דליריום חדש

Question 1

גורמים

Answer 1

תרופות
אלכוהול
אנדוקריני - היפותירואיד, היפרתירואיד, היפוגליקמיה, היפרגליקמיה
אלקטרוליטרי - היפונתרמיה, היפרקלצמיה, היפוקלצמיה
חסר תזונתי - אנצפלופתית וורניקה, בי 12
אס"ק - אנצפלופתיה כבדית, כלייתית, פגיעה פולמונרית, השתלת איברים
מנינגיטיס, אנצפליטיס
גרורות למוח
ספסיס
וסקולרי - שבץ, דימום סאב ארכנואידי
לופוס, וסקוליטיס
DIC, TTP
חבלת ראש
לאחר פרכוס
פסיכיאטרי

Question 2

הרעלת אלכוהול

Answer 2

ניסטגמוס, דיסארתריה, אטקסיה
סיכון לחבלות ראש, היפוגליקמיה
שימוש כרוני - סיכון למנינגיטיס וחסר תזונתי

Question 3

סכנות בגמילה מאלכוהול כתלות בזמן

Answer 3

Tremulousness & Hallucinations - first few days
Seizures - 1-3 days
Delirium termens - day 3-4

Question 4

Tremulousness & Hallucinations

Answer 4

self-limited
tremulousness, agitation, anorexia, nausea, insomnia, tachycardia, and hypertension.
visual hallucinations- 25% of patients.
treat: Lorazepam or diazepam IV every 5 to 15 minutes until calm and than hourly

Question 5

Seizures alcohol withdrawal

Answer 5

from toses with seizures:
40% - single seizure
90% have between one and six seizures. 
last 6 hours
Treatment is not usually required, 
if prolonged, more than six seizures, status epilepticus, - search for other causes

Question 6

Delirium Tremens

Answer 6

most serious ethanol withdrawal syndrome
lasts for up to 72 hours.
confusion, agitation, fever, sweating, tachycardia, hypertension, and hallucinations.
Death may result from concomitant infection, pancreatitis, cardiovascular collapse, or trauma. Treatment: lorazepam or diazepam
fluid and electrolyte
beta blocker for hypertension or tachycardia

Question 7

HYPOTHYROIDISM

Answer 7

1. most common cause - Hashimoto thyroiditis
2. fatigue, depression, weight gain, constipation, bradycardia, dry skin, and hair loss
3. may produce a confusional state, coma, or dementia. 4. dysarthria, deafness, or ataxia,
4. most characteristic abnormality - delayed relaxation of the tendon reflexes.
5. low serum thyroid hormone, elevated TSH
6. CSF pressure & protein - elevated
7. Hypothermia, hypoglycemia, hyponatremia, and respiratory acidosis may occur.

——— associated with entrapment neuropathy, especially carpal tunnel syndrome—————–

Question 8

treatment of severe myxedema

Answer 8

IV levothyroxine and hydrocortisone

Question 9

HYPERTHYROIDISM

Answer 9

most often - Graves disease
anxiety, palpitations, sweating, and weight loss.
younger patients - agitation, hallucinations, psychosis Old - apathetic and depressed
Neurologic examination - tremor and hyperreflexia
elevated serum T 4 , free T 4 , T 3 and free T 3
low TSH.

Question 10

HYPOGLYCEMIA - clinical findings

Answer 10

Early signs o- tachycardia, sweating, and pupillary dilation,
Late - confusional state

Signs of brainstem dysfunction - abnormal ocular movements and loss of pupillary reflexes.
Respiratory depression, bradycardia, hypotonia, and hyporeflexia ultimately supervene,

Question 11

Hypoglycemic coma

Answer 11

focal neurologic signs

focal or generalized seizures.

Question 12

Hypoglycemia treatment

Answer 12

glucose IV - 50 mL of 50% dextrose

Question 13

Hyperglycemia clinical findings

Answer 13

blurred vision
dry skin
anorexia
polyuria
polydipsia. 
hypotension 
Kussmaul respiration 
mild confusion to coma. 
Focal neurologic signs 
seizures

Question 14

Hyperglycemia - treatment

Answer 14

IV insulin
fluids
K+
antibiotics

Question 15

Hypoadrenalisem

Answer 15

addison disease
fatigue, weakness, weight loss, anorexia, hyperpigmentation of the skin, hypotension, nausea and vomiting, abdominal pain, and diarrhea or constipation.

Treatment - hydrocortisone and correction of hypovolemia, hypoglycemia, electrolyte disturbances, and precipitating illnesses.

Question 16

HYPERADRENALISM - Cushing syndrome

clinical findings and cause

Answer 16

exogenous glucocorticoids.
moon facies with facial flushing
truncal obesity, hirsutism, menstrual irregularities, hypertension, weakness,
cutaneous striae, acne, and ecchymoses.

depression or euphoria, anxiety, irritability, memory impairment, psychosis, delusions, and hallucinations.

Question 17

HYPERADRENALISM - Cushing syndrome

diagnosis

Answer 17

dexamethasone suppression test,
24-hour urine free cortisol level, or late night salivary cortisol assay.
ACTH levels - primary or secondary
MRI - localize pituitary or other ACTH-secreting tumors.

Question 18

HYPERCALCEMIA causes

Answer 18

primary hyperparathyroidism,
multiple myeloma,
PTH related secreting tumors

Question 19

Hypercalcemia Symptoms

Answer 19

thirst, polyuria, constipation, nausea and vomiting, abdominal pain, anorexia, and flank pain from nephrolithiasis.

above 8.5 mEq/L - headache, weakness, and lethargy.
Seizures are rare.

short QT interval

Question 20

Hypocalcemia symptoms

Answer 20

irritability, delirium, psychosis with hallucinations, depression, nausea and vomiting, abdominal pain, and paresthesias of the circumoral region and distal extremities.
Chvostek sign 
 Trousseau sign 
Seizures - life-threatening.
 4.5 mEq/L)
prolonged QT interval.

Question 21

WERNICKE ENCEPHALOPATHY - causes, pathology

Answer 21

usually a complication of chronic alcoholism
malnutrition - cancer, after bariatric surgery.
deficiency of thiamine (vitamin B 1 ).

neuronal loss, demyelination, and gliosis in periventricular gray matter.
Proliferation of small blood vessels and petechial hemorrhages may be seen.
medial thalamus, mammillary bodies, periaqueductal gray matter, cerebellar vermis, and oculomotor, abducens, and vestibular nuclei.

Question 22

WERNICKE ENCEPHALOPATHY - clinical findings

Answer 22

ophthalmoplegia, ataxia , and confusional state.
opthalmo - nystagmus, IV pulsy, gaze palsy (horizontal & vertical)

Hypothermia and hypotension may occur - hypothalamic involvement.

macrocytic anemia,
MRI - atrophy of the mammillary bodies

Question 23

WERNICKE ENCEPHALOPATHY - treatment

Answer 23

thiamine
opthalmoplegia and atazia resolve after 1 day
ataxia - 1 month

Question 24

VITAMIN B 12 DEFICIENCY

Answer 24

peripheral neuropathy, 
corticospinal tracts and dorsal columns,
nutritional amblyopia (visual loss), 
cognitive dysfunction 
macrocytic anemia. 
main cause - pernicious anemia , a defect in the production of intrinsic factor associated with atrophic gastritis, anti-parietal cell antibodies, and achlorhydria, 
gastric resection and vegan diet.

Question 25

B12 clinical findings

Answer 25

Distal paresthesias, gait ataxia, a bandlike sensation of tightness around the trunk or limbs, and Lhermitte sign (an electric shock–like sensation along the spine precipitated by neck flexion)

low-grade fever, glossitis, lemon-yellow discoloration of the skin, and cutaneous hyperpigmentation.

Associated peripheral nerve involvement may cause loss of tendon reflexes in the legs and urinary retention.

Question 26

B12 - lab

Answer 26

macrocytic anemia
leukopenia
hypersegmented neutrophils
thrombocytopenia

Question 27

Schilling test

Answer 27

determines whether defective intestinal absorption of vitamin B 12 (as in pernicious anemia) is the cause of B12 deficiency

Question 28

HEPATIC ENCEPHALOPATHY

cause, symptoms, lab

Answer 28

complication of cirrhosis, portosystemic shunting, chronic active hepatitis, hepatic necrosis after viral hepatitis.
ammonia and other toxins diffuse into the brain
Symptoms - nausea, anorexia, and weight loss. GI bleeding, agitation, and coma.

asterixis - a flapping tremor of the outstretched, dorsiflexed hands or feet

LAB - elevated bilirubin, transaminsae, PT, PTT, respiratory alkalosis
CSF - elevated glutamine - most specific!!!

Question 29

HEPATIC ENCEPHALOPATHY - treatment

Answer 29

underlying cause
vitamin E
FFP
rifaxamin - antibiotic that reduces ammonia-forming bacteria in the colon
lactulose

Question 30

UREMIA Renal failure

Answer 30

may produce encephalopathy
hyperventilation
motor manifestations.
seizures and focal neurologic signs are common,

Laboratory - elevated urea, creatinine, and potassium, and metabolic acidosis,

EEG - diffusely slow and may show triphasic waves or paroxysmal spikes or sharp waves.
management - treat the cause.
hydration, protein and salt restriction, and treatment of complications such as seizures.

Dialysis itself can produce an encephalopathy

Question 31

POSTINFECTIOUS ENCEPHALOMYELITIS

Answer 31

immune-mediated demyelinating disorder
1 month after a bacterial or viral infection or vaccination. Clinical features include confusion or coma and focal neurologic deficits

1. acute disseminated encephalomyelitis -
   MRI -multifocal demyelinating lesions
   CSF may show lymphocytic, polymorphonuclear pleocytosis.
2. Bickerstaff brainstem encephalitis
   similar but affects the brainstem and cerebellum
3. acute hemorrhagic leukoencephalitis (high mortality!), MRI -bihemispheric demyelinating lesions associated with hemorrhage and edema,
   CSF - may contain red blood cells.
   Treatment - methylprednisolone 3 to 5 days, followed by prednisone 4 to 6 weeks.

Question 32

SEPSIS-ASSOCIATED ENCEPHALOPATHY

Answer 32

impaired cerebral blood flow, 
BBB disruption 
cerebral edema. 
Gram-negative 
CSF examination - exclude meningitis. 
EEG abnormal. 
supportive treatment 
Mortality is high, but can be reduced by prompt diagnosis and treatment.

Question 33

HYPERTENSIVE ENCEPHALOPATHY

Answer 33

A sudden increase in blood pressure,
develop hours to days.
risk - acute glomerulonephritis or eclampsia.

Vomiting, visual disturbances, focal neurologic deficits, and focal or generalized seizures can occur.
BP - 250/150
papilledema, retinal hemorrhages,

Stroke and subarachnoid hemorrhage risk
diagnosis resolution after lowering blood pressure

Question 34

SLE

Answer 34

autoimmune
young women
skin rash, arthritis, serositis, nephritis, anemia, leukopenia, and thrombocytopenia.
neurologic involvement in 37% to 75%
most common autoimmune cause of encephalopathy.

Laboratory - antinuclear antibodies, anti-native DNA antibodies, anti-Sm antibodies, and false-positive serologic test for syphilis.

Cerebral lupus is treated with corticosteroids,
Seizures are treated with anticonvulsants.
Neurologic symptoms improve in 80%
may also resolve without treatment.

Question 35

HYPONATREMIA

causes, symptoms, neurologic signs and treatment

Answer 35

brain swelling
Causes - hypothyroidism, adrenal insufficiency, drugs (eg, thiazide diuretics, nonsteriodal anti-inflammatory drugs, ecstasy), SIADH.

symptoms - headache, lethargy, confusion, weakness, muscle cramps, nausea, and vomiting.

Neurologic signs - confusional state or coma, papilledema, tremor, asterixis, rigidity, extensor plantar responses, focal or generalized seizures, and occasionally focal neurologic deficits.

Neurologic complications - Na less than 120

Treatment - underlying cause
Immediate management - water restriction, hypertonic saline with or without intravenous furosemide.

Question 36

Vitamin B6 deficiency

Answer 36

classic clinical syndrome is a seborrhoeic dermatitis-like eruption, atrophic glossitis with ulceration, angular cheilitis, conjunctivitis, intertrigo, and neurologic symptoms of somnolence, confusion, and neuropathy

Question 37

פגיעות בדליריום

Answer 37

ערנות, גירוי, אוריאנטציה, התמצאות, קשב

Question 38

HYPONATREMIA -

Excessively rapid correction complications

Answer 38

central pontine myelinolysis (osmotic demyelination syndrome ),

confusional state, paraparesis or quad-riparesis, dysarthria, dysphagia, hyper- or hyporeflexia, and extensor plantar responses.
Severe cases - locked-in syndrome and coma

MRI may show pontine and extrapontine white matter lesions.
no treatment for central pontine myelinolysis, so prevention is essential
rasie serumn NA at rate not exceeding 8 mmol/L/d.

Question 39

MCA

vessels anatomy - function

Answer 39

Vessels:
Ascending - rolandi - broca, precentral, postcentral
Descending - parietal, temporal, optic radiation, visual cortex, WERNIKE
Leticulostriate - basal nucli

Question 40

MCA ischemia

Clinical findings by vessel

Answer 40

Rolandi, ascending- hemiparesis contra lateral without leg!!!
Hemihipoesthesis contra lateral
Motor aphasia (broca)
Descending- contralateral hemonymus hemianopsia (temporal)
Wernike - sensory aphasia
Parietal - neglect (non dominant lobe), agraphia…
Lenticulostriate - total hemianopsia
Aphasia
Hemihipoesthesis

Question 41

ACA ischemia

Clinical findings

Answer 41

Blood supply to frontal lobe and precentral gyrous of leg
Contralateral monoparesis of leg
Urine incontinance
Cognition - disinhibition, apathy (upper part)
Behave ( lower part)

Question 42

בדיקת מעבדה הכי ספציפית לאנצפלופטיה כבדית

Answer 42

גלוטמין נמוך - CSF