The Neurotransmitters: Clinical Neurology Education

A Case of Jerking Shoulder Movements with Dr. Japleen Kaur

• Michael Kentris • Season 1 • Episode 37

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Hello and welcome to our Case Presentation Series! It is a series designed to combat neurophobia in medical students and trainees from different specialties. We will discuss interesting neurology cases that medical students and trainees encounter in their rotations. 

Our first episode is with Dr. Japleen Kaur, an international medical graduate from India, on a fascinating case of jerking shoulder movements in a 56-year-old lady with a history of stroke. This case also fueled Dr. Kaur's own passion for neurology! 

You can find Dr. Japleen Kaur on X at @neuroJ99

If you are a medical student or trainee who has a neurology case to present, reach out to us on Twitter/X at @neuro_podcast or email us at contact@theneurotransmitters.com

  • Check out our website at www.theneurotransmitters.com to sign up for emails, classes, and quizzes!
  • Would you like to be a guest or suggest a topic? Email us at contact@theneurotransmitters.com
  • Follow our podcast channel on 𝕏 @neuro_podcast for future news!
  • Find me on 𝕏 @DrKentris


The views expressed do not necessarily represent those of any associated organizations. The information in this podcast is for educational and informational purposes only and does not represent specific medical/health advice. Please consult with an appropriate health care professional for any medical/health advice.

Dr. Michael Kentris :

Hello and welcome back to The Neurotransmitters. Thank you so much for joining us. I'm very happy to have a new special guest with us today, Dr. Japleen Kaur, coming to us internationally. Good morning, how are you doing today?

Dr. Japleen Kaur:

Good morning, I'm good. Thank you so much for having me on this podcast.

Dr. Michael Kentris :

Although I guess I should say it's not morning where you are. So tell us a little bit about your background, where you're coming to us from.

Dr. Japleen Kaur:

It's actually evening where I'm from, I'm talking from Punjab, the northern part of India. I'm a fresh graduate out of med school and I'm really excited to be here.

Dr. Michael Kentris :

Excellent, excellent. So we're doing something a little bit new, well, partially new. We haven't done it in a while and we're trying to make it more regular. But we're going to kind of be going through some teaching cases, real-life cases that people have experienced in their medical training, medical experience and kind of how they've managed them. And so, Japleen, I'm very grateful that you reached out and came up with this neat case. I think it's got some really good teaching points for it. So why don't you go ahead and give us the starting chief complaint, the opening vignette, if you will?

Dr. Japleen Kaur:

Right. So the most interesting part of this case was actually how we came across this patient's presentation. We were in the middle of our morning rounds. We were actually checking up on another patient when one of our nursing staff she noticed a subtle movement in this patient's left shoulder, so her observation actually led to a chain reaction of distraction that caught my attending's eye. So he was familiar with this patient, he had a long history with her and he was familiar with her past medical complaints.

Dr. Japleen Kaur:

So she did show up with the chief complaint of this slow, jerky, continuous movement in the left shoulder and she seemed to be entirely conscious during this whole episode of these subtle movements. So a little bit about this patient is that she's a 56-year-old lady with a past medical history sedative of type 2 diabetes, hypertension, a history of some stroke that we are unclear on, herpes enchephalitis and now she's presenting to us with this slow, jerky, continuous movement in the left shoulder. Based on the patient's history, this movement was ongoing since the last 12 hours and a chart review revealed that she was already on 750 milligrams of levetiracetam and nighttime alprazolam, but none of these medications seem to have suppressed her movement.

Dr. Michael Kentris :

Okay, so you said that she was awake during this entire period of time.

Dr. Japleen Kaur:

Right. Our patient was actually contributing to her own history. She was able to tell us that she had this movement that was ongoing for the last 12 hours. She wasn't able to use her arm on the affected side. She said she had this new onset weakness, so to say, in the arm. She told us that she initially started more distally and then progressed proximally.

Dr. Michael Kentris :

Okay. So it kind of evolved over the territory of that limb, is that right? Right, okay, excellent. So at this point tell me a little bit about I know you mentioned some of these historical features, right, she's got these old strokes and so forth. Did she have any chronic neurologic problems after those, or did she make a full recovery after those old injuries?

Dr. Japleen Kaur:

She did make a full recovery after the old injury but her MRI had some, her imaging had some changes but otherwise the patient was. Technically she was completely fine after the old injury.

Dr. Michael Kentris :

So you mentioned that she was on some levetiracetam. Was that prior to this admission or was that new for this particular problem?

Dr. Japleen Kaur:

That was prior to the admission. I think it is common practice on the side of the world to start the patients on antiscensure medications after the history of strokes. She did not give us any history of any seizure episodes prior to this, but she was on a prophylactic dose of levetiracetam.

Dr. Michael Kentris :

And was she taking it pretty regularly at home, to the best of your knowledge?

Dr. Japleen Kaur:

As per our knowledge, yes, yes, Okay.

Dr. Michael Kentris :

So at this point, what's happening next?

Dr. Japleen Kaur:

On examination our patient was oriented to time, place and person. Like I said, she could contribute to her own history. Of note, she did have reduced power in the affected arm and the hand. This reduction in power was more distal than it was proximal. No loss of power or sensation was noted in any other part of the body. Reflexes were normal at the time of examination. Because of the paucity of time and resources, EEG was deferred at this point of time. Her imaging revealed some cystic encephalomalacia of the right cerebral hemispheres and the left temporal region. These findings work on current with a previous stroke and herpes encephalitis. So a clinical diagnosis of epilepsia partialis continua was made. Given her history of herpes encephalitis, so this patient was started on fosphenytoin as per weight.

Dr. Michael Kentris :

So you gave a weight-based loading dose? Yes, and how was the response to that?

Dr. Japleen Kaur:

So I revisited this patient an hour later and her movements had completely subsided. She made a return to baseline and she was doing pretty well at this point. Then her part, which she said that there was a loss of part in the affected limb. She had a return of part baseline.

Dr. Michael Kentris :

Excellent. So how does that support or kind of refute our working theory as far as diagnosis?

Dr. Japleen Kaur:

So continuing. She made a full recovery on the fosphenytoin and EPC is a type of status epilepticus. I think it would support our diagnosis as initial clinical suspicion of focal onset status epilepticus.

Dr. Michael Kentris :

Now you brought up an interesting point and you said that you weren't able to get an EEG in this particular case. So tell me a little bit how that factored into, like you and your team's decision making at that point in time.

Dr. Japleen Kaur:

Right. It is a common practice here. Because we cannot, because, of course, the issues since a lot of patients on our side of the world they have out of focus expenditure for their health. We don't commonly have insurance for every patient, so the lot of tests that can't be ordered because of the capacity of resources. So, despite the absence of an EEG, because of high clinical suspicion based on her clinical features and her imaging findings, and because the attending physician had a long-term history with this patient because of his high clinical suspicion, we were able to achieve a diagnosis of EPC even without an EEG.

Dr. Michael Kentris :

Yeah, and it did sound like there were some features by the history like potential, maybe not quite, but almost like a Jacksonian March in that arm. Is that what you guys were thinking?

Dr. Japleen Kaur:

at the time.

Dr. Michael Kentris :

Excellent, and I think this brings up a very interesting point right when we talk about testing availability in different environments.

Dr. Michael Kentris :

Before we started recording, we were talking a little bit about that.

Dr. Michael Kentris :

I'm in the United States I hesitate to use the word regional referral center, but it's our local level, one trauma center in about a 60 mile radius, and I don't have necessarily like stat EEG availability for Saturdays and Sundays pretty often on the weekends due to availability of technicians and things like that.

Dr. Michael Kentris :

And even when I was a trainee at a university program for a couple of years, again even at a larger place, we didn't have stat. Well, we had stat availability, but we didn't have routine EEGs, so you had to call the technician in. So it's one of those things where not only do you need to have the money for the patient to pay it if there is a cost issue, but also the people with the expertise and skills to apply the electrodes and run the test, and in the United States at least, that is a skill set that is very much in demand. In terms of like, there's not very many training programs widespread throughout the country, and so there's kind of a national shortage here as well, and I think that really brings up the point of the importance of making clinical diagnoses.

Dr. Japleen Kaur:

Right. Well, that is something that was really stressed upon during our med school training, and we were training with our general physicians. What is really interesting about this case is that this diagnosis of EPC was not actually made by a neurologist. This was a general physician who does not routinely see cases of epilepsy. So I think that is a big learning point for everyone who is involved in this case is to be very vigilant and be able to make a decision at the time just based on a clinical afternoon.

Dr. Michael Kentris :

Yeah, I think that's an excellent point. I can't think of the last time I had a non-neurologist mention, epc. To me specifically, and for those who aren't familiar, who might be listening right, epilepsia partialis continua. I didn't know if you had any knowledge to drop on us regarding that particular entity.

Dr. Japleen Kaur:

I'll let you drop all the knowledge on that.

Dr. Michael Kentris :

So if we're using the updated nomenclature because in neurology we have obviously hundreds of years of very formal language describing different diagnoses but EPC, or epilepsia partialis continua, sometimes is called focal motor status epilepticus, and it's a very interesting entity. Very often, like in your case, it is related to some sort of structural abnormality, some sort of encephalomalacia, an old stroke, maybe some sort of tumor, something like that that causes focal irritation over the motor cortex. Generally speaking. And it's very interesting because very often in these patients who are awake and alert during these seizures, the EEG itself, even if we do get it, may not show any abnormalities. So it has to do with, kind of, the sensitivity of the EEG and the fact that you need a certain volume or I should say area of cortex to be involved before it will get through the skull to the recording electrodes, and so if it's not generating enough electricity to get to the electrodes, you might be looking with your eyes at the patient and seeing something that looks for all the world like a seizure. But then you look at the scalp EEG recording and you may see something, but you very well may not, and in fact the majority of cases I think up to 80% in some studies don't show any focal abnormalities or any, should say, focal seizures with the activity. So it's definitely one of those things where if it looks like a duck and walks like a duck, maybe it's a duck. So you definitely have to keep your clinical picture in mind and don't let your test necessarily lead you astray. So it's important to really know what is the utility of the test that I'm doing, if I even have it available.

Dr. Michael Kentris :

So yeah, I think that's a really important point and I've certainly had several cases of epilepsia partialis continua in the past and they can be really darned hard to get under control with antiseizure medications. Sometimes they will persist despite multiple antiseizure medications. And so you wound up in this bit of a difficult paradigm where, for instance, with generalized convulsive status epilepticus, we know that's definitely causing brain injury over time and we need to treat that aggressively. But with focal seizures without impaired awareness, that data isn't quite as robust and so we definitely have to weigh the risks and benefits of seizure activity versus the potential morbidity and mortality of having someone intubated and put into a medically induced coma. So I think in those cases you wind up having to tread much more carefully and not just defaulting into kind of like guideline based care. You definitely have to tailor it to the individual in those particular cases. So what else can you tell us about our patient here today, or what else did you learn that you're taking forward with you for your future care of epilepsy patients?

Dr. Japleen Kaur:

Well, this patient played a very big role in you know, for me to choose neurology as a career path, because I remember having this conversation with the patient's family that this subtle movement in her arm was a seizure episode and having to convince this patient to came from a rural background, that somebody who thinks of seizures like just generalized on electronic movements to have this conversation with them that you know seizures can't present like they did in that family member or the relative. That was a very interesting point to discuss with them. During this discussion we also talked about, you know, misconceptions about seizures that they had. They thought epilepsy was a psychiatric diagnosis. A lot of people in India believe it's because of black magic or some supernatural part. So that is something I've actually been working on in the past one year.

Dr. Japleen Kaur:

I very recently I went for this seminar with the teachers. We were getting teachers on early identification of absence seizures. We were teaching them about seizure first aid. So this case really helped me work in that direction. It's given me something to work towards, especially in my part of the world where people don't really know what epilepsy means, what seizures can present like. So I think that's something that we really need to talk about as a community. Put it out there that epilepsy is not just GTC, it could be focal.

Dr. Michael Kentris :

And that is a great point.

Dr. Michael Kentris :

And there's tons of stuff all over the literature emphasizing exactly that thing which people outside of neurology, sometimes outside of epilepsy as a subspecialty, aren't as familiar with. Like people recognizing in particular what we used to call complex partial seizures or focal seizures with impaired awareness, the different manifestations, both behavioral and motor, that can be very, very tricky to nail down and, like so many things in neurology, it all comes back to the story. So having a reliable eye witness is such an important part to making that diagnosis. Because if we think again, right, like a routine EEG, the sensitivity of a single study in isolation, it's maybe around 50% for picking up an interictal epileptoform abnormality. Mri may or may not show any structural abnormalities and so you're left with a couple of normal tests, but that doesn't rule out the possibility of seizures or epilepsy. So again, right, when you're in these areas where testing may not be readily available, as many of us frequently are, then it really comes back to does it sound, does it fit my mental model of what a seizure behaves like?

Dr. Michael Kentris :

And that's always the most challenging part, because there's always some variation, some distant edge case of a seizure, that there are reports of such and such a thing happening, and that's always the, I think, simultaneously fascinating but also sometimes frustrating part of working with epilepsy is that, like well, I'm not familiar with this particular manifestation, but maybe I need to dig into the literature a little bit and look and see is this something that's been reported? If so, does that really match up? How deep do I need to go?

Dr. Michael Kentris :

And it's one of those things that, again, one of my instructors in fellowship would always say it's just such a humbling specialty because you are always seeing new things, new manifestations. You can't ever write anything off, because as soon as you do, you wind up getting proven wrong.

Dr. Japleen Kaur:

That is very true. Do you have any advice for us trainees about how to identify these focal seizures when we look at them?

Dr. Michael Kentris :

Yes, and again this comes back to what are the resources available in your area? If patients or families have even just a smartphone, if they're able to video record an episode, that can be very, very helpful. And I think the International League Against Epilepsy actually has a really nice website I believe it's epilepsydiagnosisorg which is free to register for, and they actually have multiple video examples of different types of seizures that you can review. So I think back to my fellowship in epilepsy. We did every week we would spend at least an hour usually more like an hour of formal didactic sessions and then multiple hours throughout the day in the course of our work reviewing videos of people having seizures, and the attending would be oh, look at the way the hand turns thus, like the little twist of the hand, see the change in the facial expression. You can tell when the seizure ends because the posture changes. It's all these very, very subtle things that once you've done it for a while, you become attuned to it. You're training your mind to recognize what your eyes are seeing, and in neurology, I think movement disorder specialists are particularly good at this.

Dr. Michael Kentris :

I don't consider myself the best at movement disorders and so I'm always a little bit in awe of them. But I like to think that we have a similar type of training in epilepsy, where we're looking at these spells. So if we are able to see the spell, we can usually get a pretty good handle on not just is it epileptic or not, but where may it be coming from in terms of localization, which, as a neurologist, is kind of our watchword. But for trainees to get back to your original question I think watching videos of seizures is the most useful thing for getting better at recognizing them. So just going and finding as many video recordings as you can from reliable sources I will say YouTube, not always the best place to go because you will see sometimes non epileptic spells that are listed as seizures or other types of movement disorders or sleep disorders or other kinds of unusual phenomena. So you do have to view those with a grain of salt if you're not getting them from a kind of a vetted source.

Dr. Japleen Kaur:

I would say Thank you for that advice.

Dr. Michael Kentris :

Of course, any other final thoughts you have for us today, Japleen.

Dr. Japleen Kaur:

Well, I learned a lot today. Thank you for the little advice about learning as we go in epilepsy. I'll definitely be searching up those videos on focal seizures and learning more about epilepsy and these focal seizures.

Dr. Michael Kentris :

No, I think this is a great case. It's one of those challenging types of patients that can present. I'm glad that this patient seemed to have a good response to treatment, as we talked about. Sometimes it's not quite as cut and dry, so it's always good when you have a good response to treatment and that is one of the things that we know right. If we give an antiseizure medication, we get a good response. That's pretty suggestive, even in the absence of some of our more discrete neurologic diagnostic testing. So I think that's a great point to keep in mind is sometimes we consider it a therapeutic and a diagnostic trial of medication in some situations, right.

Dr. Japleen Kaur:

Right.

Dr. Michael Kentris :

Now you are also online, right? If people want to find you online, where should they look for you?

Dr. Japleen Kaur:

Well, I'm on Twitter and I'm very active on LinkedIn. My Twitter handle is neuroJ99. If anybody wants to reach out to me on Twitter, and how about on LinkedIn? My LinkedIn is just being called. That's just my name.

Dr. Michael Kentris :

Straight forward enough. And you can, of course, find me also on Twitter, slash X, at Dr. Kentris that's Dr. Kentris K-E-N-T-R-I-S. And of course, you can always check out our stuff linked at theneurotransmitterscom. So thank you all again for listening this time and, Japleen, thank you again for coming on and talking about this case with us.

Dr. Japleen Kaur:

Thank you for having me.

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