EMQ Part 1 Flashcards
Most likely diagnosis- 8 year old girl living with mother refuses to go to school and complains of stomach pain when she has to go? Social phobia? Acute stress disorder? Specific phobia? PTSD? Panic disorder with agoraphobia? Separation Anxiety NOS, medical condition, panic w/o agoraphobia, GAD
Separation Anxiety disorder
Young boy living in a refuge for 2 weeks is mute and withdrawn. He is unable to sleep because of recurring nightmares. Started 10 days after being admitted to a refuge. Social phobia? Acute stress disorder? Specific phobia? PTSD? Panic disorder with agoraphobia? Separation Anxiety NOS, medical condition, panic w/o agoraphobia, GAD
Acute stress disorder
Young lady who has attacks of anxiety now refuses to travel in public transport Social phobia? Acute stress disorder? Specific phobia? PTSD? Panic disorder with agoraphobia? Separation Anxiety NOS, medical condition, panic w/o agoraphobia, GAD
Panic disorder with agoraphobia
A boy who stutters refuses to speak in class due to embarrassment of his stuttering Social phobia? Acute stress disorder? Specific phobia? PTSD? Panic disorder with agoraphobia? Separation Anxiety NOS, medical condition, panic w/o agoraphobia, GAD
Social anxiety disorder
Temporo-parietal hypoperfusion on SPECT
FTD, late life depression, Schizophrenia, Neurosyphillis, Alzheimer’s disease, MS, Bipolar, complex partial seizures, LBD, CJD
Alzheimers: On CT axial- generalised cerebral atrophy and ventricular enlargment. Angled axial- reduced medial temporal lobe width. MRI- MTL atrophy. Periventricular white matter lesions. SPECT- Temporo-parietal hypoperfusion.
In vascular- infarcts with white matter lesions, SPECT= patchy multi-focal pattern.
In LBD- gen ventricular enlargement, relative preserve of MTL. SImilar WM changes. SPECT= posterior deficits, =ve D2 uptake.
FTD= FL atrophy, anterior perfusion deficits
Deep white matter hyperintensities
FTD, late life depression, Schizophrenia, Neurosyphillis, Alzheimer’s disease, MS, Bipolar, complex partial seizures, LBD, CJD
Late life depression-> associated with deep white matter hyperintensities on T2 weighted brain MRI
Reduced D2 receptor density and DAT
FTD, late life depression, Schizophrenia, Neurosyphillis, Alzheimer’s disease, MS, Bipolar, complex partial seizures, LBD, CJD
Lewy body dementia
High intensity signal in the thalamus
FTD, late life depression, Schizophrenia, Neurosyphillis, Alzheimer’s disease, MS, Bipolar, complex partial seizures, LBD, CJD
Creutzfeld Jakob variant-> Pulvinar sign= high intensity signal in the pulvinar nucleus of the thalamus
Mesial temporal sclerosis on MRI
FTD, late life depression, Schizophrenia, Neurosyphillis, Alzheimer’s disease, MS, Bipolar, complex partial seizures, LBD, CJD
Complex partial seizure- Temporal lobe epilepsy. MTS commonly referred to as hippocampal sclerosis, most common associate with intractable temporal lobe epilepsy.
Limbic encephalitis (PNS) can show high T2 signal withough enhancement. Signal similar to HSV encephalitis, changes most evident in mesial temporal lobes. BL involement most common
Match terms:
Can you show me how you brush your teeth? He understood but unable to perform
Dressing apraxia, ideomotor, constructional, ideational, conduction, dissociation, conceptual, oral, limb kinetic, gait
Ideomotor apraxia
Unable to cary out coordinated sequences of actions- taking a match from the box and lighting it
Ideational apraxia
On asking the patient to brush his teeth he picks up a pen to brush his teeth
Dressing apraxia, ideomotor, constructional, ideational, conduction, dissociation, conceptual, oral, limb kinetic, gait
Conceptual apraxia- patients make content and tool selection erros, may not recall the type of actions associated with certain tools.
Conduction apraxia- greater impairment when imitating movements than when pantomiming to command
These waves attenuate on opening the eyes
Alpha, lambda, sleep spindles, K complexes, Mu rhythm, Delta waves, theta, beta waves
Alpha 8-12 Hz, present on closing eyes and pathalogic in coma
Present in young children and in deep sleep
Alpha, lambda, sleep spindles, K complexes, Mu rhythm, Delta waves, theta, beta waves
Delta 3Hz in slow wave sleep, babies. Pathalogic- subcortical lesions diffuse lesions, metabolic encephalopathy, hydrocephalus, deep midline lesions
Brief bursts of slow waves during stage 2 NREM
K complexes- 12-14 Hz
Absent in NREM sleep in patients with Schizophrenia
12-14 Hz waves
Absent in NREM sleep in patients with Schizophrenia
Sleep spindles
Rate limiting step in DA metabolism
Tryptophan decarboxylase, Serine trans-hydroxymethylase, DOPA decarboxylase, Glutamate decarboxylase, monoamine oxidase, COMT, monoamine oxidase, phenylethanolamine N methyl transferase, tyrosine hydroxylase
Tyrosine hydroxylase.
DA metabolism:
L-Phenylalanine is converted into L-tyrosine by the enzyme phenylalanine hydroxylase, with molecular oxygen (O2) and tetrahydrobiopterin as cofactors. L-Tyrosine is converted into L-DOPA by the enzyme tyrosine hydroxylase, with tetrahydrobiopterin, O2, and iron (Fe2+) as cofactors.[19] L-DOPA is converted into dopamine by the enzyme aromatic L-amino acid decarboxylase (also known as DOPA decarboxylase), with pyridoxal phosphate as the cofactor.[19]
Rate limiting step in manufacture of glycine
Tryptophan decarboxylase, Serine trans-hydroxymethylase, DOPA decarboxylase, Glutamate decarboxylase, monoamine oxidase, COMT, monoamine oxidase, phenylethanolamine N methyl transferase, tyrosine hydroxylase
Serine trans-hydroxymethylase via cofactor pyridoxal phosphate
Rate limiting step GABA
Tryptophan decarboxylase, Serine trans-hydroxymethylase, DOPA decarboxylase, Glutamate decarboxylase, monoamine oxidase, COMT, monoamine oxidase, phenylethanolamine N methyl transferase, tyrosine hydroxylase
Glutamate decarboxylase (+pyridoxal phosphate, active form of vit B6 as cofactor. Synthesised from Glutamate. Converted back to glutamate by GABA shunt
Noradrenalin to adrenalin
Tryptophan decarboxylase, Serine trans-hydroxymethylase, DOPA decarboxylase, Glutamate decarboxylase, monoamine oxidase, COMT, monoamine oxidase, phenylethanolamine N methyl transferase, tyrosine hydroxylase
phenylethanolamine N methyl transferase
Serotonin metabolism
Tryptophan-> 5 HTP by tryptophan hydroxylase (rate limiting step)-> serotonin by 5HT decarboxylse-> 5hydroxyindoleacetic acid by MAO-A.
A patient who has epilepsy and attacks a passer-by during a seizure
Filicide, legal insanity, infrafamilial pedophilic disorder, insane automatism, extrafamilial pedophilic disorder, parricide, sane automatism, infanticide, provocation
Insane automatism: Fenwick-> due to disease of the brain, sane automatism is due to external factor (drugs/head injury), hypoglycemia due to insulin is sane automatism, insane if due to a tumor
Person who had extreme stressor at work, driving home experiences a suddent blackout and crashes into a person crossing the road
Filicide, legal insanity, infrafamilial pedophilic disorder, insane automatism, extrafamilial pedophilic disorder, parricide, sane automatism, infanticide, provocation
Sane automatism
30 yo F with a past history of sexual abuse kills her boyfriend who was taunting her about her abuse
Filicide, legal insanity, infrafamilial pedophilic disorder, insane automatism, extrafamilial pedophilic disorder, parricide, sane automatism, infanticide, provocation
Provocation
22 yr old female presents to emergency with paracetamol overdose
Antidote-
Benzo’s, physostigmine, dantrolene, flumazenil, no specific, N-acetyl cysteine, naloxone, valproate
NAC
Antidote- 24 yo diagnosis of schizophrenia presents with fever, rigidity, autonomic instability
Dantrolene- for NMS. Direct inhibition of ryanodine receptor which is major Ca channel release in SM endoplasmic reticulum.
34 on clozapine and seizures (prophylaxis)
Antidote-
Benzo’s, physostigmine, dantrolene, flumazenil, no specific, N-acetyl cysteine, naloxone, valproate
Valproate
female presents with confusion, shallow breathing and pin point pupils
Antidote-
Benzo’s, physostigmine, dantrolene, flumazenil, no specific, N-acetyl cysteine, naloxone, valproate
Naloxone
50 year old overdose on citalopram
Antidote-
Benzo’s, physostigmine, dantrolene, flumazenil, no specific, N-acetyl cysteine, naloxone, valproate
No specific antidote
37 yo given diaz IM develops hypotension and difficulty breathing
Antidote-
Benzo’s, physostigmine, dantrolene, flumazenil, no specific, N-acetyl cysteine, naloxone, valproate
Flumazenil
Fluoxetine half life
5-7 days
Venlafaxine half life
4-5 hours
Diazepam half life
Up to 100 hours
Oral resperidone half life
3 hours, 24 hours for paliperidone
Citalopram half life
24-72 hours
Lithium half life
18-35 hours
Metoclopramide half life
5 hours
Valproate half life
16 hours
19 yo presents to GP 8 month hx panic attacks lasting 15 mins, heart racing, tight chest, stomach tightening, dizzy, out of contact, sees visions of mothers face, smell of stale perfume
Shared psychotic disorder, complex partial seizure, late onset schizophrenia, fregoli, de clerambault syndrome, Djessings catatonia, capgras, autoscopic, cotard
Complex partial seizures
55 yo difficulty sleeping. No hx mental illness. Preoccupied by young people he ehars throughout the night, dirving near his house. States they deliberately keep him up, throwing dog turds on the lawn. Wife say occasional noises, no more than normal and doubts dog feces having been thrown there by people.
Shared psychotic disorder, complex partial seizure, late onset schizophrenia, fregoli, de clerambault syndrome, Djessings catatonia, capgras, autoscopic, cotard
Late onset schizophrenia- systematised encapsulated delusions.
Also include partition delusions, sensory deficits, multimodal hallucinations, eccentric personality, absence FHx and absence thought disorder
28 yo, 6 yr hx schixophrenia with TI/TW. Becomes suspicious of mother beleiving she has been replaced by another person.
Shared psychotic disorder, complex partial seizure, late onset schizophrenia, fregoli, de clerambault syndrome, Djessings catatonia, capgras, autoscopic, cotard
Capgras
26 yo woman, cleaner. States on number of occasions, director has looked at her in a certain way as walked past and indicates he is in love with her.
Shared psychotic disorder, complex partial seizure, late onset schizophrenia, fregoli, de clerambault syndrome, Djessings catatonia, capgras, autoscopic, cotard
De clerambault- erotomania
25 yo repeatedly presents to GP with concerns about sx- dysuria, joint pain, nausea, urinary retention. Despite investigations that are negative, remains concerned he has a physcial illness
GAD, factitious, hypochondriasis, Munchhausens by proxy, BDD, malingering, somatisation disorder, somatic symptom disorder, maunchausens, conversion
Somatic sx disorder
2 yo unexplained hypoglycemia. mother is insulin dependent diabetic, refuses to leave his side and constantly berates the medical and nursing staff for failure to diagnose his problems
GAD, factitious, hypochondriasis, Munchhausens by proxy, BDD, malingering, somatisation disorder, somatic symptom disorder, maunchausens, conversion
Mauchausens by proxy
22 yo male refused surgery by a number of plastic surgeons presents with extreme concerns what he describes as a bump in his nose
GAD, factitious, hypochondriasis, Munchhausens by proxy, BDD, malingering, somatisation disorder, somatic symptom disorder, maunchausens, conversion
Body dysmorphic disorder: repetitive behaviours or mental acts in response to preoccupations with perceived flaws/threats in physical appearance. If delusional- BDD with the absent insight/delusional beliefs
A woman worries persistently that her son has a chronic illness. Clean bill of health from doctor. Woman has sleepless nights about bills, cannot concentrate because of preoccupations.
GAD, factitious, hypochondriasis, Munchhausens by proxy, BDD, malingering, somatisation disorder, somatic symptom disorder, maunchausens, conversion
GAD
Woman undergoes hysterectomy, after IDC inserted, has panic attack during the procedure, insensitive nurse. From then on she is unable to urinate, nor able to change her own catheter due to the degree of anxiety.
GAD, factitious, hypochondriasis, Munchhausens by proxy, BDD, malingering, somatisation disorder, somatic symptom disorder, maunchausens, conversion
Specific phobia
Marian an 83 yo, no psych hx, 2/12 hx of depressed mood, visual hallucinations, nihilistic ruminations and social withdrawal. Past 4 weeks, progressively mute, oppositional and bed bound. Myoclonic jerks, and EEG shows periodic wave complexes.
LWD, Korsakoffs, HIV dementia, ALZ, neurosyphillis, CJD, Parkinson’s, collagen, FTD?
CJD- psych sx prominent at the start
74 yo M, referred for depression. Wife complains that he has difficulty with words and making decisions. Pt is bemused by questions and gives answers with poverty of content. Scores 27/30 on MMSE, good STM, unable to draw clock face or follow trail
LWD, Korsakoffs, HIV dementia, ALZ, neurosyphillis, CJD, Parkinson’s, collagen, FTD , vascular
FTD- intact parietal lobe, MMSE normal. MMSE not sensitive in picking up FL abnormality
66 yo M hx IHD, calf claudication, AF, problems with memory and unable to use computer. Recent endarterectomy. Scores 21 MMSE.
LWD, Korsakoffs, HIV dementia, ALZ, neurosyphillis, CJD, Parkinson’s, collagen, FTD, vascular
Vascular- cerebral atrophy, MRI shows seep white matter hyperintensities-> periventricular lucencies (leucoaraiosis), deep white matter, central grey matter lacunae. CADASIL-> migraine recurrent small sub cortical infarcts, TIA and affective disturbance
MELAS
Multi-infarct dementia, Small vessel disease, Post-stroke dementia, Specific Vascular dementia syndromes.
Hachinski index-> used to distinguish multi-infarct dementia from AD, abrupt onset, deterioration, fluctuating, step wise, focal neurological sx
CADASIL
Cerebral autosomal dominant arteriopathy with subcortical infarcts and leukoencephalopathy
MELAS
Mitochondrial myopathy, encephalopathy, lactic acidosis and stroke like episodes
46 yo former sailor in the merchant sailor presents with disorientation and possible hallucinations. Apart from slightly raised BP and lateral rectus palsy, neuro exam unremarkable
?benign hydrocephalus, neurosyphillis, neuropsych SLE, hypothyroidism, wernickes, cryptococcal meningitis, water intoxication, NMS, inappropriate ADH, hyperparathyroidism
Wernicke’s encephalopathy-> abducens nerve involemen characteristic of Wernicke’s encephalopathy
34 yo West African man, present with disorientation and slightly fatuous affect. Neuro exam normal apart from slightly irregular L pupil and slow to accommodate
?benign hydrocephalus, neurosyphillis, neuropsych SLE, hypothyroidism, wernickes, cryptococcal meningitis, water intoxication, NMS, inappropriate ADH, hyperparathyroidism
Neurosyphillis-> Argyl Robertson pupil
27 yo homosexual male, 5 year hx HIV forced to cease RVT because of side effects. Presents with onset headache, confusion, prominent hallucinations
?benign hydrocephalus, neurosyphillis, neuropsych SLE, hypothyroidism, wernickes, cryptococcal meningitis, water intoxication, NMS, inappropriate ADH, hyperparathyroidism
Cryptococcal meningitis
35 yo M with chronic SZP, hears voices telling him to prepare for impending drought by storing liquid in his body. Also on antidepressant. Presents with confusion and has low urinary osmolality on 24 hour urine collection
?benign hydrocephalus, neurosyphillis, neuropsych SLE, hypothyroidism, wernickes, cryptococcal meningitis, water intoxication, NMS, inappropriate ADH, hyperparathyroidism
Water intoxication-> psychogenic polydipsia. Low urine osmolality differentiates from SIADH
Hyperphagia and obesity
Area of brain damaged?
Bilateral temporal lobe, VM hypothalamus, intermedial temporal lobe, DLFL, caudate,/putamen, SN, lateral hypothalamus, dominant pariental lobe, medial frontal, mammilary bodies.
VM hypothalamus- centre for satiety
