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288 Cards in this Set
- Front
- Back
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What does cancer result from?
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accumulation of mutations in genes that regulate cellular proliferation - genetic and environmental factors contribute, threshold of mutations must be met before cancer actually occurs
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Where will cancer be the number one cause of mortality by the year 2020?
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we are getting better at treating Heart disease the current number one, and the population in america is getting older, so there will be increased incidence of cancer
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What are the top 3 cancers in women?
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Breast
Lung Colon and rectum |
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What are the top 3 cancers in men in the US?
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Prostate
Lung and bronchus colon and rectum |
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What is the top cancer causing death in US women? and in men?
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lung and bronchus
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What are the probabilities of men developing cancer at some point in their life?
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1 in 2 - 50%
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What are the probabilities of women developing cancer at some point in their life?
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1 in 3
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What is the 5 year relative survival rate after diagnosis of any type of cancer?
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66%
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What has the trend been since 1975 in 5 year survival with cancer diagnosis, and why?
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all have improved, due to both earlier detection and advances in treatment, survival rates really have increased with respect to prostate, breast, colon, rectum, and for leukemia
better understanding, early detection, effective treatment! |
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what are the 4 qualities in a patient that lead to making a genetic risk factor assumption?
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family history of cancer
cancer appears earlier in life multiple and bilateral tumors may include rare tumor types |
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What are envrionmental cancer causes?
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occupational exposure: asbestos
lifestyle factors biologic agents: infectious agents Iatrogenic factors (medical treatment causes) |
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What cancer types is smoking a major cause?
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lung
larynx oral cavity esophagus |
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What cancer types is smoking a contributory factor?
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pancreas
bladder kidney stomach uterine cervix |
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What are alcohol-related cancers?
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cancer of the esophagus
head and neck cancer cancer of the large bowel liver cancer pancreatic cancer breast cancer |
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What are 5 virus related cancers and what type of cancer does each virus cause?
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Hepatitis B - liver
Hepatitis C - Liver HTLV-1 - Adult T cell leukemia or lymphoma HPV - uterine cervix Epstein-Barr - Burkitt's lymphoma, nasopharynx, Hodgkin's disease |
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What did Harald zur Hausen discover?
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HPV
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What did Francoise Barre-Sinoussi and Luc Montagnier discover?
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HIV
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What are 3 bacterial related cancers and what particular cancer does each cause?
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Helicobacter pylori - stomach
schistosoma haematobium - urinary bladder opisthorchis viverrini - liver |
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What did Robin warren and Barry Marshall discover?
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H. Pylori causing peptic ulcers and leading to barret's lymphoma
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What types of cancer can ionizing radiation cause?
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breast and leukemia
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What are the characteristics of normal cells?
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oncogene expression is rare,
intermitten or coordinated growth factor secretion presence of tumor suppressor genes |
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What are the characteristics of cancer cells?
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loss of contact inhibition
increase in growth factor secretion increase in oncogene expression loss of tumor suppressor genes neovascularization |
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What is the pathogenesis sequence of events in cancer development?
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1. transformation of cell --> proliferation
2. angiogenesis 3. motility and invasion 4. embolism and circulation 5. arrest in capillary beds 6. adherence 7. extravasation into organ parenchyma 8. response to microenvironment, tumor cell proliferation and angiogenesis in new location 9. etastasis of metastases |
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What are the top three screening test that need to be remembered?
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Breast:
-clinical exam: 20-40 every 3 years and >40 every year -Mammography: 40-49 every 1-2 years and >50 every year Colon Cancer: fecal occult blood test and digital rectal exam: men and women 50+ every year Cervix: -pap smear: F 18+ every year, if normal >3 times, pap test may be performed less frequenctly at discretion of physician -pelvic exam: 18-40 every 1-3 years, with pap test and 40+ every year |
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What are the 5 possible testing schedules for colon and rectal cancer screening?
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-yearly fecal occult blood test
-fecal immunochemical test -flexible sigmoidoscropy every 5 years -yearly fecal occult blood test of fecal immunochemical test plus flexible sigmoidoscopy every 5 years -double-contract barium enema every 5 years -colonoscopy every 10 years |
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When should patients start having their cervical cancer screening?
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about 3 years after they start having vaginal intercourse, but no later than when they are 21 years old
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What are the two prostate examination tests and what demographic should be screened?
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prostate-specific antigen blood test and digital rectal examamination should be offered annulally, beginning at age 50 to men whe have at least a 10 year life expectancy
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What demographic of men are at high risk for prostate cancer? and when should they begin testing?
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african american men and men with a strong family of one or more first degree relatives diagnosed at an early age, should begin testing at age 45
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what are the 3 types of therapies for cancer?
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surgery
radiation therapy systemic therapy (chemotherapy) |
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What is a radical mastectromy vs a lumpectomy?
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radical mastectomy: take out breast, take out pec major, take out pec minor
lumpectomy - preservation of organ, can avoid major surgery |
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What are 3 types of systemic therapy?
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chemotherapy
hormonal therapy targeted treatments |
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Where are the places of action for cytotoxic agents?
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DNA synthesis with antimetabolites
DNA itself - alkylating agents DNA transcription and DNA duplication - with intercalating agents mitosis - spindle poisons |
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What are the side effects of chemotherapy?
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alopecia
mucositis pulmony fibrosis nausea/vomiting cardiotoxicity diarrhea local reaction cystitis in ovaries renal failure sterility myelosuppression myalgia phlebitis neuropathy |
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What are two cancers treated with hormonal therapy? and what are examples of treatment for each?
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prostate:
-leuprolide -goserlin -flutamide -bicalutamide breast cancer -tamoxifen -anastrazole -letrozole -exemestane |
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Explain what targeted therapy to HER2 is?
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HER2/EGFR protein is overexpressed, and HER2/HER3 heterodimer is particularly potent at signal transduction using tyrosine kinase, these signal increased cell proliferation, increased cell migration, and resistance to apoptosis,
Lapatinib,Trasuzumab, Cetuximab: overall the ErbB signaling pathway is targeted. cetuximab and trastuzumab bind to the extracellular doman of the respective recetors, the small molevule inhibitors gefitinib and erlotinib, which target ErbB1, work inside the cell and block receptors kinase activity. This has single family specificity, so JUST works on ErbB1, not ErbB2 lapatinib exerts its effect by blocking the ATP binding site at the intracellular domain. Theorectically lapatinib may exhibit potent activity against both ErbB1 and ErbB2 receptors |
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What targeted therapies work for Epidermal Growth Factor? EGFR/HER
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herceptin (trastuzumab)
Lappatinib Tarceva (erlotinib) Erbitux (cetuximab) |
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What targeted therapies are designed for C-kit?
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gleevec: Imatinib
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What targeted therapies are designed for RAF? and BCR-ABL?
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Gleevec: Imatinib
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What targeted therapies are designed for Platelet Derived growht factor?
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Gleevec: Imatinib
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What therapy drug targets angiogenesis in cancer?
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bavacizumab: avastin
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What are the 4 signs and symtoms we look at with a patient with hematologic malignancy?
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-abnormal immune system: infection, disordered wbcs,
-hematopoietic failure: anemia, low platelets -abnormal lymphoid organs: lymph nodes, spleen, liver -B cymptoms: fever, nighsweats, weight loss |
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What is the primary evaluation for patients with hematologic malignancy?
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bone marrow biopsy, imaging of lymph nodes (CT and PET scan)
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How do they do a bone marrow biopsy?
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numb the periosteum, needle goes into the marrow space, use the syringe to bring out the liquied, and then take a small piece of bone out for a core sample
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Describe Acute Leukemia -
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aggressive malignancy, rapid course, severe bone marrow and immune system failure
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What are the two general types of acute leukemia?
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acute myeloid leukemia: AML --> malignant myeloid precursors, disease of adults
acute lymphoblastic leukemia (ALL) - malignant lymphoid precursor, more common on children |
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How do we treat acute leukemias? what is the prognosis like? and how do we determine the prognosis?
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agreesive chemotherapy regimens, often hospitalized,
overall aduls tcan expect about 40% survival, prognosis based on age, blood counts at diagnosis, and cytogenetics |
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What are the cytogenetics involved in acute leukemia?
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chromosomes analysis of leukemia cells, translocated chromosomes and mutation within DNA common,
philadelphia chrom: BRC/ABL |
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what is really used to classify diagnosis?
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bone marrow biopsy
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What is an intracellular component that is helpful in diagnosis of acute myeloid leukemia?
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aurer rods in cells of the bone marrow
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What are the cytogenetic in AML prognosis:
Good Risk: Poor Risk: Intermediate Risk: |
Good Risk:
t(8;21), t(15;17), inv16 70-80% survival Poor Risk: -5, -7, trisomy 8, complex karyotype, prior MDS <10% survival Intermediate Risk: Normal Karyotype, largest subgroup, 40% adult AML has normal karyotype |
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What is the AML treatment protocol?
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Induction: 7 + 3: (7 days of continuous IV with cytarabine and anthracycline is given for 3 consecutive days as an IV push)
check BM after a week to see if patient is in remession, if not then repeat induction therapy, if so, then start consolidation therapy: Consolidation: cytarabine (works to eliminate the undetectable cells still probably present) usually an additional 3-5 courses of this therapy maintenace - not usually given in AML, but necessary part of acute promyelocytic leukemia: t(15;17) |
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What is the ALL treatment protocol?
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Remission induction: really try to rapidly kill most tumor cells and get the patient into remission, <5% leukemic blasts in the bone marrow
maintenance therapy is to kill any residual cell that was not killed by remission induction, and intensification regimens, |
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What is the treatment of relapsed AML?
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re-induction chemotherapy: better chance if greater than 6 months from prior therapy
mylotarg: CD33 antibody , approved for alder adults iwth relapsed AML, direct acting toxin/chemotherapy, attaches to CD33, then delivers toxin |
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When does a patient undergo a bone marrow transplant?
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failure to achieve remission
relapse of leukemia poor risk cytogenetic groups |
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What is the cytogenetic component of acute promyelocytic leukemia?
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t(15;17)
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What are the diagnostics of Acute Promyelocytic Leukemia?
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novel protein: PML -RARA
-fusion of promylocytic gene with retinoic acid receptor -can request urgent RISH analysis for this -can serach by PCR |
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What is the treatment for Acute Promyelocytic Leukemia?
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Induction: treat with ATRA (all-trans retinoic acid) to induce differentiation of the immature leukemic promyelocytes into mature granulocytes, as well as Idarubicin
Consolidation Maintenance therapy with the ATRA for 2 years |
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What are the epidemiologic findings for Acute lymphoblastic leukemia?
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20% acute leukemia in adults
4000 cases per year in US -cytogenetic subgroups: 20% adults will have t(9;22) - BCR/ABL |
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Precursor B cell ALL cytogenetics:
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-t(9;22) - philadelphia chromosome
-t(v; 11q23) -t(1;19) -t(12;21) -hypodiploid or hyperdiploid |
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ALL treatment regimen (ADULT):
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induction and maintenance: alternating courses 4 each:
-A: cyclophosphamide 300mg BID, 1-3 days; vincristine 2mg IV day 4 and 11; Adriamycin 50mg/ day 4; Dexamethasone 40mg/ days 1-4 and 11-14 -B: methotrexate 1gm IV day 1; Ara-c 3gm/ IV BID day 2 and 3; Methyprednisolone 50mg IV DIS deay 1-3 CNS Therapy: Intrathecal chemotherapy dosing with each cycle, Maintenance therapy: monthly cycles for 2 years: predinisone, vincristine, mercaptopurine, methotrexate cycles given every 21-27 days, 8 rounds, each time |
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Chronic wbc proliferative disorders description -
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characterized y clowly progressive overgrowth of cells in bone marrow/blood
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What are the chronic proliferative disorders in each?
Myeloid: Lymphoid: |
Myeloid:
chronic myeloid leukemia polycythemia vera essential thrombocytosis myelofibrosis Lymphoid chronic lymphocytic leukemia |
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What causes chronic myeloid leukemia?
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Chromosomes 9 and 22:
BCR(22):ABL (9) translocation constitutively active tyrosine kinase: phosphorylates intracellular proteins leading to increased proliferation, decreased apoptosis, changes in matrix interactions |
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What are the typical signs and symptoms of chronic myeloid leukemia?
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elevated wbc - mostly maturing myeloid cells
anemia, elevated or low platelets splenomegaly catbolic symptoms late disease (blast phase) resembles acute leukemia |
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What transductional components does BCR involve?
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STAT pathway
RAS --> RAF pathway |
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What transductional components does ABL involve?
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JUN kinase, MYC, Phosphatidylinositol -3 Kinase
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What are the 3 phases of CML?
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chronic phase:
-minimal blasts, t(9;22) only cytogenetic abnormal, untreated survival 5-7 years acceleration phase: -blasts 10-19% in peripheral blood, new cytogenetic abnormalities occur, untreated survival 12-18 months blast phase: peripheral blood blasts >20%, 20% may be liymphoblasts, rest maintain myeloid markers, untreated survival 4-6 months |
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What are the treatments of CML?
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Imatinub
Dasatinib Nalotinib Imatinub works by competitively binding BCR-ABL away from ATP and will prevent tyrosine kinase activity, thus preventing P-Transcription Factors and there won't be as much transcription/proliferation |
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What are the clinical signs of Polycythemia vera?
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increased in red blood cells mass
elevated hemoglobin, hematocrit |
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What is the treatment for polycthemia vera?
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phleobotomy to remove excess RBC
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What are the clinical signs of essential thrombocytosis?
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elevated platelet counts
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What are the clinical signs for myelofibrosis?
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bone marrow fibrosis
enlarged spleen |
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What are the treatments for essential thrombocytosis?
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control platelet count
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What is the treatment for myelofibrosis?
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supportive care
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What are the end results of myeloproliferative disorders?
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can terminate in marrow failure or transform to acute leukemia
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What role does JAK2 play in P vera, ET, MF?
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mutated JAK2 --> constitutively activated kinase activity -- >STAT Transcription Factor
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Multiple Myeloma:
describe disease describe current standard treatments |
malignancy of plasma cells:
secrete antibodies: malignant plasma cells in multiple myeloma make an identical antibody which is detected in serum: myeloid protein incurable with standard treatments: -dexamethason -melphalan -VAN, velcade -thalidomide BM transplant improved survival |
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What are the presentations of most lymphomas?
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enlarged lymph nodes or symptoms of marrow infiltration
B symptoms: fever, night sweats, weight loss- patients have worse prognosis if they have B symptoms |
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What are the stages of lymphoma?
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Stage 1 and 2: lymph nodes 1 side of diaphragm
Stage 3: nodes above and below diaphragm Stage 4: marrow involvement A - no B symptoms B - B symptoms |
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What are lymphomas divided into in type of disease? and give examples of each:
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Indolent Disease: follicular, MALT lymphoma, CLL/SLL
Aggressive: Diffuse Large B-cell, T-Cell lymphoma Extremely aggressive: lymphoblastic or Burkitt Lymphoma |
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What are the most aggressive lymphomas treated with?
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R-CHOP chemotherapy: cyclophosphamide, hydroxydaunorubicin (adriamycin), oncovin (vincristine), and prednisone/prednisolone
R - rituximab - a monoclonal antibody against CD20 - polymer is expressed R-CHOP much more successful than CHOP alone, even though the adverse reactions might be worse, most patients will agree to the R-CHOP |
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What do you do prior to Hematopoietic Cell Transplantation (BM transplant)?
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use high dose chemotherapy followed by hematopoietic stem cell rescue: stem cell collected from peripheral blood or bone marrow. Must get patient in remission before a BM transplant would work.
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What are the two types of BM transplants?
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Autologous (self) - patient rescued by their own havested stem cells: commonly used for lymphoma and myeloma
Allogeneic transplant - patient rescued by stem cells of another: often for very aggressive malignancy or failed after auto-transplant looking to cause harvests graft vs malignancy effect |
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What are the steps in performing a BM transplant?
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Step 1: stem cell collection via apheresis
Step 2: prepare host - usually high dose chemotherapy, can add total body irradiation Step 3: recovery, wbc's usually recover in 10-14 days, immune reconstitution can take months |
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What are some complications of allogeneic transplant?
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Graft vs Hos Disease: new donors immune system attacks host:
Skin: rash, skin can slough off GI tract: severe diarrhea, wasting Liver: Jaundice, failure each site of attack is on a scale of 1-4 depending on the severity of reaction |
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What are the outcomes of BM transplant with auto transplant vs allogeneic transplant?
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Auto: 50% long term survival
Allogeneic transplant: 30% up front mortality; 40% change long term survival for patients in remission, 10% long term survival with refractory leukemia Autotransplant the biggest cause of death is by far relapse, no real other major causes Allogeneic transplant is going to be a lot of replease deaths but a lot of graft vs host reaction deaths |
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What does ablation mean?
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dose of therapy in which a patient would never recover if we don't give them new stem cells, this comes at a great toxicity to your heart, lungs, and kidneys, so have to really analyze patient prior to therapy.
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What are the steps or what all is involved in bone marrow transplant?
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preparative therapy involves choosing:
ablative or non-ablative chemotherapy/radiation Stem cell rescue involves: patients own cells (autologous) or alternative donor (allogeneic) -all autologous cell replacement is guaranteed ablative therapy Immune Reconstitution:engraftement of stem cells |
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What are the types of Allogeneic HCT options?
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matched related donor:
fully matched donor haploidentical donor Unrelated donor: peripheral blood HC bone marrow HC cord blood HC |
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What are the types of dose intesity HC transplant options?
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autologous - ablative
allogeneic - ablative, reduced intensity, non-myeloablative |
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What is autologous transplant usually used for? and what is the treatment mortality?
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lymphoma and multiple myeloma
3-5% TRM |
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Describe the immune recovery process post autologous transplant:
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2 weeks to have any recovering of wbcs, and platelets and rbcs will tak emuch longer, up to 4-5 weeks after transplant
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What are the viral infection risks in autologous transplant?
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Herpes simplex virus - preengraftment
repiratory virus - pre and postengraftment Cytomegalovirus - postengraftment Varicella zoster virus - postengraftment |
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What are the bacterial infection risks in autologous transplant?
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gram positive, gram negative organisms,
throughout pre and post engraftment |
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What are the fungal infection risks in autologous transplant?
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candida spp. preengraftment
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What are the parasitic infection risks in autologous transplant?
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pneumocystis carinii, post engraftment
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What are the overall risk factors for autologous transplant, pre and post engraftment?
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Preengraftment:
mucositis neutropenia organ dysfunction Postengraftment: musocitis and cutaneous damage (central venous catheters) cellular immune dysfunction (steroid therapy) immunomodulating viruses hyposplenism, decrease in opsonizaiton decrease in reticuloendothelial function |
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what are Allogeneic transplants used for?
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leukemia, aplastic anemia, and refractory lymphoma
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What are the qualities of each:
preengraftment immediate postengraftment late postengraftment? |
preengraftment: extremely low wbcs
immediate postengraftment: neutrophil recovery Late postengraftment: recovery of immune function |
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What are the stem cell dose, T-cell dose, engraftment period, and GVHD risk for BM allogeneic transplant?
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Stem Cell dose: mild
T-cell dose: mild engraftment: 20-25 days GVHD: mild |
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What are the stem cell dose, T-cell dose, engraftment period, and GVHD risks for Peripheral blood allogeniec transplant?
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Stem Cell: high
T-cell dose: high engraftment: 10-14 days GVHD: mild |
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What are the stem cell dose, t cell dose, engraftment period, and GVHD risk for allogeneic cord transplant?
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Stem cell dose: low, T-cell dose low, engraftment 30-40 days, CVHD, low for level of mismatch
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What is the main cell player in GVHD?
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T-cells, the amount of T-cell in the donor transplant
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What are the viral infection risks for post allogeneic transplant?
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Herpes simplex virus: preengraftment
respiratory viruses pre-immediate-late engraftment Cytomegalovirus, human herpesviruses 6,7 immediate --> late posterengraftment varicella zoster virus - late postergraftment |
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What are the viral infection risks for post allogeneic transplants?
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gram positives, gram negatives, in preengraftment,
encapsulated bacteria in late postengraftment |
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What fungal infectious risk factors for allogeneic transplant?
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preengraftment: cadida spp
Immediate postengraft: aspergillus spp. |
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What are parasitic risks involved with allogeneic transplant?
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Immediate toxoplasma gondii, pneumocystis carinii
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What are the overall risk factors in each step of the alogeneic transplant:
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Preengraftment:
mucositis organ dysfruntion neurtropenia and other immune defects Immediate postengraftment: acute GVHD and therapy for this condition Mucocutaneous damage Cellular immune dysfuntion immunomodulating viruses Postengraftment: chronic GVHD, mucucutaneous damage cellular and human dysfunction hypospleenism, decrease in opsonizaiton, decreased in reticuloendothelial function |
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What is the appraoch to preventing infectious complications with BM transplant?
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prophylactic antimicrobials:
during neutropenia (ANC < 500) - prophylactic levofloxacin, fluconazole and through day 100 acyclovir initiate broad spectrum anti-bacterials for coverage at time of first fever monitor for evidence of viral reactivation CMV |
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what % chance does a sibling have of matching HLA?
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25%
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What is the % of unrelated donor matches found for HLA?
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50-80%
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What is a cord blood graft easier when it comes to matching?
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less than perfect match is acceptable, less reactive to foreign HLA, area protected against active immune cells
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What is involved in HLA typing?
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chromosome 6
Class 1 (A,B,C): -present intracellular antigens to CD8 cells -expressed on all nucleated cells Class 2 (DP, DQ, DR) -present extracellular antigens to CD4 cells -expressed on B-cels, macrophages, and dendritic cells |
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What is an acute GVHD?
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usually defined as occuring wihtin 100 days, major cause of acute mortality
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What is chronic GVHD?
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occurring after 100 days, major cause of long term mortality
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What is the mechanism of GVHD?
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phase 1: conditioning regimen --> -tissue damage--> TNFalpha, IL1, IL6 all realeased-->
- GI damage --> endotoxin enters circulation --> macrophages, MNCs --> TNFalpha, IL1, IL6 released --> Phase 3 -target cell apoptosis Phase 2: Host APC -Donor T cell --> IL2 released/Binds with Th1 cel --> IFNgamma, IL2 released --> activated NK, CTL, Macrophages, MNCs --> phage 3 target cell apoptosis |
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How can we prevent GVHD?
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-manipulate the new immune system as it matures
-change the graft: remove the T-cells -Change the host: patients present antigens to new immune system to activate it, possible to increase regulatory cells, NK cells of donor or host origin, CD4/25 T cells of host origin |
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What do we want to happen in BM transplant?
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Graft versus Tumor Effect: new immune cells attack the cancer tumor cells
and avoidance of graft vs host disease, |
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What is the survival rates between related donor and unrelated donor of BM transplant?
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the same
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patient presents with pencil like stool, diagnosis?
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apple-core lesion of the sigmoid colon
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ostipation means?
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intestinal obstruction
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Patient presents with black, tarry stools, diagnosis and what is the site of pathology?
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melena, the loss of atleast 60mL of blood in GI tract, usually from the esophagus, stomach, or duodenum
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What are causes of melena?
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peptic ulcers
gastritis or stress ulcers esophageal or gastric varices reflux esophagitis mallory-weiss tear |
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What is a mallor-weiss tear?
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a mucosal tear in the esophagus due to retching and vomitting
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What is a typical history for melena?
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epigastric pain
recent ingestion of alcohol, aspirin, or other anti-inflammatory drugs; recent bodily trauma, severe burns, surgery, or increased intracrannial pressure cirrhosis of the liver or other cause of portal hypertension history of heartburn retching, vomitting, ALCOHOL |
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Patient presents with black, nonsticky stools, with negative occult test, diagnosis?
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ingestion of iron, bismuth salts as in peptobismol, licorice, or even commercial chocolate cookies
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Patient present with red blood in stools, diagnosis and where is the location of the bleed?
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-cancer of the colon,
-benign polyps of the colon, -diverticula of the colon, -inflammatory conditions of the colon and rectum: -ulcerative colitis, -crohn's disease -infectious dysenteris -proctitis -ischemic colitis -hemorrhoids -anal fissure blood is usually from colon, rectum, or anus |
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What is proctitis?
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red blood in the stools from frequent anal intercourse
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Patient presents with changes in bowel habits and red blood in stool, diagnosis?
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colon cancer
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patient presents with diarrhea, rectal urgency, tenesmus, and red blood in stools, diagnosis?
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infectious dysenteris
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tenesmus means -
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feeling of difficulty during defecation
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Patient presents with lower abdominal pain, fever, and red blood in stool, diagnosis?
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ischemic colitis
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patient presents with blood on the toilet paper, on the surface of the stool, or dripping into the toilet, diagnosis?
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hemorrhoids
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patient presents with blood on toilet paper or on surface of stool, and anal pain, diagnosis?
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anal fissure
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Patient presents with pink urine, diagnosis?
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ingestion of beets
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patient presents with burning on urination, urinary urgency, and hematuria, diagnosis?
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infection, stones, tumor, or foreign body in the bladder
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What are three things that cause decreased capacity of the bladder?
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1. increased bladder sensitivity to stretch because of inflammation
2. decreased elasticity of the bladder wall 3. decreased cortical inhibition of bladder contractions |
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patient presents with urinary urgency, weakness and paralysis, diagnosis?
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motor disorders of the central nervous system such as a stroke
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Patient presents with hesitancy in starting the urinary stream, straining to void, reduced size and force of the stream, and dribbbling during the end of urination, diagnosis?
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benign prostatic hyperplasia, urethral stricture, or other obstructive lesion of the bladder or prostate
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What are the causes of impaired emptying of the bladder, with residual urine in the bladder?
|
partial mechanical obstruction of the bladder neck or proximal urethra
loss of peripheral nerve supply to the bladder (sacral) |
|
|
Chronic diabetic patient presents with weakness and sensory defect, as well as hesitance in starting the urinary stream, and straining to void, diagnosis?
|
diabetic neuropathy, causing sacral nerve disease
|
|
|
What are the causes of nocturia with high volumes?
|
decreased concentrating ability of the kidney with loss of the normal decrease in nocturnal urinary output
excessive fluid intake before bedtime fluid-retaining, edematous states, dependent edema accumulates during the day and is excreted when the patient lies down at night |
|
|
What are some habits involved in nocturia with high volumes?
|
alcohol and coffee
|
|
|
What are some conditions involved in nocturia with high volumes?
|
alcohol, coffee,
CHF, nephrotic syndrome, hepatic cirrhosis with ascites, chronic venous insufficiency |
|
|
What are the causes of nocturia with low volumes?
|
insomnia, voiding while up at night without a real urge, a pseudo-frequency
disorder of the posterior pituitary and hypothalamus a number of kidney diseases, including hypercalcemic and hypokalemic nephropathy drug toxicity from lithium |
|
|
Patient presents with thirst and polydipsia that is severe and persistent, diagnosis?
|
a disorder of the posterior pituitary and hypothalamus
number of kidney disease including hypercalcemic and hypokalemic nephropathy drug toxicity from lithium uncontrolled diabetes mellitus |
|
|
Epileptic patient presents with severe and persisten thirst and polydipsia, diagnosis?
|
lithium toxicity
|
|
|
What are the causes of polyuria?
|
deficiency of antidiuretic hormone
renal unresponsiveness to antidiuretic hormone (nephrogenic diabetes insipidus) solute diuresis: -electrolytes, such as Na_ -nonelectrolytes such as glucose -excessive water intake |
|
|
What causes primary polydipsia?
|
excessive water intake
|
|
|
Diabetic patient pressents with polyuria, thirst, and nocturia, diagnosis?
|
uncontrolled diabetes mellitus, with solute diuresis from glucose
|
|
|
level of consciousness -
|
alertness or state of aweareness of the environment
|
|
|
attention -
|
the ability to focus or concentrate over time
|
|
|
orientation
|
awareness of personal identity, place, and time, requires both memory and attention
|
|
|
short term memory
|
minutes, hours, or days
|
|
|
long term memory -
|
intervals of years
|
|
|
level of consciousness -
|
alertness or state of aweareness of the environment
|
|
|
attention -
|
the ability to focus or concentrate over time
|
|
|
orientation
|
awareness of personal identity, place, and time, requires both memory and attention
|
|
|
short term memory
|
minutes, hours, or days
|
|
|
long term memory -
|
intervals of years
|
|
|
Perceptions
|
sensory awareness of objects in the environment and their interrelationship
|
|
|
thought process
|
logic, coherence, and relevance of the patients thought as it leads to selected goalds
|
|
|
thought content
|
what the patient thinks about,
|
|
|
insight
|
awareness that symptoms or disturbed behaviors are normal or abnormal
|
|
|
judgement -
|
process of comparing and evaluating alternatives
|
|
|
affect
|
an observable, usually episodic feeling or tone
|
|
|
mood
|
a more sustained emotion,
|
|
|
language -
|
a complex symbolic system for expression
|
|
|
high cognitive functions -
|
assessed by vocabulary, fund of information, abstract thinking, calculation, construction of objects 2 - 3D
|
|
|
Patient presents that has been worrying persistently over a 6 month period, diagnosis?
|
generalized anxiety disorder
|
|
|
What characterizes post traumatic stress disorder?
|
avoidance, numbing, and hyperarousal,
|
|
|
Patient is having problems attending to household chores, paying bills, and loss of interest in their usual activities, diagnosis?
|
dementia or depression
|
|
|
What are risk factors for depression?
|
young, female, single, divorced, separated, seriously or chronically ill, or bereaved
|
|
|
What are the risk factors for dementia?
|
old age, 65 then 85, apolipoprotein E, hypertension, and mild cognitive impairment, family Hx - 3x risk,
|
|
|
a patient is drowsy, but opens their eyes and looks at you, responds to question and then falls asleep, what is this called?
|
lethargic
|
|
|
Patient presents with tense posture, restlessness, diagnosis?
|
anxiety
|
|
|
patient presents with singing, dancing, and expansive movements, diagnosis?
|
manic episode
|
|
|
patient presents with one-sided neglect, diagnosis?
|
opposite parietal cortex injury
|
|
|
patient presents with anger, hostility, suspiciousness, and evasiveness, diagnosis?
|
paranoia
|
|
|
Patient presents with a flat affect and remoteness, diagnosis?
|
schizophrenia
|
|
|
What do we anazlyse in a patients speech?
|
quantity
rate laudness articulation of words fluency |
|
|
dysarthria -
|
defective articulation
|
|
|
aphasia -
|
disorder of language
|
|
|
Patient speaks with hesitancies and gaps in the flow and rhythm of words, diagnosis?
|
aphasia
|
|
|
circumlocution -
|
phrase or sentences are substituted for a word the person cannot think of,
example: "what you write with" for "pen" |
|
|
Paraphasias -
|
words are malformed " i write with a den", wrong " i write with a bar" , or invented, I write with a dar
|
|
|
How do you test for word comprehension?
|
ask the patient to follow a one-stage command, then two-stage
|
|
|
What do we anazlyse in a patients speech?
|
quantity
rate laudness articulation of words fluency |
|
|
What are the 5 tests for aphasia?
|
word comprehension
repetition naming reading comprehension writing |
|
|
dysarthria -
|
defective articulation
|
|
|
What are the 2 common kinds of aphasia?
|
wernicke's and broca's
|
|
|
aphasia -
|
disorder of language
|
|
|
abnormalities in thought process: Circumstantiality -
-and what type of people have this? |
speech characterized by indirection and delay in reaching the point because of unneccessary detail, although component of the description have a meaningful connection
- people with obsessions |
|
|
Patient speaks with hesitancies and gaps in the flow and rhythm of words, diagnosis?
|
aphasia
|
|
|
circumlocution -
|
phrase or sentences are substituted for a word the person cannot think of,
example: "what you write with" for "pen" |
|
|
Paraphasias -
|
words are malformed " i write with a den", wrong " i write with a bar" , or invented, I write with a dar
|
|
|
How do you test for word comprehension?
|
ask the patient to follow a one-stage command, then two-stage
|
|
|
What are the 4 tests for aphasia?
|
word comprehension
repetition naming reading comprehension writing |
|
|
What are the 2 common kinds of aphasia?
|
wernicke's and broca's
|
|
|
abnormalities in thought process: Circumstantiality -
-and what type of people have this? |
speech characterized by indirection and delay in reaching the point because of unneccessary detail, although component of the description have a meaningful connection
- people with obsessions |
|
|
What do we anazlyse in a patients speech?
|
quantity
rate laudness articulation of words fluency |
|
|
dysarthria -
|
defective articulation
|
|
|
aphasia -
|
disorder of language
|
|
|
Patient speaks with hesitancies and gaps in the flow and rhythm of words, diagnosis?
|
aphasia
|
|
|
circumlocution -
|
phrase or sentences are substituted for a word the person cannot think of,
example: "what you write with" for "pen" |
|
|
Paraphasias -
|
words are malformed " i write with a den", wrong " i write with a bar" , or invented, I write with a dar
|
|
|
How do you test for word comprehension?
|
ask the patient to follow a one-stage command, then two-stage
|
|
|
What are the 4 tests for aphasia?
|
word comprehension
repetition naming reading comprehension writing |
|
|
What are the 2 common kinds of aphasia?
|
wernicke's and broca's
|
|
|
abnormalities in thought process: Circumstantiality -
-and what type of people have this? |
speech characterized by indirection and delay in reaching the point because of unneccessary detail, although component of the description have a meaningful connection
- people with obsessions |
|
|
Abnormalities in thought: derailment -
and what type of disorders? |
speech in which a person shifts from one subject to others that are unrelated or related only obliquely
schizophrenia, manic episodes, |
|
|
Flight of ideas -
and what type of disorders? |
an almost continous flow of accelerated speech in which a person changes abruptly from topic to topic, understandable associations, play on words, distracting stimuli
manic episodes |
|
|
neologisms -
disorders? |
invented or distorted words, words with new and highly idiosyncratic meanings
schizophrenia, aphasia |
|
|
Incoherence abnormal thought process -
diagnosis? |
speech that is largely incomprehensible because of illogic, lack of meaningful connections
schizophrenia |
|
|
blocking - abnormal thought
diagnosis? |
sudden interruption of speech in midsentence or before completion of an idea,
schizophrenia |
|
|
Confabulation -
disease? |
fabrication of facts of events in response to question, to fill in the gaps in an impaired memory
amnesia |
|
|
perserveration -
disease? |
persistent repetition of words
schizophrenia |
|
|
echolalia -
disease? |
repetition of the wordsa nd phrases of others
schizophrenia |
|
|
clanging -
diagnosis? |
speech in which a person chooses a word on the basis of sound rather than meaning
schizophrenia and manic episodes |
|
|
compulsoins -
diagnosis? |
repetitive behaviors or mental acts
|
|
|
compulsions -
diagnosis? |
repetitive behaviors or mental acts
compulsions, obsessions, phobias, anxieties |
|
|
obsessions -
diagnosis? |
recurrent, uncontrollable thoughts, images, or impulses
|
|
|
Phobias
|
persistent irrational fear, desire to avoid stimulus
|
|
|
anxieties -
|
apprehensions, fears, tensions, or uneasiness
|
|
|
feelings of unreality -
|
things int he environment are strange, unreal, or remote
|
|
|
feelings of depersonalizatoin -
diagnosis? |
sense that one's self is different, changed, or unreal, has lost identity or become detached from one's mind or body
psychotic disorders |
|
|
delusions -
and examples: |
false, fixed, personal beliefs, not shared by other members of the person's culture
-delusion of persecution delusion of grandeur delusional jealousy delusions of reference (external events, object or people have a particular unusual significance) delusions of being controlled somatic delusion - disease, disorder, or physical defect systematized delusion - single delusion with many elaboration or cluster of related delusions around single theme |
|
|
illusions -
diagnosis: |
misinterpretations of real external stimuli
grief reactions, delirium, acute and postrraumatic stress disorders, ans schizophrenia |
|
|
hallucinations
diagnosis? |
subjective sensory perceptions in the absence of relevant external stimuli
-delirium, dementia, PTS, schizophrenia, alcoholism |
|
|
What does digit span test for?
|
attention, say a series of digits starting with two at a time, and then ask patient to repeat numbers
|
|
|
What are 3 tests used to test attention?
|
digit span, serial 7's, and spelling backwards
|
|
|
What do we use to test abstract thinking?
|
ask patient what a proverb means:
-a stitch in time saves nine -don't count your chickens before they're hatched -the proof of the pudding is in the eating |
|
|
What is the diagnosis if a person has a concrete response to the proverbs question?
|
mental retardation, delirium, or dementia, coudl also be educational
|
|
|
A patient responds with bizarre interpretations of a proverb, diagnosis?
|
schizophrenia
|
|
|
Depressed patients are a what level of higher risk for suicide?
|
8x greater than general population
|
|
|
A patient opens their eyes and looks at you, but responds slowly and are somewhat confused, what is this called?
|
obtunded
|
|
|
Patient presents with facial immonbility, diagnosis?
|
Parkinsons
|
|
|
What are 10 abnormal thought processes?
|
circumstantiality
dereailment flight of ideas neologisms incoherence blocking confabulation perservaration echolalia clanging |
|
|
Patient presents with echolalia, diagnosis?
|
abnormal thought process, often occurs in schizophrenia and manic episodes
|
|
|
What are 7 types of abnormal thought contents?
|
compulsions
obsessions phobias anxieties feelings of unreality feelings of depersonalization delusions |
|
|
What are 2 abnormalities in perception?
|
illusions
hallucinations |
|
|
What are two types of large vessel vasculitis?
|
Takayasu's Arteritis and Giant Cell Arteritis
|
|
|
What are 4 examples of medium vessel vasculitis?
|
polyarteritis nodosa
kawasaki's disease buerger's disease DNS vasculitis |
|
|
What are 6 examples of small vessel vasculitis?
|
hypersensitivity vasculitis
vryglobulinemia henoch-schonlein purpura wegener's granulomatosis microscropic polyangiitis churg-Strauss vasculitis |
|
|
What are 9 presentations that will cause you to suspect a vasculitis?
|
1. multisystem disease
2. unexplained constitutional signs and symptoms 3. skin lesions 4. ischemic vascular changes: (gangrene, claudication, reynaud's, livedo reicularis) 5. glomerulonephritis 6. mononeuritis multiplox (wrist drop, ankle drop) 7. Myalgia, arthralgia/arthritis 8. abdominal pain (intestinal angina - eat and shortly after stomach hurts then will go away) 9. testicular pain |
|
|
What are 9 mimickers of vasculitis and their underlying causes?
|
1. New heart murmur - SBE
2. Necrosis of lower extremity digits - Cholesterol emboli (can occur after a catheter has been put in/taken out) 3. splinter hemorrhages - SBE 4. liver dysfunction - hep C 5. drug abue - HIV, Hep C, cocaine 6. history of cancer 7. unusually high fever - SBE 8. high risk sexual activity - HIV |
|
|
52 yo woman presents with jaw claudication, diplopia, scalp tenderness, weight loss, and fatigue, diagnosis?
|
Giant Cell arteritis: Temporal Arteritis
|
|
|
What is polymyalgia Rheumatica and what is it associated with?
|
pain and stiffness in proximal muscle groups: shoulders and hips
associated with Giant Cell arteritis: 50% of people with Giant cell arteritis will have polymyalgia rheumatica, not true in the reverse but be precautious and describe symptoms of giant cell so patient is aware |
|
|
What is amaurosis fugax ? and what is it associated with?
|
- transient loss of vision, associated with giant cell arteritis
|
|
|
Patient presents with:
new headache jaw claudication unexplained fever poliymyalgia rheumatica, diagnosis? |
Giant cell arteritis
|
|
|
How do we confirm diagnosis of Giant cell arteritis?
|
check ESR, should be elevated:
male = age/2 female =(age + 10)/ 2 BIOPSY:3-4cm biopsy, may need to biopsy the other side, obtain biopsy within 7-14 days of starting steroids - if really think it is giant cell go ahead and start Rx on prednisone |
|
|
What is treatment for Giant Cell Arteritis? and what does this do to disease?
|
Prednisone:
systemic symptoms improve quickly <72 hours local symptoms gradually can give asprin to prevent, minimalize blindness |
|
|
45 yo male presents with mononeuritis multiplex, palpable purpura, myalgias, abdominal pain and renal failure, diagnosis?
|
polyarteritis nodosa
|
|
|
Clinical complications of Polyarteritis Nodosa are?
|
CHF, MI
Seizures, stroke interstitial pneumonitis jaw claudication testicular pain retinal hemorrhage hypertension |
|
|
Diagnosis of Polyarteritis Nodosa:
|
biopsy symptomatic site
angiogram hep B (seen in 10-50%) ANCA negative beading of blood vessels - can't biopsy, but can look at if they are deeper |
|
|
Treatment of Polyarteritis Nodosa:
|
Prednisone
Cytoxan |
|
|
What type of vasculitis can Hep B cause? and when?
|
associated with polyarterisis nodosa
- within 6 months of Hep B infection |
|
|
What are the 3 things you want to rule out of mickers in polyarteritis nodosa?
|
Hep B
HIV Acute Bacterial endocarditis |
|
|
What is the Rx for Polyarteritis nodosa?
|
prednisone, plasmapheresis, antiviral agents
|
|
|
What are the 3 places Wegener's Granulomatosis presents?
|
1. upper respiratory tract and lower respiratory tract
2. medium vessels 3. glomerulonephritis |
|
|
42 yo patient presents with chronic purulent nasal discharge, epistaxis, otitis media, and subglottic stenosis,
diagnosis? |
Wegener's granulomatosis
|
|
|
What 9 upper respiratory tract symptoms are found in wegener's granulomatosis?
|
1. chronic sinusitis
2. chronic purulent nasal discharge 3. epistaxis 4. nasal ulcerations 5. nasal septum perforation 6. cartilage disruption (saddle-nose deformity) 7. oral ulcers (painful or painless) 8. otitis media 9. subglottic stenosis (stridor and respiratory difficulties) |
|
|
What other pathologies can cause saddle nose deformity?
|
wegeners granulomatosis
syphilis leprosea - all of which infect the cartilage and cause deformity |
|
|
What are symtoms of lower respiratory tract wegener's involvement?
|
asymptomatic
chronic cough alveolar hemorrhage (shows up on X-ray) pneumonitis respiratory insufficiency pleuritis |
|
|
What are the findings of renal involvement in Wegener's Granulomatosis?
|
pauci-immune necrotizing glomerulonephritis
asymptomatic active urine sediment hematuria pyuria proteinuria casts (rbc casts) |
|
|
What is proptosis?
|
retro-orbital pseudotumor
|
|
|
What ANCA is most associated with Wegener's granulomatosis?
|
anti proteinase 3 : c-ANCA
|
|
|
What ANCA is most associated with Microscropic polyangiitis?
|
anti-myeloperoxidase: p-ANCA
|
|
|
What ANCA is most associated with Churg-Strauss disease?
|
p-ANCA
|
|
|
What is the treatment for generalized WG?
|
cytoxan and predinisone
plus bactrim- prophylaxis against pneumocystis carinii |
|
|
What is the Rx for limited WG? and specifically what is involved?
|
severe lower respiratory tract involvement
cytoxan and prednisone plus bactrim |
|
|
What is the Rx for Milder WG?
and what is the involvement of the disease? |
methotrexate or cyclosporin
recurrent upper respiratory infections, recurrent otitis media |
|
|
Child presents with conjunctivitis, fever, strawberry tongue, cervial lymphadenopathy, rash of the trunk, and desquamation, diagnosis?
and what is the problem in this disease, major risk factor? |
Kawasaki's
coronary arteritis --> mycocarditis, pericarditis, and arteritis predisposed to aneurysms in up to 20% |
|
|
Young male presents with claudication of feet and hands, long term, heavy smoker, diagnosis?
and what is the Rx? |
Beurger's or Thromboangiitis Obliterans
- completed discontinuation of smoking or tobacco use |
|
|
delirium -
|
a syndrome of transient disorder of brain funciton, manifested by global congitive impairment and other behavioral phenomena
A disturbance of consciousness, attention, cognition and perception. |
|
|
Presentation of delirium:
|
Develops over a short period of time - usually hours to days and fluctuates during the course of a given day.
Frequently represents a sudden and significant decline from a previous level of functioning and CANNOT be better accounted for by a preexisting dementia. |
|
|
Finding of the cause of delirium invovles?
|
There is usually evidence from the history, physical exam or lab tests that the delirium is a direct physiological consequence of a general medical condition, substance intoxication or withdrawal, use of medication, toxin exposure or combination of these factors.
|
|
|
Prevalence of delirium:
|
Hospitalized, medically ill - 10 - 30%
Hospitalized, elderly - 10 - 40% Hospitalized, cancer patients - 25% Hospitalized, AIDS patients - 30 - 40% Post-operative patients - 51% Terminally ill - 80% when near death |
|
|
Signs and Symptoms of delirium are?
|
decreased clarity or awareness of the environment
decreased ability to focus, sustain or shift attention poor memory (usually recent memory) disorientation (to time or place) incoherent dysarthria dysnomia dysgraphia frank aphasia perceptual disturbances - illusions, hallucinations, misinterpretations paranoia disturbances of sleep - daytime sleepiness, nighttime agitation, reversal of day & night cycle hyper/hypoalert hyper/hypoactive agitated or lethargic anxiety, fearfulness, depression, irritability, anger, euphoria, apathy |
|
|
What are the risk factors for people that could develop delirium?
|
surgical patients - hip and cardiotomy
transplant patients - prednisone can cause people to have lots of psychiatric manifestations burn victims dialysis patients/renal failure - toxins can build up in between, and cause psychosis pre-existing dementia “poly-pharmacy” CNS lesions liver failure elderly |
|
|
What are the 4 top etiologies for delirium?
|
1. General Medical Condition - CNS, metabolic, cardiopulmonary, systemic illness
2. Substance Use or Withdrawal 3. Multiple etiologies 4. Unclear etiology |
|
|
What are the 7 differential diagnosis that you have to exclude before landing on delirium?
|
1. CNS disorder - trauma, seizure, postictal, vascular disease, neoplasm
2. Metabolic - renal or hepatic failure, anemia, hypoxia, hypoglycemia, thiamine deficiency, acid-base abnormality, fluid or electrolyte imbalance 3. Cardiopulmonary - MI, CHF, arrhythmia, shock, respiratory failure 4. Systemic Illness - infection, neoplasm, severe trauma, post-op states, sensory deprivation, temperature dysregulation 5. Drugs of Abuse 6. Medications - anticholinergics, antihistaminics, steroids, etc. 7. Toxins - carbon monoxide, organic solvents, carbon dioxide, insectisides |
|
|
What are the four domains to assess in the "work-up"?
|
1. Physical Status
- good history and physical (neuro esp.) - review of op notes, anesthesia used - careful review of chart notes - careful review of MEDICATIONS 2. Mental Status - thorough interview and mental status exam 3. Basic Laboratory tests - electrolytes, glucose, calcium, albumin, BUN, creatinine, AST, ALT, bilirubin, Mg, PO4, alkaline phosphatase - CBC - EKG - O2 saturation or ABG - urinalysis 4. Additional labs tests if indicated clinically - urine drug screen - urine culture - heavy metal screen - VDRL - B12 and folate levels 4. Additional lab tests (cont’d) - ammonia level - blood cultures if febrile - lumbar puncture - head CT or MRI - EEG - serum levels of medications - lithium, digoxin, theophylline, cyclosporine, etc. |
|
|
What are the areas to ask about in the mental status exam?
|
JOIMAT
judgment, orientation, information relay (speech and meaning)/ impulse control/insight, memory/mood, appearance/affect, thought process/content SMARTJPIC speech, mood/memory, affect/appearance/attitude, reliability, thought process/content, judgment, perception of reality, insight/impulse control, cognition General description – appearance, behavior, attitude towards examiner Speech- quantity, rate, and quality Mood – patient’s internal emotional state Affect – objective appearance Thought disturbance – process e.g. loosening of associations, flight of ideas, thought blocking, neologisms Thought disturbance – content e.g. delusions, obsessions, compulsions, phobias, ideas of reference, paranoia Perceptual Disturbance – hallucination, illusions Sensorium and cognition – orientation, memory, attention, concentration, calculation, reading and writing, visuospatial relations and language. Impulse Control – include here issues about suicidal and homicidal ideations. Judgment and Insight Reliability |
|
|
What is the typical course of delirium? and how does it affect people differently?
|
Some patients may exhibit prodromal course 1-3 days prior to delirium.
Duration of sx’s - >1 week to < 2 months Typically sx’s resolve within 10-12 days Majority recover, but some may progress to stupor, coma, seizures or death. Full recovery less likely in the elderly - only 4-40% show full recovery by time of discharge. |
|
|
What is the mortality like with delirium?
|
in elderly - estimates between 22 - 76 % chance of dying during that hospital stay
after hospitalization - 25 % die within 6 months |
|
|
What is the morbidity of delirium?
|
Significant morbidity:
increased rate of pneumonia increased rate of decubitus ulcers longer hospital stays post-op complications seizures |
|
|
What is the 3 step treatment for delirium?
|
1. Environmental
- limit too much noise - avoid “too quiet” - replace glasses and hearing aids - more familiar and less “alien” - nightlights 2. Supportive - structure and support for the patient - provide reorientation frequently - reassure pt. that sx’s are temporary and reversible - support and education for the family 3. Somatic Interventions - treat the underlying medical condition - antipsychotics (high-potency) e.g. haloperidol, risperidone - benzodiazepines - never use alone - primarily for EtOH withdrawal |
