Delirium

Front 1

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?

- Biggest risk factor?

- Other common causes?

- EEG findings?

- Treatment?

Back 1

First step:

- In her case, UA and culture

- Work up also includes glucose, Na, blood cultures, B12, RPR

- Make sure to look at med list- benadryl, opiates, benzos.

Biggest risk factor:

- Age. Underlying dementia is the second biggest.

Other common causes:

- Acute substance withdrawal.

- Look for it on the 2nd or 3rd post-op day in alcoholic.

EEG Findings:

- Diffuse background slowing of background rhythm.

- Psychosis has normal EEG

Treatment:

- Reduce excessive stimuli, calendar and clock to orient patient. Stop unnecessary meds. Give haloperidol if agitated.

Front 2

A 78 y/o F presents w/ memory loss, aphasia, apraxia, and gets lost while driving..

- Diagnosis?

- Pathology?

- Genes?

- Treatment?

Back 2

Diagnosis:

- Alzheimer's Dementia. MC type.

- On MMSE, prompting does not increase recall.

Pathology:

- Global brain atrophy.

- B-amyloid plaques or tau tangles.

Genes:

- APP (on chromosome 21), ApoE E2

Treatment:

- Donepezil, rivastigmine, galantamine (diarrhea)

- Memantine.

Front 3

A 78 y/o F presents w/ memory loss and becomes more sexually explicit, apathy.

- Diagnosis?

- Pathology?

- Treatment?

Back 3

Diagnosis:

- Frontotemporal Dementia (Pick's disease)

Pathology:

- Lobar atrophy

- Intra-neuronal silver staining inclusions

Treatment:

- Olanzepine for severe disinhibition.

Front 4

A 78 y/o F presents w/ memory loss, and fluctuations in consciousness, visual hallucinations and shuffling gait.

- Diagnosis?

- Pathology?

- Treatment?

Back 4

Diagnosis:

- Lewy body dementia

Pathology:

- Intra cytoplasmic alpha-synuclein inclusions in neocortex

Treatment:

- Give Ach-Ease inhibitors. NOT L-dopa. Avoid neuroleptics.

Front 5

A 78 y/o F presents w/ memory loss and sudden, step-wise decrease in memory/cognitions.

- Diagnosis?

Back 5

Vascular Dementia.

Front 6

A 78 y/o F presents w/ memory loss, plus loss of vibration sense, labile affect. Pupil that accommodates but doesn't react.

- Diagnosis?

- Dx how?

- Tx?

Back 6

Diagnosis:

- Tertiary syphilis

Diagnose how?

- +RPR, VDRL. Do spinal tap to look for spirochetes.

Tx:

- IV PNC. If PNC-allergic, must desensitize.

Front 7

A 78 y/o F presents w/ memory loss, plus myoclonus, startle response, seizures. Recently had a corneal transplant.

- Diagnosis

- Pathology?

- EEG findings?

Back 7

Diagnosis:

- Creutzfeldt Jakob

Pathology:

- Spongiform encephalopathy

EEG Findings:

- Triphasic bursts

Front 8

A 78 y/o F presents w/ memory loss, plus incontinence, gait disturbance/frequency falls, and rapidly developing dementia:

- Diagnosis?

- Diagnose how?

- Tx?

Back 8

Diagnosis:

- Normal pressure hydrocephalus

Diagnose how:

- CT/MRI shows hydrocephalus, spinal tap shows normal opening pressure

Treatment:

- Ventriculoperitoneal shunt improves cognitive function in 50-67% of patients.

Front 9

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 his last drink?

- How long till he develops confusion, fluctuations in consciousness and the feeling of ants crawling on him?

Back 9

- Around 12-24 hours. (bimodal peak at 8 hours and 48 hours)

- 48-72 hours since last drink is when delirium tremens usually start.

Front 10

His blood alcohol level is 225mg/mL. How long till its out of his system?

Back 10

Around 9 hours. Alcohol is metabolized by zero order kinetics (same amount/unit time = 25 mg/hr).

Front 11

If an alcoholic, and meds include propranolol, lactulose, and allopurinol, what would be the best sign to monitor for his withdrawals?

Back 11

Beta-blockers mask the signs of autonomic hyperactivity, but you can follow hyperreflexia to dose the benzos during w/drawal.

Front 12

Alcoholic:

- Best initial treatment of our patient?

- What if he's a Child's class C cirrhotic?

Back 12

Best initial treatment:

- Diazepam or chlordiazepoxide b/c they have 80 & 120hr ½-lives respectively.

What if he's a Child's class C cirrhotic?

- Lorazepam, oxazepam or temazepam because they are glucuronidated prior to elimination

Front 13

What is the most specific test for ETOH consumption in the past 10 days?

Back 13

Carbohydrate-deficient transferrin.

Less specific-elevated GGT and AST more than twice ALT.

Front 14

A patient comes in with confusion, ataxia, and crossed eyes on PE.

- Diagnosis?

- Cause?

- Complication?

Back 14

Diagnosis:

- Wernicke Encephalopathy

Cause:

- Thiamine deficiency. Give thiamine first, then glucose containing fluids.

Complication:

- Can progress to Korsakoff's syndrome (irreversible damage to maxillary bodies, etc.)- apathy, anter/retrograde amnesia and confabulation. Can see MB atrophy on MRI.

Front 15

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?

- You realize his pupils are dilated. Does that change your diagnosis?

- What sxs do you expect as he starts to withdrawal?

- Treatment?

Back 15

Best first step:

- Intubate the patient. Then give IV or IM naloxone(full mu-opiate antagonist)

Dilated pupils...:

- No. The hypoxia 2/2 respiratory depression can cause hypoxia

What sxs to expect w/ withdrawal:

- hypoxiaJoint and muscle pain, photophobia, goosebumps, diarrhea, tachycardia, HTN, GI cramps, dilated pupils, anxiety/depression

Treatment:

- Clonidine for autonomic sxs, ibuprofen for muscle cramps, loperimide for diarrhea.

- Methadone, buprenorphrine or Naltrexone can be used for long-term dependence.

Front 16

Pt presents w/ horizontal nystagmus, dilated pupils, ataxia, and acute psychosis...

- Diagnosis?

- Tx?

Back 16

Hallucinogen (PCP) intoxication.

Can use haloperidol for acute psychosis.

Front 17

Pt presents s/p MVC with injected conjunctiva, sedation and is asking for Doritos (cool ranch plz).

- Diagnosis?

Back 17

Cannabis intoxication.

Front 18

Pt presents with SI, hypersomnia, depression and anergia.

- Diagnosis?

Back 18

Cocaine/Amphetamine withdrawal

Front 19

Pt presents with dilated pupils, seizure, tachycardia and HTN.

- Likely diagnosis?

- Best first test?

- Tx of HTN and tachycardia?

Back 19

Diagnosis:

- Cocaine/Amphetamine intoxication

Best first test:

- EKG then urine tox screen. Treat seizure with lorazepam.

Treatment of HTN and tachycardia:

- CCB. BB are CONTRAINDICATED!