth Edition), 2006

    Seizures, simple partial: Medical causes
    (Professional Guide to Signs & Symptoms (Fifth Edition))

    Brain abscess

    Seizures can occur in the acute stage of abscess formation or after resolution of the abscess. Decreased LOC varies from drowsiness to deep stupor. Early signs and symptoms reflect increased intracranial pressure and include a constant, intractable headache, nausea, and vomiting. Later signs and symptoms include ocular disturbances, such as nystagmus, decreased visual acuity, and unequal pupils. Other findings vary according to the abscess site and may include aphasia, hemiparesis, and personality changes.

    Brain tumor

    Focal seizures are commonly the earliest indicators of a brain tumor. The patient may report morning headache, dizziness, confusion, vision loss, and motor and sensory disturbances. He may also develop aphasia, generalized seizures, ataxia, decreased LOC, papilledema, vomiting, increased systolic blood pressure, and widening pulse pressure. Eventually, he may assume a decorticate posture.

    Head trauma

    Any head injury can cause seizures, but penetrating wounds are characteristically associated with focal seizures. The seizures usually begin 3 to 15 months after injury, decrease in frequency after several years, and eventually stop. The patient may develop generalized seizures and a decreased LOC that may progress to coma.

    Multiple sclerosis

    Focal or generalized seizures may occur with this disorder, usually during the late stages. Other findings include visual deficits, paresthesia, constipation, muscle weakness, spasticity, paralysis, hyperreflexia, intention tremor, gait ataxia, dysphagia, dysarthria, emotional lability, impotence, and urinary frequency, urgency, and incontinence.

    Neurofibromatosis

    Multiple brain lesions cause focal seizures and, at times, generalized seizures. Inspection reveals café-au-lait spots, multiple skin tumors, scoliosis, and kyphoscoliosis. Related findings include dizziness, ataxia, progressive monocular blindness, nystagmus, and endocrine abnormalities.

    Sarcoidosis

    Multiple lesions from this disorder affect the brain, producing focal and generalized seizures. Associated findings include a nonproductive cough with dyspnea, substernal pain, malaise, fatigue, arthralgia, myalgia, weight loss, tachypnea, dysphagia, skin lesions, and impaired vision.

    Stroke

    A major cause of seizures in patients older than age 50, a stroke may induce focal seizures up to 6 months after its onset. Related effects depend on the type and extent of the stroke but may include decreased LOC, contralateral hemiplegia, dysarthria, dysphagia, ataxia, unilateral sensory loss, apraxia, agnosia, and aphasia. A stroke may also cause visual deficits, memory loss, poor judgment, personality changes, emotional lability, headache, urinary incontinence or retention, and vomiting. It may result in generalized seizures.

    » READ BOOK EXCERPT ONLINE »

    Source: Professional Guide to Signs & Symptoms (Fifth Edition), 2006

    Asterixis [Liver flap, flapping tremor]: Medical causes
    (Professional Guide to Signs & Symptoms (Fifth Edition))

    Hepatic encephalopathy

    A life-threatening disorder, hepatic encephalopathy initially causes mild personality changes and a slight tremor. The tremor progresses to asterixis—a hallmark of hepatic encephalopathy—and is accompanied by lethargy, aberrant behavior, and apraxia. Eventually, the patient becomes stuporous and displays hyperventilation. After slipping into a coma, the patient exhibits characteristic hyperactive reflexes, positive Babinski’s reflex, and fetor hepaticus. He also may experience bradycardia, decreased respirations, and seizures.

    Respiratory insufficiency, severe

    Characterized by life-threatening respiratory acidosis, severe respiratory insufficiency initially produces headache, restlessness, confusion, apprehension, and decreased reflexes. Eventually, the patient becomes somnolent and may demonstrate asterixis before slipping into a coma. Associated signs and symptoms of respiratory insufficiency include difficulty breathing and rapid, shallow respirations. The patient may be hypertensive in early disease but hypotensive later.

    Uremic syndrome

    Uremic syndrome is a life-threatening disorder that initially causes lethargy, somnolence, confusion, disorientation, behavior changes, and irritability. Eventually, signs and symptoms appear in diverse body systems. Asterixis is accompanied by stupor, paresthesia, muscle twitching, fasciculations, and footdrop. Other signs and symptoms include polyuria and nocturia followed by oliguria and then anuria, elevated blood pressure, signs of heart failure and pericarditis, Kussmaul’s respirations, anorexia, nausea, vomiting diarrhea, GI bleeding, weight loss, ammonia breath odor, and metallic taste (dysgeusia).

    Other causes

    Drugs

    Certain drugs, such as the anticonvulsant phenytoin, may cause asterixis.

    » READ BOOK EXCERPT ONLINE »

    Source: Professional Guide to Signs & Symptoms (Fifth Edition), 2006

    Tremors: Medical causes
    (Professional Guide to Signs & Symptoms (Fifth Edition))

    Alcohol withdrawal syndrome

    Acute alcohol withdrawal after long-term dependence may first be manifested by resting and intention tremors that appear as soon as 7 hours after the last drink and progressively worsen. Other early signs and symptoms include diaphoresis, tachycardia, elevated blood pressure, anxiety, restlessness, irritability, insomnia, headache, nausea, and vomiting. Severe withdrawal may produce profound tremors, agitation, confusion, hallucinations, and seizures.

    Alkalosis

    Severe alkalosis may produce a severe intention tremor along with twitching, carpopedal spasms, agitation, diaphoresis, and hyperventilation. The patient may complain of dizziness, tinnitus, palpitations, and peripheral and circumoral paresthesia.

    Benign familial essential tremor

    This disorder of early adulthood produces a bilateral essential tremor that typically begins in the fingers and hands and may spread to the head, jaw, lips, and tongue. Laryngeal involvement may result in a quavering voice.

    Cerebellar tumor

    An intention tremor is a cardinal sign of this disorder; related findings may include ataxia, nystagmus, incoordination, muscle weakness and atrophy, and hypoactive or absent deep tendon reflexes.

    General paresis

    This effect of neurosyphilis may cause an intention tremor accompanied by clonus, a positive Babinski’s sign, ataxia, Argyll Robertson pupils, and a diffuse, dull headache.

    Graves’ disease

    Fine tremors of the hand, nervousness, weight loss, fatigue, palpitations, dyspnea, and increased heat intolerance are typical signs and symptoms of this disorder. An enlarged thyroid gland (goiter) and exophthalmos are also characteristic.

    Hypercapnia

    Elevated partial pressure of carbon dioxide may result in a rapid, fine intention tremor. Other common findings include headache, fatigue, blurred vision, weakness, lethargy, and decreasing level of consciousness (LOC).

    Hypoglycemia

    Acute hypoglycemia may produce a rapid, fine intention tremor accompanied by confusion, weakness, tachycardia, diaphoresis, and cold, clammy skin. Early patient complaints typically include a mild generalized headache, profound hunger, nervousness, and blurred or double vision. The tremor may disappear as hypoglycemia worsens and hypotonia and decreased LOC become evident.

    Kwashiorkor

    Coarse intention and resting tremors may occur in the advanced stages of this disease. Examination reveals myoclonus, rigidity of all extremities, hyperreflexia, hepatomegaly, and pitting edema in the hands, feet, and sacral area. Other signs include a flat affect, pronounced hair loss, and dry, peeling skin.

    Multiple sclerosis (MS)

    An intention tremor that waxes and wanes may be an early sign of MS, but visual and sensory impairments are usually the earliest findings. Associated effects vary greatly and may include nystagmus, muscle weakness, paralysis, spasticity, hyperreflexia, ataxic gait, dysphagia, and dysarthria. Constipation, urinary frequency and urgency, incontinence, impotence, and emotional lability may also occur.

    Parkinson’s disease

    Tremors, a classic early sign of this degenerative disease, usually begin in the fingers and may eventually affect the foot, eyelids, jaw, lips, and tongue. The slow, regular, rhythmic resting tremor takes the form of flexion-extension or abduction-adduction of the fingers or hand, or pronation-supination of the hand. Flexion-extension of the fingers combined with abduction-adduction of the thumb is known as the characteristic pill-rolling tremor.

    Leg involvement produces flexion-extension foot movement. Lightly closing the eyelids causes them to flutter. The jaw may move up and down, and the lips may purse. The tongue, when protruded, may move in and out of the mouth in tempo with tremors elsewhere in the body. The rate of the tremor remains constant over time, but its amplitude varies.

    Other characteristic findings include cogwheel or lead-pipe rigidity, bradykinesia, propulsive gait with forward-leaning posture, monotone voice, masklike facies, drooling, dysphagia, dysarthria, and occasionally oculogyric crisis (eyes fix upward, with involuntary tonic movements) or blepharospasm (eyelids close completely).

    Porphyria

    Involvement of the basal ganglia in porphyria can produce a resting tremor with rigidity accompanied by chorea and athetosis. As the disease progresses, generalized seizures may appear along with aphasia and hemiplegia.

    Thalamic syndrome

    Central midbrain syndromes are heralded by contralateral ataxic tremors and other abnormal movements along with Weber’s syndrome (oculomotor palsy with contralateral hemiplegia), paralysis of vertical gaze, and stupor or coma.

    Anteromedial-inferior thalamic syndrome produces varying combinations of tremor, deep sensory loss, and hemiataxia. However, the main effect of this syndrome may be an extrapyramidal dysfunction, such as hemiballismus or hemichoreoathetosis.

    Thyrotoxicosis

    Neuromuscular effects of this disorder include a rapid, fine intention tremor of the hands and tongue, along with clonus, hyperreflexia, and Babinski’s reflex. Other common signs and symptoms include tachycardia, cardiac arrhythmias, palpitations, anxiety, dyspnea, diaphoresis, heat intolerance, weight loss despite increased appetite, diarrhea, an enlarged thyroid and, possibly, exophthalmos.

    Wernicke’s encephalopathy

    An intention tremor is an early sign of this thiamine deficiency. Other features include ocular abnormalities (such as gaze paralysis and nystagmus), ataxia, apathy, and confusion. Orthostatic hypotension and tachycardia may also develop.

    West Nile encephalitis

    This brain infection is caused by West Nile virus, a mosquito-borne flavivirus endemic in Africa, the Middle East, western Asia, and the United States. Mild infections are common and include fever, headache, and body aches, commonly accompanied by rash and swollen lymph glands. More severe infections are marked by headache, high fever, neck stiffness, stupor, disorientation, coma, tremors, occasional seizures, and paralysis. Death rarely occurs.

    Wilson’s disease

    This disorder of abnormal copper metabolism produces slow “wing-flapping” tremors in the arms and pill-rolling tremors in the hands; these tremors appear early in the disease and progressively worsen. The most characteristic sign, however, is Kayser-Fleischer rings—rusty brown rings around the corneas. Other signs and symptoms include incoordination, dysarthrial chorea, ataxia, muscle spasms and rigidity, abdominal distress, fatigue, personality changes, hypotension, syncope, and seizures. Liver and spleen enlargement, ascites, jaundice, and hyperpigmentation may also occur.

    Other causes

    Drugs

    Phenothiazines (particularly piperazine derivatives such as fluphenazine) and other antipsychotics may cause resting and pill-rolling tremors. Metoclopramide and metyrosine also cause these tremors occasionally. Lithium toxicity, sympathomimetics (such as terbutaline and pseudoephedrine), amphetamines, and phenytoin can all cause tremors that disappear when the dosage is decreased.

    Herb Alert

    i>Herbal products, such as ephedra (ma huang), have been known to cause serious adverse reactions, which may include tremors. (Note: The FDA has banned the sale of dietary supplements containing ephedra because they pose an unreasonable risk of injury or illness.)

    Manganese toxicity

    Early signs of manganese poisoning include resting tremor, chorea, propulsive gait, cogwheel rigidity, personality changes, amnesia, and masklike facies.

    Mercury poisoning

    The chronic form of mercury poisoning is characterized by irritability, copious amounts of saliva, loose teeth, gum disease, slurred speech, and tremors.

    » READ BOOK EXCERPT ONLINE »

    Source: Professional Guide to Signs & Symptoms (Fifth Edition), 2006

    Seizures: Differential Overview

    (Field Guide to Bedside Diagnosis)

    ❑ Generalized (grand mal)

    ❑ Partial (focal)

    ❑ Complex partial (temporal lobe)

    ❑ Absence (petit mal)

    ❑ Vasovagal syncope

    ❑ Myoclonic

    ❑ Akinetic (drop attacks)

    ❑ Psychomotor

    ❑ Pseudoseizures

    » READ BOOK EXCERPT ONLINE »

    Source: Field Guide to Bedside Diagnosis, 2007

    Tremor/InvoluntaryMovements: Differential Overview
    (Field Guide to Bedside Diagnosis)

    Tremor

    ❑ Anxiety

    ❑ Physiologic tremor

    ❑ Essential tremor

    ❑ Parkinson disease

    ❑ Cerebellar disease

    ❑ Hyperthyroidism

    ❑ Opiate withdrawal

    ❑ Myoclonus

    ❑ Multiple sclerosis

    ❑ Amyotrophic lateral sclerosis

    Involuntary Movements

    ❑ Tics

    ❑ Drugs

    ❑ Systemic lupus erythematosus

    ❑ Rheumatic fever

    ❑ Huntington disease

    ❑ Tourette syndrome

    ❑ Wilson disease

    » READ BOOK EXCERPT ONLINE »

    Source: Field Guide to Bedside Diagnosis, 2007

    Fasciculations: Medical causes
    (Alarming Signs and Symptoms: Lippincott Manual of Nursing Practice Series)

    Amyotrophic lateral sclerosis

    Coarse fasciculations usually begin in the small muscles of the hands and feet, and then spread to the forearms and legs. Widespread, symmetrical muscle atrophy and weakness may result in dysarthria; difficulty chewing, swallowing, and breathing; and, occasionally, choking and drooling.

    Bulbar palsy

    Fasciculations of the face and tongue commonly appear early. Progressive signs and symptoms include dysarthria, dysphagia, hoarseness, and drooling. Eventually, weakness spreads to the respiratory muscles.

    Guillain-Barré syndrome

    Fasciculations may occur, but the dominant neurologic symptom is muscle weakness, which typically begins in the legs and spreads quickly to the arms and face. Other findings include paresthesia, incontinence, footdrop, tachycardia, dysphagia, and respiratory insufficiency.

    Herniated disk

    Fasciculations of the muscles innervated by compressed nerve roots may be widespread and profound, but the overriding symptom is severe low back pain that may radiate unilaterally to the leg. Coughing, sneezing, bending, and straining exacerbate the pain. Related effects include muscle weakness, atrophy, and spasms; paresthesia; footdrop; steppage gait; and hypoactive deep tendon reflexes in the leg.

    Poliomyelitis (spinal paralytic)

    Coarse fasciculations, usually transient but occasionally persistent, accompany progressive muscle weakness, spasms, and atrophy. The patient may also exhibit decreased reflexes, paresthesia, coldness and cyanosis in the affected limbs, bladder paralysis, dyspnea, elevated blood pressure, and tachycardia.

    Spinal cord tumors

    Fasciculations may develop along with muscle atrophy and cramps, asymmetrically at first and then bilaterally as cord compression progresses. Motor and sensory changes distal to the tumor include weakness or paralysis, areflexia, paresthesia, and a tightening band of pain. Bowel and bladder control may be lost.

    Syringomyelia

    Fasciculations may occur along with Charcot’s joints, areflexia, muscle atrophy, and deep, aching pain. Additional findings include thoracic scoliosis and loss of pain and temperature sensation over the neck, shoulders, and arms.

    Other causes

    Pesticide poisoning

    Ingestion of organophosphate or carbamate pesticides commonly produces acute onset of long, wavelike fasciculations and muscle weakness that rapidly progresses to flaccid paralysis. Other common effects include nausea, vomiting, diarrhea, loss of bowel and bladder control, hyperactive bowel sounds, and abdominal cramping. Cardiopulmonary findings include bradycardia, dyspnea or bradypnea, and pallor or cyanosis. Seizures, vision disturbances (pupillary constriction or blurred vision), and increased secretions (tearing, salivation, pulmonary secretions, or diaphoresis) may also occur.

    » READ BOOK EXCERPT ONLINE »

    Source: Alarming Signs and Symptoms: Lippincott Manual of Nursing Practice Series, 2007

    Myoclonus: Medical causes
    (Alarming Signs and Symptoms: Lippincott Manual of Nursing Practice Series)

    Alzheimer’s disease

    Generalized myoclonus may occur in advanced stages of Alzheimer’s disease, which is a slowly progressive dementia. Other late findings include mild choreoathetoid movements, muscle rigidity, bowel and bladder incontinence, delusions, and hallucinations.

    Creutzfeldt-Jakob disease

    Diffuse myoclonic jerks appear early in Creutzfeldt-Jakob disease — a rapidly progressive dementia. Initially random, they gradually become more rhythmic and symmetrical, often occurring in response to sensory stimuli. Associated effects include ataxia, aphasia, hearing loss, muscle rigidity and wasting, fasciculations, hemiplegia, and vision disturbance, or possibly, blindness.

    Encephalitis (viral)

    With encephalitis, myoclonus is usually intermittent and either localized or generalized. Associated findings vary but may include rapidly decreasing level of consciousness, fever, headache, irritability, nuchal rigidity, vomiting, seizures, aphasia, ataxia, hemiparesis, facial muscle weakness, nystagmus, ocular palsies, and dysphagia.

    Encephalopathy

    Hepatic encephalopathy occasionally produces myoclonic jerks in association with asterixis and focal or generalized seizures.

    Hypoxic encephalopathy may produce generalized myoclonus or seizures almost immediately after restoration of cardiopulmonary function. The patient may also have a residual intention myoclonus.

    Uremic encephalopathy commonly produces myoclonic jerks and seizures. Other signs and symptoms include apathy, fatigue, irritability, headache, confusion, gradually decreasing level of consciousness, nausea, vomiting, oliguria, edema, and papilledema. The patient may also exhibit elevated blood pressure, dyspnea, arrhythmias, and abnormal respirations.

    Epilepsy

    With idiopathic epilepsy, localized myoclonus is usually confined to an arm or leg and occurs singly or in short bursts, usually upon awakening. It’s usually more frequent and severe during the prodromal stage of a major generalized seizure, after which it diminishes in frequency and intensity.

    Myoclonic jerks are usually the first signs of myoclonic epilepsy, the most common cause of progressive myoclonus. At first, myoclonus is infrequent and localized, but over a period of months, it becomes more frequent and involves the entire body, disrupting voluntary movement (intention myoclonus). As the disease progresses, myoclonus is accompanied by generalized seizures and dementia.

    Other causes

    Drug withdrawal

    Myoclonus may be seen in patients with alcohol, opioid, or sedative withdrawal, or delirium tremens.

    Poisoning

    Acute intoxication with methyl bromide, bismuth, or strychnine may produce an acute onset of myoclonus and confusion.

    » READ BOOK EXCERPT ONLINE »

    Source: Alarming Signs and Symptoms: Lippincott Manual of Nursing Practice Series, 2007

    Seizures, generalized tonic-clonic: Medical causes
    (Alarming Signs and Symptoms: Lippincott Manual of Nursing Practice Series)

    Alcohol withdrawal syndrome

    Seizures as well as status epilepticus may develop 7 to 48 hours after abrupt cessation of alcohol consumption by the individual with alcohol dependency. Restlessness, hallucinations, profuse diaphoresis, and tachycardia may also occur.

    Brain abscess

    Generalized seizures may occur in the acute stage of abscess formation or after the abscess disappears. Decreased level of consciousness (LOC) varies from drowsiness to deep stupor according to the size and location of the abscess. Early signs and symptoms reflect increased intracranial pressure (ICP) and include constant headache, nausea, vomiting, and focal seizures. Typical later features include ocular disturbances, such as nystagmus, impaired vision, and unequal pupils. Other findings vary with the abscess site, but may include aphasia, hemiparesis, abnormal behavior, and personality changes.

    Brain tumor

    Generalized seizures may occur, depending on the tumor’s location and type. Other findings include a slowly decreasing LOC, morning headache, dizziness, confusion, focal seizures, vision loss, motor and sensory disturbances, aphasia, and ataxia. Later findings include papilledema, vomiting, increased systolic blood pressure, widening pulse pressure and, eventually, decorticate posture.

    Cerebral aneurysm

    Occasionally, generalized seizures may occur with an aneurysm rupture. Premonitory signs and symptoms may last several days, but the onset is typically abrupt with severe headache, nausea, vomiting, and a decreased LOC. Related signs and symptoms vary according to the site and amount of bleeding, but may include nuchal rigidity, irritability, hemiparesis, hemisensory defects, dysphagia, photophobia, diplopia, ptosis, and unilateral pupil dilation.

    Chronic renal failure

    End-stage renal failure produces the rapid onset of twitching, trembling, myoclonic jerks, and generalized seizures. Related signs and symptoms include anuria or oliguria, fatigue, malaise, irritability, decreased mental acuity, muscle cramps, peripheral neuropathies, anorexia, and constipation or diarrhea. Integumentary effects include skin color changes (yellow, brown, or bronze), pruritus, and uremic frost. Other effects include ammonia breath odor, nausea and vomiting, ecchymoses, petechiae, GI bleeding, mouth and gum ulcers, hypertension, and Kussmaul’s respirations.

    Eclampsia

    Generalized seizures are a hallmark of eclampsia. Related findings include severe frontal headache, nausea and vomiting, vision disturbances, increased blood pressure, fever of up to 104° (40° C), peripheral edema, and sudden weight gain. The patient may also exhibit oliguria, irritability, hyperactive deep tendon reflexes (DTRs), and a decreased LOC.

    Encephalitis

    Seizures are an early sign of encephalitis, indicating a poor prognosis; they may also occur after recovery as a result of residual damage. Other findings include fever, headache, photophobia, nuchal rigidity, neck pain, vomiting, aphasia, ataxia, hemiparesis, nystagmus, irritability, cranial nerve palsies (causing facial weakness, ptosis, and dysphagia), and myoclonic jerks.

    Epilepsy (idiopathic)

    In most cases, the cause of recurrent seizures is unknown.

    Head trauma

    In severe cases, generalized seizures may occur at the time of injury. (Months later, focal seizures may occur.) Severe head trauma may also cause a decreased LOC, leading to coma. Other signs and symptoms may include soft-tissue injury of the face, head, or neck as well as facial edema and clear or bloody drainage from the mouth, nose, or ears. The patient may also exhibit Battle’s sign, lack of response to oculocephalic and oculovestibular stimulation, and bony deformity of the face, head, or neck. Motor and sensory deficits may occur along with altered respirations. Examination may reveal signs of increasing ICP, such as decreased response to painful stimuli, nonreactive pupils, bradycardia, increased systolic pressure, and widening pulse pressure. If the patient is conscious, he may exhibit visual deficits, behavioral changes, and headache.

    Hepatic encephalopathy

    Generalized seizures may occur late in hepatic encephalopathy. Associated late-stage findings in the comatose patient include fetor hepaticus, asterixis, hyperactive DTRs, and a positive Babinski’s sign.

    Hypertensive encephalopathy

    A life-threatening disorder, hypertensive encephalopathy may cause seizures along with severely increased blood pressure, a decreased LOC, intense headache, vomiting, transient blindness, paralysis and, eventually, Cheyne-Stokes respirations.

    Hypoglycemia

    Generalized seizures usually occur with severe hypoglycemia, accompanied by blurred or double vision, motor weakness, hemiplegia, trembling, excessive diaphoresis, tachycardia, myoclonic twitching, and a decreased LOC.

    Hyponatremia

    Seizures develop when serum sodium levels fall below 125 mEq/L, especially if the decrease is rapid. Hyponatremia also causes orthostatic hypotension, headache, muscle twitching and weakness, fatigue, oliguria or anuria, cold and clammy skin, decreased skin turgor, irritability, lethargy, confusion, and stupor or coma. Excessive thirst, tachycardia, nausea, vomiting, and abdominal cramps may also occur. Severe hyponatremia may cause cyanosis and vasomotor collapse, with a thready pulse.

    Hypoparathyroidism

    Worsening tetany causes generalized seizures. Chronic hypoparathyroidism produces neuromuscular irritability and hyperactive DTRs.

    Hypoxic encephalopathy

    Besides generalized seizures, hypoxic encephalopathy may produce myoclonic jerks and coma. Later, if the patient has recovered, dementia, visual agnosia, choreoathetosis, and ataxia may occur.

    Multiple sclerosis (MS)

    MS rarely produces generalized seizures. Characteristic findings include vision deficits, paresthesia, constipation, muscle weakness, paralysis, spasticity, hyperreflexia, intention tremor, ataxic gait, dysphagia, dysarthria, impotence, and emotional lability. Urinary frequency, urgency, and incontinence may also occur.

    Neurofibromatosis

    Multiple brain lesions from neurofibromatosis cause focal and generalized seizures. Inspection reveals café-au-lait spots, multiple skin tumors, scoliosis, and kyphoscoliosis. Related findings include dizziness, ataxia, monocular blindness, and nystagmus.

    Porphyria (intermittent acute)

    Generalized seizures are a late sign of porphyria, indicating severe CNS involvement. Acute porphyria also causes severe abdominal pain, tachycardia, psychotic behavior, muscle weakness, and sensory loss in the trunk.

    Sarcoidosis

    Lesions may affect the brain, causing generalized and focal seizures. Associated findings include a nonproductive cough with dyspnea, substernal pain, malaise, fatigue, arthralgia, myalgia, weight loss, tachypnea, dysphagia, skin lesions, and impaired vision.

    Stroke

    Seizures (focal more common than generalized) may occur within 6 months of an ischemic stroke. Associated signs and symptoms vary with the location and extent of brain damage. They include a decreased LOC, contralateral hemiplegia, dysarthria, dysphagia, ataxia, unilateral sensory loss, apraxia, agnosia, and aphasia. The patient may also develop visual deficits, memory loss, poor judgment, personality changes, emotional lability, urine retention or urinary incontinence, constipation, headache, and vomiting.

    Other causes

    Arsenic poisoning

    Besides generalized seizures, arsenic poisoning may cause a garlicky breath odor, increased salivation, and generalized pruritus. GI effects include diarrhea, nausea, vomiting, and severe abdominal pain. Related effects include diffuse hyperpigmentation, paresthesia of the extremities, alopecia, irritated mucous membranes, weakness, muscle aches, peripheral neuropathy, and sharply defined edema of the eyelids, face, and ankles.

    Barbiturate withdrawal

    In chronically intoxicated patients, barbiturate withdrawal may produce generalized seizures 2 to 4 days after the last dose. Status epilepticus is possible.

    Diagnostic tests

    Contrast agents used in radiologic tests may cause generalized seizures.

    Drugs

    Toxic blood levels of some drugs, such as theophylline, lidocaine, Indocin, meperidine, penicillins, and cimetidine, may cause generalized seizures. Phenothiazines, tricyclic antidepressants, amphetamines, isoniazid, and vincristine may cause seizures in patients with preexisting epilepsy.

    » READ BOOK EXCERPT ONLINE »

    Source: Alarming Signs and Symptoms: Lippincott Manual of Nursing Practice Series, 2007

    Myoclonus: Medical causes
    (Signs & Symptoms: A 2-in-1 Reference for Nurses)

    Alzheimer’s disease

    Generalized myoclonus may occur in advanced stages of this slowly progressive dementia. Other late findings in Alzheimer’s disease include mild choreoathetoid movements, muscle rigidity, bowel and bladder incontinence, delusions, and hallucinations.

    Creutzfeldt-Jakob disease

    Diffuse myoclonic jerks appear early in Creutzfeldt-Jakob disease — a rapidly progressive dementia. Initially random, they gradually become more rhythmic and symmetrical, typically occurring in response to sensory stimuli. Associated effects include ataxia, aphasia, hearing loss, muscle rigidity and wasting, fasciculations, hemiplegia, and vision disturbances or, possibly, blindness.

    Encephalitis (viral)

    With viral encephalitis, myoclonus is usually intermittent and either localized or generalized. Associated findings vary but may include rapidly decreasing LOC, fever, headache, irritability, nuchal rigidity, vomiting, seizures, aphasia, ataxia, hemiparesis, facial muscle weakness, nystagmus, ocular palsies, and dysphagia.

    Encephalopathy

    Hepatic encephalopathy occasionally produces myoclonic jerks in association with asterixis and focal or generalized seizures.

    Hypoxic encephalopathy may produce generalized myoclonus or seizures almost immediately after restoration of cardiopulmonary function. The patient may also have a residual intention myoclonus.

    Uremic encephalopathy commonly produces myoclonic jerks and seizures. Other signs and symptoms include apathy, fatigue, irritability, headache, confusion, gradually decreasing LOC, nausea, vomiting, oliguria, edema, and papilledema. The patient may also exhibit elevated blood pressure, dyspnea, arrhythmias, and abnormal respirations.

    Epilepsy

    With idiopathic epilepsy, localized myoclonus is usually confined to an arm or leg and occurs singly or in short bursts, usually upon awakening. It’s usually more frequent and severe during the prodromal stage of a major generalized seizure, after which it diminishes in frequency and intensity.

    Myoclonic jerks are usually the first signs of myoclonic epilepsy, the most common cause of progressive myoclonus. At first, myoclonus is infrequent and localized, but over a period of months, it becomes more frequent and involves the entire body, disrupting voluntary movement (intention myoclonus). As the disease progresses, myoclonus is accompanied by generalized seizures and dementia.

    Other causes

    Drug withdrawal

    Myoclonus may be seen in patients with alcohol, opioid, or sedative withdrawal, or delirium tremens.

    Poisoning

    Acute intoxication with methyl bromide, bismuth, or strychnine may produce an acute onset of myoclonus and confusion.

    » READ BOOK EXCERPT ONLINE »

    Source: Signs & Symptoms: A 2-in-1 Reference for Nurses, 2007

    Seizures, complex partial: Medical causes
    (Signs & Symptoms: A 2-in-1 Reference for Nurses)

    Brain abscess

    If the brain abscess is in the temporal lobe, complex partial seizures commonly occur after the abscess disappears. Related problems may include headache, nausea, vomiting, generalized seizures, and a decreased level of consciousness (LOC). The patient may also develop central facial weakness, auditory receptive aphasia, hemiparesis, and ocular disturbances.

    Head trauma

    Severe trauma to the temporal lobe (especially from a penetrating injury) can produce complex partial seizures months or years later. The seizures may decrease in frequency and eventually stop. Head trauma also causes generalized seizures and behavior and personality changes.

    Temporal lobe tumor

    Complex partial seizures may be the first sign of a tumor in the temporal lobe. Other signs and symptoms include headache, pupillary changes, and mental dullness. Increased intracranial pressure may cause a decreased LOC, vomiting and, possibly, papilledema.

    » READ BOOK EXCERPT ONLINE »

    Source: Signs & Symptoms: A 2-in-1 Reference for Nurses, 2007

    Seizures, generalized tonic-clonic: Medical causes
    (Signs & Symptoms: A 2-in-1 Reference for Nurses)

    Alcohol withdrawal syndrome

    Sudden withdrawal from alcohol dependence may cause seizures 7 to 48 hours later as well as status epilepticus. The patient may also be restless and exhibit hallucinations, profuse diaphoresis, and tachycardia.

    Arsenic poisoning

    Besides generalized seizures, arsenic poisoning may cause a garlicky breath odor, increased salivation, and generalized pruritus. GI effects include diarrhea, nausea, vomiting, and severe abdominal pain. Related effects include diffuse hyperpigmentation; sharply defined edema of the eyelids, face, and ankles; paresthesia of the extremities; alopecia; irritated mucous membranes; weakness; muscle aches; and peripheral neuropathy.

    Brain abscess

    Generalized seizures may occur in the acute stage of abscess formation or after the abscess disappears. Depending on the size and location of the abscess, decreased level of consciousness (LOC) varies from drowsiness to deep stupor. Early signs and symptoms reflect increased intracranial pressure (ICP) and include constant headache, nausea, vomiting, and focal seizures. Typical later features include ocular disturbances, such as nystagmus, impaired vision, and unequal pupils. Other findings vary with the abscess site but may include aphasia, hemiparesis, abnormal behavior, and personality changes.

    Brain tumor

    Generalized seizures may occur, depending on the tumor’s location and type. Other findings include a slowly decreasing LOC, morning headache, dizziness, confusion, focal seizures, vision loss, motor and sensory disturbances, aphasia, and ataxia. Later findings include papilledema, vomiting, increased systolic blood pressure, widening pulse pressure, and (eventually) decorticate posture.

    Cerebral aneurysm

    Occasionally, generalized seizures may occur with an aneurysmal rupture. Premonitory signs and symptoms may last several days, but onset is typically abrupt with severe headache, nausea, vomiting, and decreased LOC. Depending on the site and amount of bleeding, related signs and symptoms vary but may include nuchal rigidity, irritability, hemiparesis, hemisensory defects, dysphagia, photophobia, diplopia, ptosis, and unilateral pupil dilation.

    Eclampsia

    Generalized seizures are a hallmark of eclampsia. Related findings include severe frontal headache, nausea and vomiting, vision disturbances, increased blood pressure, fever of up to 104° F (40° C), peripheral edema, and sudden weight gain. The patient may also exhibit oliguria, irritability, hyperactive deep tendon reflexes (DTRs), and decreased LOC.

    Encephalitis

    Seizures are an early sign of encephalitis, indicating a poor prognosis; they may also occur after recovery as a result of residual damage. Other findings include fever, headache, photophobia, nuchal rigidity, neck pain, vomiting, aphasia, ataxia, hemiparesis, nystagmus, irritability, cranial nerve palsies (causing facial weakness, ptosis, dysphagia), and myoclonic jerks.

    Head trauma

    In severe cases, generalized seizures may occur at the time of injury. (Months later, focal seizures may occur.) Severe head trauma may also cause a decreased LOC, leading to coma; soft-tissue injury of the face, head, or neck; clear or bloody drainage from the mouth, nose, or ears; facial edema; bony deformity of the face, head, or neck; Battle’s sign; and lack of response to oculocephalic and oculovestibular stimulation. Motor and sensory deficits may occur along with altered respirations. Examination may reveal signs of increasing ICP, such as decreased response to painful stimuli, nonreactive pupils, bradycardia, increased systolic pressure, and widening pulse pressure. If the patient is conscious, he may exhibit vision deficits, behavioral changes, and headache.

    Hepatic encephalopathy

    Generalized seizures may occur late in hepatic encephalopathy. Associated late-stage findings in the comatose patient include fetor hepaticus, asterixis, hyperactive DTRs, and a positive Babinski’s sign.

    Hypertensive encephalopathy

    Hypertensive encephalopathy, a life-threatening disorder, may cause seizures along with severely increased blood pressure, decreased LOC, intense headache, vomiting, transient blindness, paralysis, and (eventually) Cheyne-Stokes respirations.

    Hypoglycemia

    Generalized seizures usually occur with severe hypoglycemia, accompanied by blurred or double vision, motor weakness, hemiplegia, trembling, excessive diaphoresis, tachycardia, myoclonic twitching, and decreased LOC.

    Hyponatremia

    Seizures develop when serum sodium levels fall below 125 mEq/L, especially if the decrease is rapid. Hyponatremia also causes orthostatic hypotension, headache, muscle twitching and weakness, fatigue, oliguria or anuria, cold and clammy skin, decreased skin turgor, irritability, lethargy, confusion, and stupor or coma. Excessive thirst, tachycardia, nausea, vomiting, and abdominal cramps may also occur. Severe hyponatremia may cause cyanosis and vasomotor collapse, with a thready pulse.

    Hypoparathyroidism

    Worsening tetany causes generalized seizures. Chronic hypoparathyroidism produces neuromuscular irritability, Chvostek’s sign, dysphagia, tetany, and hyperactive DTRs.

    Hypoxic encephalopathy

    Besides generalized seizures, hypoxic encephalopathy may produce myoclonic jerks and coma. Later, if the patient has recovered, dementia, visual agnosia, choreoathetosis, and ataxia may occur.

    Neurofibromatosis

    Multiple brain lesions from neurofibromatosis cause focal and generalized seizures. Inspection reveals café-au-lait spots, multiple skin tumors, scoliosis, and kyphoscoliosis. Related findings include dizziness, ataxia, monocular blindness, and nystagmus.

    Renal failure (chronic)

    End-stage renal failure produces rapid onset of twitching, trembling, myoclonic jerks, and generalized seizures. Related signs and symptoms include anuria or oliguria, fatigue, malaise, irritability, decreased mental acuity, muscle cramps, peripheral neuropathies, anorexia, and constipation or diarrhea. Integumentary effects include skin color changes (yellow, brown, or bronze), pruritus, and uremic frost. Other effects include ammonia breath odor, nausea and vomiting, ecchymoses, petechiae, GI bleeding, mouth and gum ulcers, hypertension, and Kussmaul’s respirations.

    Stroke

    Seizures (focal more often than generalized) may occur within 6 months of an ischemic stroke. Associated signs and symptoms vary with the location and extent of brain damage. They include decreased LOC, contralateral hemiplegia, dysarthria, dysphagia, ataxia, unilateral sensory loss, apraxia, agnosia, and aphasia. The patient may also develop visual deficits, memory loss, poor judgment, personality changes, emotional lability, urine retention or urinary incontinence, constipation, headache, and vomiting.

    Other causes

    Barbiturate withdrawal

    In chronically intoxicated patients, barbiturate withdrawal may produce generalized seizures 2 to 4 days after the last dose. Status epilepticus is possible.

    Diagnostic tests

    Contrast agents used in radiologic tests may cause generalized seizures.

    Drugs

    Toxic blood levels of some drugs, such as theophylline, lidocaine, meperidine, penicillins, and cimetidine, may cause generalized seizures. Phenothiazines, tricyclic antidepressants, amphetamines, isoniazid, and vincristine may cause seizures in patients with preexisting epilepsy.

    » READ BOOK EXCERPT ONLINE »

    Source: Signs & Symptoms: A 2-in-1 Reference for Nurses, 2007

    Seizures, simple partial: Medical causes
    (Signs & Symptoms: A 2-in-1 Reference for Nurses)

    Brain abscess

    Seizures can occur in the acute stage of abscess formation or after resolution of the abscess. Decreased LOC varies from drowsiness to deep stupor. Early signs and symptoms reflect increased intracranial pressure and include a constant, intractable headache, nausea, and vomiting. Later signs and symptoms include ocular disturbances, such as nystagmus, decreased visual acuity, and unequal pupils. Other findings vary according to the abscess site and may include aphasia, hemiparesis, and personality changes.

    Brain tumor

    Focal seizures are commonly the earliest indicators of a brain tumor. The patient may report morning headache, dizziness, confusion, vision loss, and motor and sensory disturbances. He may also develop aphasia, generalized seizures, ataxia, decreased LOC, papilledema, vomiting, increased systolic blood pressure, and widening pulse pressure. Eventually, he may assume a decorticate posture.

    Head trauma

    Any head injury can cause seizures, but penetrating wounds are characteristically associated with focal seizures. The seizures usually begin 3 to 15 months after injury, decrease in frequency after several years, and eventually stop. The patient may develop generalized seizures and a decreased LOC that may progress to coma.

    Multiple sclerosis

    Focal or generalized seizures may occur with multiple sclerosis, usually during the late stages. Other findings include visual deficits, paresthesia, constipation, muscle weakness, spasticity, paralysis, hyperreflexia, intention tremor, gait ataxia, dysphagia, dysarthria, emotional lability, impotence, and urinary frequency, urgency, and incontinence.

    Neurofibromatosis

    With neurofibromatosis, multiple brain lesions cause focal seizures and, at times, generalized seizures. Inspection reveals café-au-lait spots, multiple skin tumors, scoliosis, and kyphoscoliosis. Related findings include dizziness, ataxia, progressive monocular blindness, nystagmus, and endocrine abnormalities.

    Stroke

    A major cause of seizures in patients older than age 50, a stroke may induce focal seizures up to 6 months after its onset. Related effects depend on the type and extent of the stroke but may include decreased LOC, contralateral hemiplegia, dysarthria, dysphagia, ataxia, unilateral sensory loss, apraxia, agnosia, and aphasia. A stroke may also cause vision deficits, memory loss, poor judgment, personality changes, emotional lability, headache, urinary incontinence or retention, and vomiting. It may result in generalized seizures.

    » READ BOOK EXCERPT ONLINE »

    Source: Signs & Symptoms: A 2-in-1 Reference for Nurses, 2007

    Tremors: Medical causes
    (Signs & Symptoms: A 2-in-1 Reference for Nurses)

    Alcohol withdrawal syndrome

    Acute alcohol withdrawal after long-term dependence may first be manifested by resting and intention tremors that appear as soon as 7 hours after the last drink and progressively worsen. Other early signs and symptoms include diaphoresis, tachycardia, elevated blood pressure, anxiety, restlessness, irritability, insomnia, headache, nausea, and vomiting. Severe withdrawal may produce profound tremors, agitation, confusion, hallucinations and, possibly, seizures.

    Alkalosis

    Severe alkalosis may produce a severe intention tremor along with twitching, carpopedal spasms, agitation, diaphoresis, and hyperventilation. The patient may complain of dizziness, tinnitus, palpitations, and peripheral and circumoral paresthesia.

    Cerebellar tumor

    An intention tremor is a cardinal sign of a cerebellar tumor; related findings may include ataxia, nystagmus, incoordination, muscle weakness and atrophy, and hypoactive or absent deep tendon reflexes.

    Graves’ disease

    Fine tremors of the hand, nervousness, weight loss, fatigue, palpitations, dyspnea, and increased heat intolerance are some of the typical signs of Graves’disease. It’s also characterized by an enlarged thyroid gland (goiter) and exophthalmos.

    Hypercapnia

    Hypercapnia (elevated partial pressure of carbon dioxide) may result in a rapid, fine intention tremor. Other common findings include headache, fatigue, blurred vision, weakness, lethargy, and decreased level of consciousness (LOC).

    Hypoglycemia

    Acute hypoglycemia may produce a rapid, fine intention tremor accompanied by confusion, weakness, tachycardia, diaphoresis, and cold, clammy skin. Early patient complaints typically include mild generalized headache, profound hunger, nervousness, and blurred or double vision. The tremor may disappear as hypoglycemia worsens and hypotonia and decreased LOC become evident.

    Kwashiorkor

    Coarse intention and resting tremors may occur in the advanced stages of kwashiorkor. Examination reveals myoclonus, rigidity of all extremities, hyperreflexia, hepatomegaly, and pitting edema in the hands, feet, and sacral area. Other signs include a flat affect, pronounced hair loss, and dry, peeling skin.

    Multiple sclerosis

    An intention tremor that waxes and wanes may be an early sign of multiple sclerosis. Commonly, visual and sensory impairments are the earliest findings. Associated effects vary greatly and may include nystagmus, muscle weakness, paralysis, spasticity, hyperreflexia, ataxic gait, dysphagia, and dysarthria. Constipation, urinary frequency and urgency, incontinence, impotence, and emotional lability may also occur.

    Parkinson’s disease

    Tremors, a classic early sign of Parkinson’s disease, usually begin in the fingers and may eventually affect the foot, eyelids, jaw, lips, and tongue. The slow, regular, rhythmic resting tremor takes the form of flexion-extension or abduction-adduction of the fingers or hand, or pronation-supination of the hand. Flexion-extension of the fingers combined with abduction-adduction of the thumb yields the characteristic pill-rolling tremor.

    Leg involvement produces flexion-extension foot movement. Lightly closing the eyelids causes them to flutter. The jaw may move up and down, and the lips may purse. The tongue, when protruded, may move in and out of the mouth in tempo with tremors elsewhere in the body. The rate of the tremor holds constant over time, but its amplitude varies.

    Other characteristic findings include cogwheel or lead-pipe rigidity, bradykinesia, propulsive gait with forward-leaning posture, monotone voice, masklike facies, drooling, dysphagia, dysarthria, and occasionally oculogyric crisis (eyes fix upward, with involuntary tonic movements) or blepharospasm (eyelids close completely).

    Porphyria

    Involvement of the basal ganglia in porphyria can produce a resting tremor with rigidity, accompanied by chorea and athetosis. As the disease progresses, generalized seizures may appear along with aphasia and hemiplegia.

    Thalamic syndrome

    Central midbrain syndromes are heralded by contralateral ataxic tremors and other abnormal movements, along with Weber’s syndrome (oculomotor palsy with contralateral hemiplegia), paralysis of vertical gaze, and stupor or coma.

    Anteromedial-inferior thalamic syndrome produces varying combinations of tremor, deep sensory loss, and hemiataxia. However, the main effect of this syndrome may be an extrapyramidal dysfunction, such as hemiballismus or hemichoreoathetosis.

    Thyrotoxicosis

    Neuromuscular effects of thyrotoxicosis include a rapid, fine intention tremor of the hands and tongue, along with clonus, hyperreflexia, and Babinski’s reflex. Other common signs and symptoms include tachycardia, cardiac arrhythmias, palpitations, anxiety, dyspnea, diaphoresis, heat intolerance, weight loss despite increased appetite, diarrhea, an enlarged thyroid and, possibly, exophthalmos.

    Wernicke’s disease

    An intention tremor is an early sign of Wernicke’s disease. Other features of Wernicke’s disease include ocular abnormalities (such as gaze paralysis and nystagmus), ataxia, apathy, and confusion. Orthostatic hypotension and tachycardia may also develop.

    West Nile encephalitis

    In West Nile encephalitis, mild infections are common and include fever, headache, and body aches, commonly accompanied by rash and swollen lymph glands. More severe infections are marked by headache, high fever, neck stiffness, stupor, disorientation, coma, tremors, occasional seizures, paralysis and, rarely, death.

    Other causes

    Drugs

    Phenothiazines (particularly piperazine derivatives such as fluphenazine) and other antipsychotics may cause resting and pill-rolling tremors. Infrequently, metoclopramide and metyrosine also cause these tremors. Lithium toxicity, sympathomimetics (such as terbutaline and pseudoephedrine), amphetamines, and phenytoin can all cause tremors that disappear with dose reduction.

    Manganese toxicity

    Early signs of manganese poisoning include resting tremor, chorea, propulsive gait, cogwheel rigidity, personality changes, amnesia, and masklike facies.

    Mercury poisoning

    Mercury is a chronic form of poisoning that’s characterized by irritability, copious amounts of saliva, loose teeth, gum disease, slurred speech and tremors.

    » READ BOOK EXCERPT ONLINE »

    Source: Signs & Symptoms: A 2-in-1 Reference for Nurses, 2007

    Seizures: Principal Causes of Seizures
    (The Diagnostic Approach to Symptoms and Signs in Pediatrics)

    1. Febrileseizures
    2. Hypoxic-ischemic encephalopathy
    3. Brain disorders
      1. Cerebralmalformations
      2. Intracranial infection
      3. Intracranial hemorrhage
      4. Other
    4. Hypertensive encephalopathy
    5. Drugs and toxins
    6. Metabolic disorders
      1. Hypoglycemia
      2. Hypocalcemia
      3. Hypomagnesemia
      4. Hyponatremia
      5. Hypernatremia
      6. Uremia
      7. Bilirubin encephalopathy (kernicterus)
      8. Pyridoxine dependency
      9. Inborn errors of metabolism
    7. Selected epileptic syndromes
      1. Neonatalseizures
      2. Benign neonatal epilepsy
      3. Infantile spasms (West syndrome)
      4. Lennox-Gastaut syndrome
      5. Benign focal epilepsy with centrotemporalspikes
      6. Temporal lobe epilepsy
      7. Juvenile myoclonic epilepsy
      8. Posttraumatic epilepsy
      9. Childhood absence epilepsy
    8. Unknown

    » READ BOOK EXCERPT ONLINE »

    Source: The Diagnostic Approach to Symptoms and Signs in Pediatrics, 2006

    Fasciculations: Medical causes
    (Nursing: Interpreting Signs and Symptoms)

    Amyotrophic lateral sclerosis (ALS).With ALS, coarse fasciculations usually begin in the small muscles of the hands and feet, and then spread to the forearms and legs. Widespread, symmetrical muscle atrophy and weakness may result in dysarthria; difficulty chewing, swallowing, and breathing; and, occasionally, choking and drooling.

    Bulbar palsy.Fasciculations of the face and tongue commonly appear early with bulbar palsy. Progressive signs and symptoms include dysarthria, dysphagia, hoarseness, and drooling. Eventually, weakness spreads to the respiratory muscles.

    Poliomyelitis (spinal paralytic).With poliomyelitis, coarse fasciculations, usually transient but occasionally persistent, accompany progressive muscle weakness, spasms, and atrophy. The patient may also exhibit decreased reflexes, paresthesia, coldness and cyanosis in the affected limbs, bladder paralysis, dyspnea, elevated blood pressure, and tachycardia.

    Spinal cord tumors.With spinal cord tumors, fasciculations may develop along with muscle atrophy and cramps, asymmetrically at first and then bilaterally as cord compression progresses. Motor and sensory changes distal to the tumor include weakness or paralysis, areflexia, paresthesia, and a tightening band of pain. Bowel and bladder control may be lost.

    Other causes

    Pesticide poisoning.Ingestion of organophosphate or carbamate pesticides commonly produces an acute onset of long, wavelike fasciculations and muscle weakness that rapidly progresses to flaccid paralysis. Other common effects include nausea, vomiting, diarrhea, loss of bowel and bladder control, hyperactive bowel sounds, and abdominal cramping. Cardiopulmonary findings include bradycardia, dyspnea or bradypnea, and pallor or cyanosis. Seizures, vision disturbances (pupillary constriction or blurred vision), and increased secretions (tearing, salivation, pulmonary secretions, or diaphoresis) may also occur.

    » READ BOOK EXCERPT ONLINE »

    Source: Nursing: Interpreting Signs and Symptoms, 2007

    Myoclonus: Medical causes
    (Nursing: Interpreting Signs and Symptoms)

    Alzheimer's disease.Generalized myoclonus may occur in advanced stages of Alzheimer's disease, a slowly progressive dementia. Other late findings include mild choreoathetoid movements, muscle rigidity, bowel and bladder incontinence, delusions, and hallucinations.

    Creutzfeldt-Jakob disease.Diffuse myoclonic jerks appear early in Creutzfeldt-Jakob disease. Initially random, they gradually become more rhythmic and symmetrical, usually occurring in response to sensory stimuli. Associated effects include ataxia, aphasia, hearing loss, muscle rigidity and wasting, fasciculations, hemiplegia, and vision disturbances, or possibly, blindness.

    Encephalitis (viral).With viral encephalitis, myoclonus is usually intermittent and either localized or generalized. Associated findings vary, but may include rapidlydecreasing LOC, fever, headache, irritability, nuchal rigidity, vomiting, seizures, aphasia, ataxia, hemiparesis, facial muscle weakness, nystagmus, ocular palsies, and dysphagia.

    Encephalopathy.Hepatic encephalopathy occasionally produces myoclonic jerks in association with asterixis and focal or generalized seizures.

    Hypoxic encephalopathy may produce generalized myoclonus or seizures almost immediately after restoration of cardiopulmonary function. The patient may also have a residual intention myoclonus.

    Uremic encephalopathy commonly produces myoclonic jerks and seizures. Other signs and symptoms include apathy, fatigue, irritability, headache, confusion, gradually decreasing LOC, nausea, vomiting, oliguria, edema, and papilledema. The patient may also exhibit elevated blood pressure, dyspnea, arrhythmias, and abnormal respirations.

    Epilepsy.With idiopathic epilepsy, localized myoclonus is usually confined to an arm or leg and occurs singly or in short bursts, usually upon awakening. It's usually more frequent and severe during the prodromal stage of a major generalized seizure, after which it diminishes in frequency and intensity.

    Myoclonic jerks are usually the first signs of myoclonic epilepsy, the most common cause of progressive myoclonus. At first, myoclonus is infrequent and localized, but over a period of months, it becomes more frequent and involves the entire body, disrupting voluntary movement (intention myoclonus). As the disease progresses, myoclonus is accompanied by generalized seizures and dementia.

    Other causes

    Drug withdrawal.Myoclonus may be seen in patients with alcohol, opioid, or sedative withdrawal or delirium tremens.

    Poisoning.Acute intoxication with methyl bromide, bismuth, or strychnine may produce an acute onset of myoclonus and confusion.

    » READ BOOK EXCERPT ONLINE »

    Source: Nursing: Interpreting Signs and Symptoms, 2007

    Seizures, absence: Medical causes
    (Nursing: Interpreting Signs and Symptoms)

    Idiopathic epilepsy.Some forms of absence seizure are accompanied by learning disabilities.

    Other causes

    Drugs.Drugs that lower the threshold for seizures, such as alcohol, cocaine, penicillin in high doses, isoniazid, and phenothiazines may trigger seizures in patients with preexisting epilepsy.

    » READ BOOK EXCERPT ONLINE »

    Source: Nursing: Interpreting Signs and Symptoms, 2007

    Seizures, complex partial: Medical causes
    (Nursing: Interpreting Signs and Symptoms)

    Brain abscess.If the brain abscess is in the temporal lobe, complex partial seizures commonly occur after the abscess disappears. Related problems may include headache, nausea, vomiting, generalized seizures, and decreased level of consciousness (LOC). The patient may also develop central facial weakness, auditory receptive aphasia, hemiparesis, and ocular disturbances.

    Head trauma.Severe trauma to the temporal lobe (especially from a penetrating injury) can produce complex partial seizures months or years later. The seizures may decrease in frequency and eventually stop. Head trauma also causes generalized seizures and behavior and personality changes.

    Herpes simplex encephalitis.Herpes simplex virus commonly attacks the temporal lobe, resulting in complex partial seizures. Other features include fever, headache, coma, and generalized seizures.

    Temporal lobe tumor.Complex partial seizures may be the first sign of a temporal lobe tumor. Other signs and symptoms include headache, pupillary changes, and mental dullness. Increased intracranial pressure may cause decreased LOC, vomiting and, possibly, papilledema.

    » READ BOOK EXCERPT ONLINE »

    Source: Nursing: Interpreting Signs and Symptoms, 2007

    Seizures, generalized tonic-clonic: Medical causes
    (Nursing: Interpreting Signs and Symptoms)

    Brain abscess.Generalized seizures may occur in the acute stage of a brain abscess formation or after the abscess disappears. Depending on the size and location of the abscess, a decreased LOC varies from drowsiness to deep stupor. Early signs and symptoms reflect increased intracranial pressure (ICP) and include a constant headache, nausea, vomiting, and focal seizures. Typical later features include ocular disturbances, such as nystagmus, impaired vision, and unequal pupils. Other findings vary with the abscess site but may include aphasia, hemiparesis, abnormal behavior, and personality changes.

    Brain tumor.Generalized seizures may occur with a brain tumor, depending on it's location and type. Other findings include a slowly decreasing LOC, a morning headache, dizziness, confusion, focal seizures, vision loss, motor and sensory disturbances, aphasia, and ataxia. Later findings include papilledema, vomiting, increased systolic blood pressure, widening pulse pressure and, eventually, a decorticate posture.

    Chronic renal failure.End-stage renal failure produces the rapid onset of twitching, trembling, myoclonic jerks, and generalized seizures. Related signs and symptoms include anuria or oliguria, fatigue, malaise, irritability, decreased mental acuity, muscle cramps, peripheral neuropathies, anorexia, and constipation or diarrhea. Integumentary effects include skin color changes (yellow, brown, or bronze), pruritus, and uremic frost. Other effects include an ammonia breath odor, nausea and vomiting, ecchymoses, petechiae, GI bleeding, mouth and gum ulcers, hypertension, and Kussmaul's respirations.

    Eclampsia.Generalized seizures are a hallmark of eclampsia. Related findings include a severe frontal headache, nausea and vomiting, vision disturbances, increased blood pressure, a fever of up to 104° F (40° C), peripheral edema, and sudden weight gain. The patient may also exhibit oliguria, irritability, hyperactive deep tendon reflexes (DTRs), and decreased LOC.

    Encephalitis.Seizures are an early sign of encephalitis, indicating a poor prognosis; they may also occur after recovery as a result of residual damage. Other findings include fever, headache, photophobia, nuchal rigidity, neck pain, vomiting, aphasia, ataxia, hemiparesis, nystagmus, irritability, cranial nerve palsies (causing facial weakness, ptosis, and dysphagia), and myoclonic jerks.

    Epilepsy (idiopathic).In most cases, the cause of recurrent seizures is unknown.

    Head trauma.With severe head trauma, generalized seizures may occur at the time of injury. (Months later, focal seizures may occur.) Severe head trauma may also cause decreased LOC, leading to coma; soft-tissue injury of the face, head, or neck; clear or bloody drainage from the mouth, nose, or ears; facial edema; bony deformity of the face, head, or neck; Battle's sign; and a lack of response to oculocephalic and oculovestibular stimulation. Motor and sensory deficits may occur along with altered respirations. Examination may reveal signs of increasing ICP, such as a decreased response to painful stimuli, nonreactive pupils, bradycardia, increased systolic pressure, and widening pulse pressure. If the patient is conscious, he may exhibit visual deficits, behavioral changes, and headache.

    Hepatic encephalopathy.Generalized seizures may occur latein hepatic encephalopathy. Associated late-stage findings in the comatose patient include fetor hepaticus, asterixis, hyperactive DTRs, and a positive Babinski's sign.

    Hypoglycemia.Generalized seizures usually occur with severe hypoglycemia, accompanied by blurred or double vision, motor weakness, hemiplegia, trembling, excessive diaphoresis, tachycardia, myoclonic twitching, and decreased LOC.

    Hyponatremia.Seizures may develop when the serum sodium level falls below 125 mEq/L, especially if the sodium loss is rapid. Hyponatremia also causes orthostatic hypotension, headache, muscle twitching and weakness, fatigue, oliguria or anuria, cold and clammy skin, decreased skin turgor, irritability, lethargy, confusion, and stupor or coma. Excessive thirst, tachycardia, nausea, vomiting, and abdominal cramps may also occur. Severe hyponatremia may cause cyanosis and vasomotor collapse, with a thready pulse.

    Hypoparathyroidism.Chronic hypoparathyroidism produces neuromuscular irritability and hyperactive DTRs. Worsening tetany causes generalized seizures.

    Hypoxic encephalopathy.Besidesgeneralized seizures, hypoxic encephalopathy may produce myoclonic jerks and coma. Later, if the patient has recovered, dementia, visual agnosia, choreoathetosis, and ataxia may occur.

    Neurofibromatosis.Multiple brain lesions from neurofibromatosis cause focal and generalized seizures. Inspection reveals café-au-lait spots, multiple skin tumors, scoliosis, and kyphoscoliosis. Related findings include dizziness, ataxia, monocular blindness, and nystagmus.

    Stroke.Seizures (focal more commonly than generalized) may occur within 6 months of an ischemic stroke. Associated signs and symptoms vary with the location and extent of brain damage. They include decreased LOC, contralateral hemiplegia, dysarthria, dysphagia, ataxia, unilateral sensory loss, apraxia, agnosia, and aphasia. The patient may also develop visual deficits, memory loss, poor judgment, personality changes, emotional lability, urine retention or urinary incontinence, constipation, headache, and vomiting.

    Other causes

    Arsenic poisoning.Besides generalized seizures, arsenic poisoning may cause a garlicky breath odor, increased salivation, and generalized pruritus. GI effects include diarrhea, nausea, vomiting, and severe abdominal pain. Related effects include diffuse hyperpigmentation; sharply defined edema of the eyelids, face, and ankles; paresthesia of the extremities; alopecia; irritated mucous membranes; weakness; muscle aches; and peripheral neuropathy.

    Barbiturate withdrawal.In chronically intoxicated patients, barbiturate withdrawal may produce generalized seizures 2 to 4 days after the last dose. Status epilepticus is possible.

    Diagnostic tests.Contrast agents used in radiologic tests may cause generalized seizures.

    Drugs.Toxic blood levels of some drugs, such as theophylline, lidocaine, meperidine, penicillins, and cimetidine, may cause generalized seizures. Phenothiazines, tricyclic antidepressants, amphetamines, isoniazid, and vincristine may cause seizures in patients with preexisting epilepsy.

    » READ BOOK EXCERPT ONLINE »

    Source: Nursing: Interpreting Signs and Symptoms, 2007

    Seizures, simple partial: Medical causes
    (Nursing: Interpreting Signs and Symptoms)

    Brain abscess.Seizures can occur in the acute stage of a brain abscess formation or after resolution of the abscess. A decreased LOC varies from drowsiness to deep stupor. Early signs and symptoms reflect increased intracranial pressure and include a constant, intractable headache; nausea; and vomiting. Later signs and symptoms include ocular disturbances, such as nystagmus, decreased visual acuity, and unequal pupils. Other findings vary according to the abscess site and may include aphasia, hemiparesis, and personality changes.

    Brain tumor.Focal seizures are commonly the earliest indicators of a brain tumor. The patient may report a morning headache, dizziness, confusion, vision loss, and motor and sensory disturbances. He may also develop aphasia, generalized seizures, ataxia, decreased LOC, papilledema, vomiting, increased systolic blood pressure, and widening pulse pressure. Eventually, he may assume a decorticate posture.

    Head trauma.Any head injury can cause seizures, but penetrating wounds are characteristically associated with focal seizures. The seizures usually begin 3 to 15 months after injury, decrease in frequency after several years, and eventually stop. The patient may develop generalized seizures and decreased LOC that may progress to coma.

    Stroke.A major cause of seizures, a stroke may induce focal seizures up to 6 months after its onset. Related effects depend on the type and extent of the stroke, but may include decreased LOC, contralateral hemiplegia, dysarthria, dysphagia, ataxia, unilateral sensory loss, apraxia, agnosia, and aphasia. A stroke may also cause visual deficits, memory loss, poor judgment, personality changes, emotional lability, headache, urinary incontinence or urine retention, and vomiting. It may result in generalized seizures.

    » READ BOOK EXCERPT ONLINE »

    Source: Nursing: Interpreting Signs and Symptoms, 2007

    Asterixis [Liver flap, flapping tremor]: Medical causes
    (Nursing: Interpreting Signs and Symptoms)

    Hepatic encephalopathy.A life-threatening disorder, hepatic encephalopathy initially causes mild personality changes and a slight tremor. The tremor progresses into asterixis—a hallmark of hepatic encephalopathy—and is accompanied by lethargy, aberrant behavior, and apraxia. Eventually, the patient becomes stuporous and displays hyperventilation. When he slips into a coma, hyperactive reflexes, a positive Babinski's sign, and fetor hepaticus are characteristic signs. The patient may also experience bradycardia, decreased respirations, and seizures.

    Severe respiratory insufficiency.Characterized by life-threatening respiratory acidosis, severe respiratory insufficiency initially produces headache, restlessness, confusion, apprehension, and decreased reflexes. Eventually, the patient becomes somnolent and may demonstrate asterixis before slipping into a coma. Associated signs and symptoms of respiratory insufficiency include difficulty breathing and rapid, shallow respirations. The patient may be hypertensive in early disease but hypotensive later.

    Uremic syndrome.A life-threatening disorder, uremic syndrome initially causes lethargy, somnolence, confusion, disorientation, behavior changes, and irritability. Eventually, signs and symptoms appear in diverse body systems. Asterixis is accompanied by stupor, paresthesia, muscle twitching, fasciculations, and footdrop. Other signs and symptoms include polyuria and nocturia followed by oliguria and, then, anuria; elevated blood pressure; signs of heart failure and pericarditis; deep, gasping respirations (Kussmaul's respirations); anorexia; nausea; vomiting; diarrhea; GI bleeding; weight loss; ammonia breath odor; and metallic taste (dysgeusia).

    Other causes

    Drugs.Certain drugs, such as the anticonvulsant phenytoin, may cause asterixis.

    » READ BOOK EXCERPT ONLINE »

    Source: Nursing: Interpreting Signs and Symptoms, 2007

    Tremors: Medical causes
    (Nursing: Interpreting Signs and Symptoms)

    Alcohol withdrawal syndrome.Acute alcohol withdrawal after long-term dependence may first be manifested by resting and intention tremors that appear as soon as 7 hours after the last drink and progressively worsen. Other early signs and symptoms include diaphoresis, tachycardia, elevated blood pressure, anxiety, restlessness, irritability, insomnia, headache, nausea, and vomiting. Severe withdrawal may produce profound tremors, agitation, confusion, hallucinations and, possibly, seizures.

    Alkalosis.Severe alkalosis may produce a severe intention tremor along with twitching, carpopedal spasms, agitation, diaphoresis, and hyperventilation. The patient may complain of dizziness, tinnitus, palpitations, and peripheral and circumoral paresthesia.

    Benign familial essential tremor.Benign familial essential tremor produces a bilateral essential tremor that typically begins in the fingers and hands and may spread to the head, jaw, lips, and tongue. Laryngeal involvement may result in a quavering voice.

    Cerebellar tumor.An intention tremor is a cardinal sign of cerebellar tumor; related findings may include ataxia, nystagmus, incoordination, muscle weakness and atrophy, and hypoactive or absent deep tendon reflexes.

    Graves' disease.Fine tremors of the hand, nervousness, weight loss, fatigue, palpitations, dyspnea, and increased heat intolerance are some of the typical signs of Graves' disease. It's also characterized by an enlarged thyroid (goiter) and exophthalmos.

    Hypercapnia.Elevated partial pressure of carbon dioxide may result in a rapid, fine intention tremor. Other common findings include headache, fatigue, blurred vision, weakness, lethargy, and decreasing level of consciousness (LOC).

    Hypoglycemia.Acute hypoglycemia may produce a rapid, fine intention tremor accompanied by confusion, weakness, tachycardia, diaphoresis, and cold, clammy skin. Early patient complaints typically include a mild generalized headache, profound hunger, nervousness, and blurred or double vision. The tremor may disappear as hypoglycemia worsens and hypotonia and decreased LOC become evident.

    Multiple sclerosis (MS).An intention tremor that waxes and wanes may be an early sign of MS. Commonly, vision and sensory impairments are the earliest findings. Associated effects vary greatly and may include nystagmus, muscle weakness, paralysis, spasticity, hyperreflexia, ataxic gait, dysphagia, and dysarthria. Constipation, urinary frequency and urgency, incontinence, impotence, and emotional lability may also occur.

    Parkinson's disease.Tremors, a classic early sign of Parkinson's disease, usually begin in the fingers and may eventually affect the foot, eyelids, jaw, lips, and tongue. The slow, regular, rhythmic resting tremor takes the form of flexion-extension or abduction-adduction of the fingers or hand, or pronation-supination of the hand. Flexion-extension of the fingers combined with abduction-adduction of the thumb yields the characteristic pill-rolling tremor.

    Leg involvement produces flexion-extension foot movement. Lightly closing the eyelids causes them to flutter. The jaw may move up and down, and the lips may purse. The tongue, when protruded, may move in and out of the mouth in tempo with tremors elsewhere in the body. The rate of the tremor holds constant over time, but its amplitude varies.

    Other characteristic findings include cogwheel or lead-pipe rigidity, bradykinesia, propulsive gait with forward-leaning posture, monotone voice, masklike facies, drooling, dysphagia, dysarthria, and occasionally oculogyric crisis (eyes fix upward, with involuntary tonic movements) or blepharospasm (eyelids close completely).

    Thalamic syndrome.Central midbrain syndromes are heralded by contralateral ataxic tremors and other abnormal movements, along with Weber's syndrome (oculomotor palsy with contralateral hemiplegia), paralysis of vertical gaze, and stupor or coma.

    Anteromedial-inferior thalamic syndrome produces varying combinations of tremor, deep sensory loss, and hemiataxia. However, the main effect of this syndrome may be an extrapyramidal dysfunction, such as hemiballismus or hemichoreoathetosis.

    Thyrotoxicosis.Neuromuscular effects of thyrotoxicosis include a rapid, fine intention tremor of the hands and tongue, along with clonus, hyperreflexia, and Babinski's reflex. Other common signs and symptoms include tachycardia, cardiac arrhythmias, palpitations, anxiety, dyspnea, diaphoresis, heat intolerance, weight loss despite increased appetite, diarrhea, an enlarged thyroid and, possibly, exophthalmos.

    Wernicke's disease.An intention tremor is an early sign of Wernicke's disease. Other features include ocular abnormalities (such as gaze paralysis and nystagmus), ataxia, apathy, and confusion. Orthostatic hypotension and tachycardia may also develop.

    West Nile encephalitis.This brain infection causes fever, headache, and body aches, commonly accompanied by a rash and swollen lymph glands. More severe infections are marked by headache, high fever, neck stiffness, stupor, disorientation, coma, tremors, occasional seizures, paralysis and, rarely, death.

    Other causes

    Drugs.Phenothiazines (particularly piperazine derivatives such as fluphenazine) and other antipsychotics may cause resting and pill-rolling tremors. Less commonly, metoclopramide and metyrosine also cause these tremors. Lithium toxicity, sympathomimetics (such as terbutaline and pseudoephedrine), amphetamines, and phenytoin can all cause tremors that disappear with dose reduction.

    » READ BOOK EXCERPT ONLINE »

    Source: Nursing: Interpreting Signs and Symptoms, 2007


     » Next page: Risk Factors for Convulsions

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