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30 y/o man and his wife present for couples counseling. He constantly accuses her of cheating. He's in a feud w/ the neighbor b/c he feels they are attacking his character when they say they like his flowerbeds.
Paranoid PD Low dose anti-psychotics can help paranoid behavior.
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30 y/o man, never been married or have any close friends. Works as a night security guard and in his free time works on his model ships in his basement.
Schizoid PDDistinguish from Avoidant b/c they don't WANT relationships
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30 y/o man, never been married or have any close friends because "people make him uncomfortable". He is unemployed because he spends his time reading books on how to communicate with animals so he can "be at one with nature".
Schizotypal PD Distinguish from Schizoid by magical thinking/ interests. Distinguish from Schizophrenia by lack of delus/hallu
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25y/o man comes to court mandated counseling for beating his girlfriend. He was kicked out of high school for fighting & just got out jail for stealing a car.
Antisocial PD. 2/3 have substance abuse (most common co-morbid condition).
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His girlfriend has a hx of unstable relationships, has superficial cuts on both wrists, is impulsive in her spending and sexual practices.
Borderline PD. Commonly defensive mechanism used splitting.
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26 y/o MS2 is asked to seek counseling. Her classmates complain that she dresses too provocatively to class. She recently tried to seduce a professor.
Histrionic PD. Look for substance abuse or eating d/o ( comorbid condition)
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A 22 y/o MS1 doesn't feel like he needs to come to any classes or labs because he "already has the brilliance to be a doctor.
- Narcissistic PD.
- Can be confused w/ hypomania b/c of grandiosity. Give individual thearpy
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30 y/o woman has no friends and avoids happy hours with her coworkers b/c she fears ridicule and rejection. She feels "no one would want to be friends with me".
- Avoidant PD.
- Can tx social phobia sxs w/ b-blocker or SSRI
- -- different from social phobia because it is more persasive
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30 y/o woman has jumped from one relationship to another because she "doesn't do well alone". She calls her friends and family >20x a day to get their input on her daily decisions.
- Dependent PD.
- Look for co-morbid depression and anxiety. SSR - treat co-morbid condition.
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25 y/o MS4 spends more time color coding her notes and textbook highlighting than actually studying. She makes lists and study schedules 3 times per day. People don't like to work with her because she is so "anal"
- Obsessive Compulsive PD.
- Different from OCD b/c the actions are "ego-syntonic"- these people aren't bothered by there compulsions !!!
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78 y/o lady is brought in from her nursing home for altered mental status. She sleeps more during the day and becomes agitated at night-reporting seeing green men in the corner. She also complains of pain upon urination. First step in work up
Delirium and the first step is a medical work up. - do UA and culture, also glc, na, blood culture, b12, RPR - Make sure to look at med list benadryl, opiates bzs.
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What is the biggest risk factor for delrium
- AGE !!
- then underlying dementia is the 2nd biggest
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Other Common causes of delrium
Acute substance withdrawal. Look for it on the 2nd or rd post-op day in alcoholic
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What are the EEG changes of the Delrium
- Diffuse background slowing of the background rhythm - Slow waves
- psychosis has a normal eeg
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Treatment of Delrium
- Reduce excessive stimuli, calendar and clock to orient the patient
- STOP unecessary meds
- Give haloperidol if agitated
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A 78 y/o female presents with memory loss...
•Aphasia, apraxia, gets lost while driving?
Alzheimer's Dementia. MC type.On MMSE, prompting does not ↑recall
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what is the pathology of MRI
- Diffuse brain atrophy, b-amyloid plaques or tau tangles. decrease ACH ( decrease basal nucleous of meyhert)
- tangles correlate with the degreee of dementia
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What are the genes associated to alzheimer's dementia.
- Early onset: APP (Chr 21), presenilin-1
- (Chr 14), presenilin-2 (Chr 1)
- Late onset: ApoE4 (Chr 19)
- ApoE2 (Chr 19) is protective.
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Treatment for alzheimers
- Rivastigmine, Donepezil, galantamine (diarrhea).
- Ach - esterase inhibitors - Cause diarrhea
- Memantine- NMDA antagonist - want to decrease excitability
- non of these improve the memory only decrease rate of decline
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A 78 y/o female presents with memory loss Becomes more sexually explicit, apathy.
Frontotemporal Dementia. (Pick's Dz).
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Pathology of frontaltemporal pick diz
Lobar atrophy, intra neuronal silver staining inculsions- spares the parietal lobe
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What is the treatment for fontaltemporal, aka pick diz.
Olanzepine for severe disinhibition. (stop the behavioral problems)
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A 78 y/o female presents with memory loss Fluctuation in consciousness, visual hallucinations and shuffling gait
Lewybody dementia
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Lewy body dementia pathology
Intra cytoplasmic Alpha-synuclein inclusions in neocortex ( lewy body)
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Lewy body dementia treatment -
Give Ach-Ease inhibitors. NOT L-dopa. Avoid neuroleptics.- no haliperdol or benzo's
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A 78 y/o female presents with memory loss...
Sudden, step-wise decrease in memory/cognitions
What is it and what is the work up
- Vascular Dementia.
- - Work up is MRI and MRA
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A 78 y/o female presents with memory loss Loss of vibration sense, labile affect. Pupil that accommodates but doesn't react.
What is it what is the test
What is the treatment
- Tertiary Syphilis.
- DX: +RPR, VDRL. Do spinal tap to look for spirochetes.- ( if seen you have to iv penicillin)
- Tx: IV penicillin. If Pen-allergic, must desensitize.
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A 78 y/o female presents with memory loss Myoclonus, startle response, seizures. Recently had a corneal transplant.
What is it?
What is the pathology ?
EEG findings ?
- Creutzfeldt Jakob.
- Pathology: Spongiform encephalopathy
- EEG finidngs: triphasic bursts
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A 78 y/o female presents with memory loss Incontinence, gait disturbance/freqfalls, and rapidly developing
Dx:
Work up:
TX:
- DX: Normal Pressure Hydrocephalus.
- Work up: CT/MRI shows hydrocephalus, spinal tap shows nl opening pressure
- Tx: Ventriculoperitoneal shunt improves cognitive fxn in 50-67% of pts
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A 50 y/o known alcoholic presents to the ER with tonic clonic seizures. BP 180/110, HR 118, T 100.1.
How long since the last drink
12-24hrs. (bimodal peak at 8 and 48hrs)
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A 50 y/o known alcoholic presents to the ER with tonic clonic seizures. BP 180/110, HR 118, T 100.1.
How long till he develops confusion, fluctuations in consciousness and the feeling of ants crawling on him?
~48-72hrs since last drink is when delirium tremens usually start.
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A 50 y/o known alcoholic presents to the ER with tonic clonic seizures. BP 180/110, HR 118, T 100.1.
His blood alcohol level is 225mg/mL. How long till its out of his system?
~9hrs, Alcohol is metabolized by zero order kinetics (same amt/unit time = 25mg/hr)
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A 50 y/o known alcoholic presents to the ER with tonic clonic seizures. BP 180/110, HR 118, T 100.1.
If his medications included propranolol, lactulose, and allopurinol, what would be the best sign to monitor for his withdrawals?
Beta-blockers mask the signs of autonomic hyperactivity, but you can follow hyperreflexia to dose the benzos during w/drawal.
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Best intial treatment for our patient with alcohol withdrawl
Diazepam or chloridiazepoxide b/c they have 80 & 120 hr 1/2 lives respectively
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WHAT if the alcoholic has child class C ( cirrohosis )
Lorazepam, oxazepam or tempazepam
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MOSt specific test for ETOH consumption in the past 10 days
Carbohydrate-deficient transferrin. Less specific-elevated GGT and AST more than twice ALT.
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Our next patient comes in w/ confusion, ataxia, and you find ophthalmoplegia: Dx?
- Wernicke Encephalopathy. Caused by thiamine deficiency Give thiamine 1st, then glucose containing fluids.
- REVERSIBLE
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Wernicke can progress to what and how can you tell
Can progress to Korsakoff's syndrome (irreversible damage to mamillary bodies, etc)-apathy, anter/retrograde amnesia and confabulation. Can see MB atrophy on MRI
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A patient is brought into the ER in a non-responsive state. His BP is 100/60, HR is 50, RR is 6. He has multiple track marks on his arms.
•Best first step?
• Diagnosis ?
- Diagnosis - heroin
- Best intial step- intubate ( under 8 intubate always ABC)
- Then give IV or IM naloxone(full mu-opiate antagonist)
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A patient is brought into the ER in a non-responsive state. His BP is 100/60, HR is 50, RR is 6. He has multiple track marks on his arms.---> NOW
You realize his pupils are dilated. Does that change your dx?
No. The hypoxia 2/2 respiratory depression can cause hypoxia
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•What sxs to you expect as he starts to withdraw? heorin
- Juicey - goosebumps
- Joint and muscle pain, photophobia, goosebumps, diarrhea, tachycardia, HTN, GI cramps, dilated pupils, anxiety/depression
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Treatment for heorin for withdrawal symptoms
depression Clonidine for autonomic sxs, ibuprofen for muscle cramps, loperamide for diarrhea.Methadone, buprenorphine or Naltrexone can be used for long-term dependence.
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Pt presents with horizontal nystagmus, dilated pupils, ataxia and acute psychosis.
Hallucinogen (PCP) intoxication. Can use haloperidol for acute psychosis
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Pt presents s/p MVC with injected conjunctiva, sedation and is asking for Doritos.
Cannabis intoxication.
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Pt presents with Suicidal ideation, hypersomnia, depression and anergia
Cocaine/Amphetamine withdrawal.
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Pt presents with dilated pupils, seizure, tachycardia and HTN.
-Best 1st test
Cocaine/Amphetamine intoxication EKG 1st then urine tox screen. Tx seizure w/ lorazepam
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Tx of HTN and tachycardia in a patient with cocaine/amphetamine intoxication
Calcium channel blocker. Beta-blockers are CONTRAINDICATED!
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When is death considered permanent
6 years - 11 years - considered concrete operational
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IQ of 40-55
Moderate retardation
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Iq of 55 -70
Mild retardation
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IQ of 25-40
Severe retardation
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What is the average and standard deviation for IQ
Average is 100 - std is 15
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