"Tremors" that look like seizures (Full Version)

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nyptjen -> "Tremors" that look like seizures (January 7, 2007 1:50:00 PM)

I'm currently working in acute care. I now have this patient who I'm having trouble with and any input would be appreciated. I do have a small idea about some things but here's the case:

Gentleman in his late 40's. Has had a history of cardiac issues with a permanant pacemaker placed. The patient began having "tremors" that look like grand mal seizures. No activity shows up on multiple tests which led the doctors to say that they are not seizures only tremors. These tremors are accompanied by headaches (patient notes that these are constant and only intensify with the tremors) as well as chest pain. Patient is on telemetry and no activity has been abnormal during any episode.

These tremors last between 10 seconds and 6 minutes and with changes of position. Neuro says that it's a cardiac issue, cardiology says it's a neuro issue. The guy has been to several different hospitals and this is his second admission in less than a month here.

As far as social history, he divorced his wife approximately 4 years ago. This is about the time when he notes the symptoms started. He has since been remarried and there are a total of 6 children between the two of them with the youngest being 3 years old. New wife broke her wrist in 2 places while trying to "handle" him at home just before this admission.

When he was given to me (after seeing 3 other therapists who each unsuccessfully tried to stand him) I tried him on the tilt table. By 25 degrees he would have the uncontrollable tremors where he would be practically unresponsive.

I'd like to mention that the patient has no difficulty in sitting, and one of the nurses witnessed him walk to the bathroom. When I mentioned the walk to the bathroom the patient stated that he did not feel safe, and shook the whole way but "needed to go."

The patient claims that his blood pressure spikes when he's having these tremors but he is moving so much I am unable to take an accurate reading (even when he's strapped on the tilt table). I can say that they have him on BP meds and he runs around 105/65 before and after the tremors.

The doctors want us to progress treatment and the patient wants to start walking with a walker.

Safety wise, this guy makes me nervous. His actions/symptoms aren't consistent.

Has anyone ever seen anything like this before? Any suggestions?

Thanks for all of your help.

Jen



nari -> Re: "Tremors" that look like seizures (January 7, 2007 2:11:00 PM)

Jen,

Not particularly uncommon on two counts: the neuros and the cardios disagreeing and the symptoms. Sometimes these tremors become so severe they are scary for others; however, oddly enough, left to themselves, these patients rarely hurt themselves.
I would suspect a social worker/psychologist or a counsellor needs to be involved. This poor guy porbably has what used to be called a "functional disorder" (a silly expression) and is not aware of either his inconsistency,or his volitional actions. It is unlikely that there is an organic reason for the S&S, with the level so far of medical intervention.
The only way I know of, and which does work, is to tell him that he will start to feel better each day, and tomorrow, he will be able to stand up, and then later tomorrow, take a few steps....etc.
It's important to be firm, and realise that this is not a pantomime he is playing with full awareness. He is not aware of his behaviour.

Hope that helps a bit - you definitely need social work or (neuro)psych support, if available.

Nari



Dr.Wagner -> Re: "Tremors" that look like seizures (January 8, 2007 5:22:00 AM)

I have a pretty big sense this is a Neuro-Psychiatric issue and is likely pretty complex from that stand point. I don't get the sense that this is truly a "medical" issue. I certainly don't get the sense this is a cardiac issue at all.

I think you are right on the nose when you feel his symptoms and actions are not consistent...and I think this is directly related to the psychiatric component. Problem is, congnitive/psychiatric issues have such a social stigma it is a difficult issue to breach.

Now, of course the patient has the "option" to seek second,third, fourth opinions from neurologists...and that is what I suggest. But...I really think there are other issues at hand. And I think you sense that as well.



nyptjen -> Re: "Tremors" that look like seizures (January 10, 2007 12:43:00 PM)

I will say that the psych issue has been brought up. The patient has been refusing psych consults.

The gentleman has has multiple "second" opinions, he has been to at least 4 major hospitals addressing this issue.

Cardiology is now talking about putting in an arterial line to get a true blood pressure as the patient insists that it goes in the neighborhood of 290/230 when he has his episodes.

Yesterday his "tremors" lasted 9 1/2 minutes, and now his wife notes that they have lasted as long as 45 minutes.

I think one of my big problems is if I know that there is a possibility that his blood pressure is going up this high, should I continue with the tilt table? The patient notes that he wants to continue because his goal continues to be to walk, but the risk of stroking out or placing that big of a stress on the body worries me.

The patient insists that he has problems with stress and positional changes but he had these tremors several minutes after maintaining a position on the tilt table and it is not an immediate change.

Thanks for your input!

Jen



Dr.Wagner -> Re: "Tremors" that look like seizures (January 11, 2007 6:29:00 AM)

Yeah...he won't "stroke out". If you are concerned take pre and post manual blood pressures during every treatment session.
While I am not discounting the possibility of said hypertension during these episodes...I would simply have to "see it to believe it"...and I think the cardiologists feel the same way by stating the possibility of the arterial line placement.

But, I would feel confident you are practicing well within the realms of safety. Primarily because this is an unpredictable "tremor" and therefore if you cannot predict the symptoms, do your best to document the BPs and your preventative measures.



PhysioThis -> Re: "Tremors" that look like seizures (January 11, 2007 12:51:00 PM)

Jennifer-
Has this guy ever fallen or otherwise injured himself during these tremors? My bet is that he hasn't.

In my experience with these types, I have found that a validation-type approach works sometimes. Most of the PT sessions are spent conversing - you doing 90% listening - no judgement either with facial expression or body language on your part. Let him talk, give him the safety and feedback with your verbal and physical gestures to express himself however he needs to. While you do this, you can work on exercise, weight bearing, weight shifting, partial sit-to-stand, scooting side to side on a mat, etc. The conversation is part therapeutic and part distraction.

No guarantees on how well this will work in the long-term, but he might show you progress after a few sessions.

My bet is that he's got major esteem/depression issues if he's got such cardiac issues in his 40's requiring a pacemaker. Add divorce, probably job/career loss, and I be he's an emotional mess and has no way to cope with it. He certainly needs psych, but is obviously not ready for it.

Good luck.



Dr.Wagner -> Re: "Tremors" that look like seizures (January 11, 2007 3:37:00 PM)

The injury point is good...but remember an actual objectively identified injury, not the nebulous "I hit my back...yadda yadda yadda injury"



nyptjen -> Re: "Tremors" that look like seizures (January 12, 2007 11:12:00 AM)

To date the patient has not injured himself, only his wife has had a broken wrist from "handling" him during one of his tremors. He has reported falling and the wife notes that there was almost a MVC when he had an episode (that lasted ~20 minutes) while she was driving.

The guy is very flat affect. It wasn't until the 7th or 8th treatment that he even opened up to previous employment (postal service for 23 years) or where he met his new wife. Getting this guy to talk is like pulling teeth. I've tried engaging conversation just to try to distract him from what we were doing but I sometimes felt like I was playing the shrink with all of my questions and just trying to make conversation.

I've been trying to document everything, taking BPs every 2-5 minutes and with each change in activity... still hitting a wall with treatment though.

The good news on my end, the patient went home today. The patient's original plan was to try outpatient aquatic therapy (I had to laugh, but then advised him against it). He then asked if he could continue coming to the inpatient gym to be seen as an outpatient and keep me as the therapist. He noted that to date I'm the only one who "gets him." I think they finally decided on some home health, but I have the sneaking suspicion that he'll be readmitted shortly with some new symptom. I'm hoping for the best though.

Thanks again!



PhysioThis -> Re: "Tremors" that look like seizures (January 13, 2007 4:51:00 PM)

This is an extraordinarily self-centered person. There are perhaps a number of disorders that fit here - psychosomatic, histrionic, conversion, borderline, even sociopathic - but I've seen this too many times in my career, all to often with negative affects on too many good-intentioned, although too niave, clinicians.

My previous post was written with restraint and in the spirit of giving this person 100% benefit of doubt. But if any of the history you have relayed has truth, it is clear, this is a person who is very much aware of what he is doing and has an MO of manipulation of whoever will fall under his spell. He is looking to withdraw from his societal role as breadwinner, producer, community member, etc. but wants to reap all+ the benefits of an upstanding member of the community. There is absolutely no role for PT, PM&R, ortho, or neuro in his care - all disciplines have much to gain in terms of finance from him, and they will b/c he will allow them to do so to a degree (until things become too invasive - let's see how far the central line issue goes). He may re-admit himself to try to get to you as well. His comments to you are his first attempts at "entry " to you soul - depending upon your response he will be back, to try to get you to serve him in some manner.

He is so incredibly selfish that he can even commit abuses against "loved ones" (i.e. broken wrist), create risk (near mva) with his nonsense. These drama come about b/c it is very difficult to consistently fake the things he is faking, and in his mind, he thinks that, if he can present his "episodes" to the outside world in such severe and drastic ways and circumstsnces, they will play as nothing else possible but real because of the "severity".

He has little or no conscience. He is just more of a total wuss than your garden variety serial killer. He is scum. Our lawyer-laden healthcare system perpetuate his behavior and breed his kind.

Keep all of your personal info personal. He will call you in the clinic, be prepared to be terse. If he is readmitted, be sure an alternate therapist treats him.



Dr.Wagner -> Re: "Tremors" that look like seizures (January 15, 2007 3:43:00 AM)

By the way...was was his past admission for? I have a sense it was for chest pain...is this true?



nyptjen -> Re: "Tremors" that look like seizures (January 15, 2007 12:28:00 PM)

The first of the recent admissions was for chest pain/headaches. The second admission was for "neurogenic bladder." During treatment the patient continued to complain that he wasn't able to go. I spoke to the cardiologist who noted that his input/output ratio was normal and that the patient refused to straight cath and was voiding on his own.

While the patient was on IV fluids and easily measured everything added up, then they discontinued the IV and the patient was supposed to record how much he was drinking. He reported drinking 8 cans of 7up and then was unable to go (but a bladder scan showed that there was nothing there to void).

But the chest pain and headaches did remain present/exacerbated with all activities.



Dr.Wagner -> Re: "Tremors" that look like seizures (January 16, 2007 3:38:00 AM)

This guy is full of ...err bologna.



jbird007 -> Re: "Tremors" that look like seizures (January 16, 2007 9:58:00 AM)

lol@Doc Wagner.
full of bologna?

fleet enema???

Is this goofball taking anti-depressants?
Using recreational drugs?

J



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