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Young boy living in a refuge for 2 weeks is mute and withdrawn.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
Apathy, reduced motivation, impaired self care
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.
Medial frontal lobe-> damage associated with akinetic mutism
Gertsmann’s syndrome- agraphia, acalculia, finger agnosia, L/R disorientation
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.
Dominant parietal lobe
Anterograde and retrograde amnesia
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.
Mammillary bodies-> Korsakoff’s
Young man observed to have small testes, Ix reveal XXY chromosomes
?Turners, pseudohermaphrotidism, testicular feminisation syndrome (androgen insensitivity syndrome), anorexia nervosa, transvestitic fetishism, adrenogenital syndrome, klinefelters
Klinefelters-> 90% have hypogonadism, scant facial hair, gyneocomastia, 6% have psychotic disorder including SZP and bipolar
Female- webbed neck, short, dysgenesis of gonads, XO xsome
?Turners, pseudohermaphrotidism, testicular feminisation syndrome (androgen insensitivity syndrome), anorexia nervosa, transvestitic fetishism, adrenogenital syndrome, klinefelters
Turners
Infant appears female at birth, later found to have cryptorchid testes that produce testosterone to which tissues do not respond to. Secondary sex characteristic are female
?Turners, pseudohermaphrotidism, testicular feminisation syndrome (androgen insensitivity syndrome), anorexia nervosa, transvestitic fetishism, adrenogenital syndrome, klinefelters
Testicular feminisation syndrome
Infant born with ambiguous genitalia. External appearance, family’s conviction about infants gender, advice from professionals lead to determination of gender identity
?Turners, pseudohermaphrotidism, testicular feminisation syndrome (androgen insensitivity syndrome), anorexia nervosa, transvestitic fetishism, adrenogenital syndrome, klinefelters
Pseudohermaphroditism
XX female at birth presents with enlarged external genitalia giving the appearance of a scrotal sac and testes
?Turners, pseudohermaphrotidism, testicular feminisation syndrome (androgen insensitivity syndrome), anorexia nervosa, transvestitic fetishism, adrenogenital syndrome, klinefelters
Adrenogenital syndrome
Developmentally delayed man sexually assaults a child
?mens rea, forseeability, actus reus, automatism, fitness to plead, disease of the mind, duress, provication, irresistible impulse, ultimate issue
Mens rea- guilty mind. Mcnaughtens rule. Accused was laboring such a defect of reason from disease of the mind and not to understand the nature and quality of the act he was doing, or if he did know, did not know what he was doing was wrong. Not guilty by reason of insanity must fulfill mens rea.
An adolescent commits a crime to prevent a gang raping his sister
?mens rea, forseeability, actus reus, automatism, fitness to plead, disease of the mind, duress, provication, irresistible impulse, ultimate issue
Duress
A patient regarded as being high risk of suicide absconds from the ward and kills himself
?mens rea, forseeability, actus reus, automatism, fitness to plead, disease of the mind, duress, provocation, irresistible impulse, ultimate issue
Forseeability
Victim of DV kills the perpetrator
?mens rea, forseeability, actus reus, automatism, fitness to plead, disease of the mind, duress, provication, irresistible impulse, ultimate issue
Provocation- act/omission is the result of a loss of self control on the accused that was induced by any conduct of the deceased towards or affecting the accused
“I have no doubt my wife is having an affair with my neighbour”
Delusion of:
perception, reference, persecution, nihilistic, delusional perception, passivity, love, memory, infidelity, normal phenomena
Delusion of infidelity
“I didn’t do this, they made me do it”
Delusion of:
perception, reference, persecution, nihilistic, delusional perception, passivity, love, memory, infidelity, normal phenomena
Delusion of passivity
“The television presenter wa s wearing a purple shirt to indicate that I am gay”
Delusion of:
perception, reference, persecution, nihilistic, delusional perception, passivity, love, memory, infidelity, normal phenomena
Delusion of reference
“I saw a cat crossing the road and I knew immediately, that there is a plot against me”
Delusion of:
perception, reference, persecution, nihilistic, delusional perception, passivity, love, memory, infidelity, normal phenomena
Delusional percept. Delusional perception is the abnormal significance attached to a real percept without any cause that is understandable in rational or emotional terms. Occurs in 2 stages-> real perception with delusional inerpretation.
Autochthonous delusions occur as single stage, out of the blue-> Wahneinfall delusion
My intestines are blocked
Delusion of:
perception, reference, persecution, nihilistic, delusional perception, passivity, love, memory, infidelity, normal phenomena
Nihilistic delusion
Neuritic plaques almost universal
?FTD, NPH, vascular, adrenoleucodystrophy, shy-drager syndrome, huntington’s disease, picks, MS, LBD, alzheimer’s
Alzheimer’s
Neuritic= amyloid
Neurofibrillary tangles
?FTD, NPH, vascular, adrenoleucodystrophy, shy-drager syndrome, huntington’s disease, picks, MS, LBD, alzheimer’s
Alzheimer’s
Numerous rounded inclusion bodies within the nucleus consisting of alpha synuclein
?FTD, NPH, vascular, adrenoleucodystrophy, shy-drager syndrome, huntington’s disease, picks, MS, LBD, alzheimer’s
Lewy body dementia
Cystic formation with lacunar changes and reactive gliosis
?FTD, NPH, vascular, adrenoleucodystrophy, shy-drager syndrome, huntington’s disease, picks, MS, LBD, alzheimer’s
Vascular dementia
Tau protein accumulation in neurons wth ballon cells and hirano bodies
?FTD, NPH, vascular, adrenoleucodystrophy, shy-drager syndrome, huntington’s disease, picks, MS, LBD, alzheimer’s
FTD
A young man with mood-incongruent auditory hallucinations, complex delusions and social withdrawal
Risk factor ?childhood emotional neglect, HIV positive, smoking, alcohol, involved in accident 2 months ago, reduced visual acuity, perinatal hypoxia, use of corticosteroids, impaired hearing, regular use of NSAIDS
Perinatal hypoxia- risk factor for schizophrenia
26 yo M with low mood, recurrent nightmares, flashbacks and avoidance
Risk factor ?childhood emotional neglect, HIV positive, smoking, alcohol, reduced visual acuity, perinatal hypoxia, use of corticosteroids, impaired hearing, regular use of NSAIDS, police officer in child abuse unit
Police office
45 yo male with encephalopathy, confusion, ataxia and opthalmoplegia
Risk factor ?childhood emotional neglect, HIV positive, smoking, alcohol, involved in accident 2 months ago, reduced visual acuity, perinatal hypoxia, use of corticosteroids, impaired hearing, regular use of NSAIDS
Alcohol
A cognitive intact older man with visual hallucinations
Risk factor ?childhood emotional neglect, HIV positive, smoking, alcohol, involved in accident 2 months ago, reduced visual acuity, perinatal hypoxia, use of corticosteroids, impaired hearing, regular use of NSAIDS, accident 2 months ago
Reduced visual acuity- Charles Bonnet Syndrome. Well defined, organised, clear images over which the subject has little control, deafferation of the visual association areas of the cerebral cortex
33 yo female with affective instability, emotions and relationships, and frequent wrist cutting
Risk factor ?childhood emotional neglect, HIV positive, smoking, alcohol, involved in accident 2 months ago, reduced visual acuity, perinatal hypoxia, use of corticosteroids, impaired hearing, regular use of NSAIDS
Childhood emotional neglect
Subacute brain degeneration caused by transient agent leading to dementia- restricted to new guinea
?Ganser’s syndrome, NPH, Koro, CJD, MS, Gertsmanns, Kuru, progressive multifocal leucoencephalopathy, gertsmann straussler syndrome, adrenoleurcodystrophy
Kuru
Clinically and pathalogically similar to CJD but longer duration to death
?Ganser’s syndrome, NPH, Koro, CJD, MS, Gertsmanns, Kuru, progressive multifocal leucoencephalopathy, gertsmann straussler syndrome, adrenoleurcodystrophy
Gerstmann-Straussler syndrome
It can complicate AIDS or disorders of the reticuloendothelium
?Ganser’s syndrome, NPH, Koro, CJD, MS, Gertsmanns, Kuru, progressive multifocal leucoencephalopathy, gertsmann straussler syndrome, adrenoleurcodystrophy
Progressive multifocal leukoencephalopathy caused by JC polyomavirus
MRI shows focal neurological deficits and associated demyelinating lesions, however need ID in CSF for definitive diagnosis
This is probably the best known of the human spongiform encephalopathies and consists essentially of a dementing illness that runs a very rapid course
?Ganser’s syndrome, NPH, Koro, CJD, MS, Gertsmanns, Kuru, progressive multifocal leucoencephalopathy, gertsmann straussler syndrome, adrenoleurcodystrophy
CJD
Development of memory impairment over weeks or months, unsteady gait and urinary incontinence
?Ganser’s syndrome, NPH, Koro, CJD, MS, Gertsmanns, Kuru, progressive multifocal leucoencephalopathy, gertsmann straussler syndrome, adrenoleurcodystrophy
Normal pressure hydrocephalus
24 indonesian woman presents with exaggerated response to fright in a trance-like state with echopraxia, echolalia and command obedience
?brain fag, ataque de nervios, latah, pibloktoq, susto, windigo, koro, tajin kyofusho, dhat, amok
Latah- ++startle response to frightening stimuli
27 yo chinese gentleman presents with acute panic attack and intense fear that his penis is shrinking into his abdomen. Anticipates it will ultimately cause his death
?brain fag, ataque de nervios, latah, pibloktoq, susto, windigo, koro, tajin kyofusho, dhat, amok
Koro (china/southeast asia)
A 32 yr old eskimo woman presents with a dissociative woman lasting 1 hour. Characterised by extreme agitation including tearing off her clothes and rolling in the snow. This is followed by a comlpete amnesia of the episode. ?brain fag, ataque de nervios, latah, pibloktoq, susto, windigo, koro, tajin kyofusho, dhat, amok
Pibloktoq– arctic hysteria.
22 yr old North american native presents with depression, suicidal thoughts a delusional compulsion to eat human flesh
?brain fag, ataque de nervios, latah, pibloktoq, susto, windigo, koro, tajin kyofusho, dhat, amok
Windigo- psychosis describing insatiable craving for human flesh, even when other food is available
18 yo west african student preparaing for exams presnts in a state of distress with inability to concentrate, poor memory and pains in his neck.
?brain fag, ataque de nervios, latah, pibloktoq, susto, windigo, koro, tajin kyofusho, dhat, amok
Brain fag- students of souther Nigeria
Parents of a 14 year old girl are concerned about low weight and her having not attained menses. She beleives she has gone a long way in getting to ideal weight and avoids fatty food. BMI is 16.6
?celiac, AN, SLE, addison’s, cushings, BN, IBS, TB, endometriosis, hyperthyroidism
AN
Domineering parents of Di, 24 yo, concerned about weight loss and infrequent menstrual periods. Mother feels that the critical attitude causes Di’s tremors and frequent stools. Di refuses to put central heating on because makes her sweat. Father thinks its deliberate
?celiac, AN, SLE, addison’s, cushings, BN, IBS, TB, endometriosis, hyperthyroidism
Hyperthyroidism
35 yo woman, concerned about hyperpigmentation in buccal mucosa. Pleased about recent weight loss. Reports nausea, constipation, abdominal/joint pain, feeling dizzy and confused at times
?celiac, AN, SLE, addison’s, cushings, BN, IBS, TB, endometriosis, hyperthyroidism
Addison’s-> diagnosis with rapid ACTH stimulation test (Synacthen)
25 yo female complains of being too fat and feeling low. She tries to diet by making herself sick and using laxatives. However, she often loses control and eats huge amounts of food over short periods and then feels guilty and makes herself sick. Her weight is normal
Bulimia nervosa
50 year old woman presents to GP complaining of weight loss. Bulky, smelly stools, abdo pain, bloating, NV, angular stomatitis, and ulces. Gastro found villous atrophy on biopsy
?celiac, AN, SLE, addison’s, cushings, BN, IBS, TB, endometriosis, hyperthyroidism
Celiac
60 yo female has facial grimaces and movements of her mouth with occasional protracted movements of her tongue. She has been on antipsychotic for past 30 years.
?narcolepsy, dystonia, catalepsy, huntingtons, TD, steroptypy, akathisia, cataplexy, tardive dystonia, myoclonus fit
Tardive dyskinesia
20 yo male has occasional episodes of collapse by loss of muscle tone. The often occurs when he is laughing
?narcolepsy, dystonia, catalepsy, huntingtons, TD, steroptypy, akathisia, cataplexy, tardive dystonia, myoclonus fit
Cataplexy
24 yo M develops involuntary painful protrusion of his tongue, an hour after he is given haloperidol
?narcolepsy, acute dystonia, catalepsy, huntingtons, TD, steroptypy, akathisia, cataplexy, tardive dystonia, myoclonus fit
Acute dystonia
A young manager gets recurrent irrisitible episodes of sleep during the day, even while in important meeting, despite sleeping well in the night
?narcolepsy, dystonia, catalepsy, huntingtons, TD, steroptypy, akathisia, cataplexy, tardive dystonia, myoclonus fit
Narcolepsy
Diagnosed with Polysomnogram showing short REM sleep latency <15 mins and multiple sleep latency test showing mean sleep latency <8 minutes and 2+ sleep inset REM periods. CSF hypocretin <110 is also criterion. Treatment consists of stimulants, - ritalin, modafanil, dexamph
Middle aged male presents with sudden jerking movements of the arms. He also has a dysarthria and recently developed changes in his gait and complains of feeling depressed. Father died age 50 and had similar problems
?narcolepsy, dystonia, catalepsy, huntingtons, TD, steroptypy, akathisia, cataplexy, tardive dystonia, myoclonus fit
Huntington’s chorea
Abrupt, unpredictable, nonrhythmic, continuous random flow of muscle contractioins
Randomly flowing jerks.
Milkmaids grip, hung up reflexes on leg after knee jerk
56 yo M with history of chronic alcohol consumption, presents with a one week history of drowsiness, confusion, lethargy and slurred speech. His breath smells sweet
?Wernicke’s encephalopathy, DKA, SAH, alcohol intoxication, tetanus, Sjorgrens syndrome, meningitis, hypoglycemia, hepatic encephalopathy
Hepatic encephalopathy
37 yo F is brought to ED with sudden onset severe headache, collapse and fluctuating consciousness. On examination, she has a stiff neck and papilloedema
?Wernicke’s encephalopathy, DKA, SAH, alcohol intoxication, tetanus, Sjorgrens syndrome, meningitis, hypoglycemia, hepatic encephalopathy
SAH
25 yo woman presents with 24 hours history of headache, photophobia, stiff neck, vomiting and fever. She has tachycardia, hypotension, papilloedema, and skin rach. Her CSF is turbid with polymorphs and low glucose
?Wernicke’s encephalopathy, DKA, SAH, alcohol intoxication, tetanus, Sjorgrens syndrome, meningitis, hypoglycemia, hepatic encephalopathy
Meningitis
Very low sensitivity for Kernig sign, nuchal rigidity, brudzinski sign
60 yo man with a history of insulin dependent diabetes is brought to ED with complaints of increasing tremulousness, drowsiness, confusion and sweating since that morning. He had a seizure at noon.
?Wernicke’s encephalopathy, DKA, SAH, alcohol intoxication, tetanus, Sjorgrens syndrome, meningitis, hypoglycemia, hepatic encephalopathy
Hypoglycemia
Neurogenic or neuroglycopenic
Seurogenic-> sweating, shakiness, tachyC, anxiety
Neuroglycopenic- weakness, tiredness, inappropriate behaviour
Hyperglycemia-> thirst, polyuria, polydipsia, nocturia
Acidosis-> kussmals breathing
35 yo M with history of chronic alcohol abuse, in ED confusion, vomiting and headache. Ataxia, lateral rectus palsy, sluggish pupils
?Wernicke’s encephalopathy, DKA, SAH, alcohol intoxication, tetanus, Sjorgrens syndrome, meningitis, hypoglycemia, hepatic encephalopathy
Wernickes
30 yo woman complains of weakness in arms and legs after fall. Long history of eating disorder, lethargy, constipation and abdominal distension
Electrolyte abnormality? uremia, hypoglycemia, hyperkalemia, hypercalcemia, hypernatremia, hypokalemia, hypermagnesaeia, hyponatremia, hypocalcemia, hyperglycemia
Hypokalemia
36 yo diabetic man presents w/ nausea and muscle cramps. Recently became depressed and last week commenced fluoxetine 20mg
Electrolyte abnormality? uremia, hypoglycemia, hyperkalemia, hypercalcemia, hypernatremia, hypokalemia, hypermagnesaeia, hyponatremia, hypocalcemia, hyperglycemia
Hyponatremia
Low serum osmolality, low serum sodium, increased urine osmolality.
32 yo M with chronic schizophrenia, commenced clozapine 4 weeks ago. Now he becomes agitated, confused, complains of abdominal pain
Electrolyte abnormality? uremia, hypoglycemia, hyperkalemia, hypercalcemia, hypernatremia, hypokalemia, hypermagnesaeia, hyponatremia, hypocalcemia, hyperglycemia
Hyperglycemia
Associated with DKA
53 yo F with alcohol dependence visits the GP complaining of severe anxiety. Revealse she drank a bottle of whiskey 16 hours ago
Electrolyte abnormality? uremia, hypoglycemia, hyperkalemia, hypercalcemia, hypernatremia, hypokalemia, hypermagnesaeia, hyponatremia, hypocalcemia, hyperglycemia
Hypoglycemia
25 yo M with sarcoidosis complains of increased thirst, low mood and thinks his wife is trying to poison him
Electrolyte abnormality? uremia, hypoglycemia, hyperkalemia, hypercalcemia, hypernatremia, hypokalemia, hypermagnesaeia, hyponatremia, hypocalcemia, hyperglycemia
Hypercalcemia
30-50 percent of patients with sarcoidosis have hypercalciuria, 10-20 percent hypercalcemia, aggrevated by exposure to usnlight.
Increased intestinal calcium absorption induced by high serum calcitriol concentrations is primary abnormality
Generalised theta or delta wave activities
Most likely disorder- typical absence, metabolic encephalopathy, generalised anxiety, focal structural, herpse simplex, myoclonic epilepsy, subsacute sclerosing panencephalitis, CJD, huntington’s, depressive pseudodementia
Metabolic encephalopathy
3 Hz bilateral, symmetrical spike and wave activities
Most likely disorder- typical absence, metabolic encephalopathy, generalised anxiety, focal structural, herpse simplex, myoclonic epilepsy, subsacute sclerosing panencephalitis, CJD, huntington’s, depressive pseudodementia
Typical absence seizure
Focal slow wave activity
Most likely disorder- typical absence, metabolic encephalopathy, generalised anxiety, focal structural, herpse simplex, myoclonic epilepsy, subsacute sclerosing panencephalitis, CJD, huntington’s, depressive pseudodementia
Focal structural lesion
Fast spike and wave activity
Most likely disorder- typical absence, metabolic encephalopathy, generalised anxiety, focal structural, herpse simplex, myoclonic epilepsy, subsacute sclerosing panencephalitis, CJD, huntington’s, depressive pseudodementia
Myoclonic epilepsy
Periodic, generalised, 1-2 Hz sharp waves over low amplitude and slow background
Most likely disorder- typical absence, metabolic encephalopathy, generalised anxiety, focal structural, herpse simplex, myoclonic epilepsy, subsacute sclerosing panencephalitis, CJD, huntington’s, depressive pseudodementia
CJD
Biphasic or triphasic discharges that are initially sporadic and may even be asymmetric. As it advances, pattern becomes generalised and synchronous with continuous periodic stereotypic 200-400 millisecond sharp waves occurring at intervals of 05.1.0 seconds
Depression in the elderly
?impaired DL PFC on fMRI, medial TL atrophy on MRI, focal atrophy of the frontal lobes on MRI, BL high signal in pulvinar nucelus of thalamus on MRI, activation of primary auditory cortex on fMRI, diffuse cerebral edema on CT, high signal lesions in cerebella peduncles, periventricular WM changes on MRI, multipl discrete WM lesions with variable enhancement on MRI, depp WM hyperintensities on MRI
Deep white matter hyperintensities on MRI
Auditory hallucinations in Schizophrenia
?impaired DL PFC on fMRI, medial TL atrophy on MRI, focal atrophy of the frontal lobes on MRI, BL high signal in pulvinar nucelus of thalamus on MRI, activation of primary auditory cortex on fMRI, diffuse cerebral edema on CT, high signal lesions in cerebella peduncles, periventricular WM changes on MRI, multipl discrete WM lesions with variable enhancement on MRI, depp WM hyperintensities on MRI
Activation of primary auditory cortex on fMRI
Working memory tasks in Schizophrenia
?impaired DL PFC on fMRI, medial TL atrophy on MRI, focal atrophy of the frontal lobes on MRI, BL high signal in pulvinar nucelus of thalamus on MRI, activation of primary auditory cortex on fMRI, diffuse cerebral edema on CT, high signal lesions in cerebella peduncles, periventricular WM changes on MRI, multipl discrete WM lesions with variable enhancement on MRI, depp WM hyperintensities on MRI
Impaired DL PFC function on MRI
Variant CJD
?impaired DL PFC on fMRI, medial TL atrophy on MRI, focal atrophy of the frontal lobes on MRI, BL high signal in pulvinar nucelus of thalamus on MRI, activation of primary auditory cortex on fMRI, diffuse cerebral edema on CT, high signal lesions in cerebella peduncles, periventricular WM changes on MRI, multipl discrete WM lesions with variable enhancement on MRI, depp WM hyperintensities on MRI
Bilateral high signal pulvinar nucleus of thalamus on MRI
Alzheimer’s disease
?impaired DL PFC on fMRI, medial TL atrophy on MRI, focal atrophy of the frontal lobes on MRI, BL high signal in pulvinar nucelus of thalamus on MRI, activation of primary auditory cortex on fMRI, diffuse cerebral edema on CT, high signal lesions in cerebella peduncles, periventricular WM changes on MRI, multipl discrete WM lesions with variable enhancement on MRI, depp WM hyperintensities on MRI
Medial temporal lobe atrophy on MRI
74 yo M presents with apathy, self-neglect, social isolation and perseveration. Choose a rapid bedside test- Ray-Osterrieth complex figure test, Benton Visual Retention test, Riveread Behavioural memory test, California Psychological inventory, Cattell Personality Factor Questionnaire, Stanford-Binet, Wisconsin card sorting test, Mennesota Multiphasic Personality INventory 2, Rotschach Inkblot test, digit span
Digit span
Common neuropsych test to detect preforntal lobe pathology
hoose a rapid bedside test- Ray-Osterrieth complex figure test, Benton Visual Retention test, Riveread Behavioural memory test, California Psychological inventory, Cattell Personality Factor Questionnaire, Stanford-Binet, Wisconsin card sorting test, Mennesota Multiphasic Personality INventory 2, Rotschach Inkblot test, digit span
Wisconsin card sorting test
Others include- Trail making, Stroop test, Colour word inference test, design fluency, Tower test, verbal fluency
Projective test used by psychologists to evaluate persons patterns of thought/attitudes/observational capacity and emotional responses
?Ray-Osterrieth complex figure test, Benton Visual Retention test, Riveread Behavioural memory test, California Psychological inventory, Cattell Personality Factor Questionnaire, Stanford-Binet, Wisconsin card sorting test, Mennesota Multiphasic Personality INventory 2, Rotschach Inkblot test, digit span
Rorschach inkblot test
A test involving the subject, first asked to copy a complex figure made of basic geometric shapes, and then to draw it from memory
?Ray-Osterrieth complex figure test, Benton Visual Retention test, Riveread Behavioural memory test, California Psychological inventory, Cattell Personality Factor Questionnaire, Stanford-Binet, Wisconsin card sorting test, Mennesota Multiphasic Personality INventory 2, Rotschach Inkblot test, digit span
Ray-Osterriethcomplex figure test- testing of visiospatial constructional ability and visual memory
A test developed to detect impairment of everyday memory functioning and to monitor change following treatment for memory difficulties
?Ray-Osterrieth complex figure test, Benton Visual Retention test, Riveread Behavioural memory test, California Psychological inventory, Cattell Personality Factor Questionnaire, Stanford-Binet, Wisconsin card sorting test, Mennesota Multiphasic Personality INventory 2, Rotschach Inkblot test, digit span
Rivermead behavioural memory test
Questionnaire of T/F designed to evaluate thoughts/emotions/attitudes/behavioural traits of an individual
? Ray-Osterrieth complex figure test, Benton Visual Retention test, Riveread Behavioural memory test, California Psychological inventory, Cattell Personality Factor Questionnaire, Stanford-Binet, Wisconsin card sorting test, Mennesota Multiphasic Personality INventory 2, Rotschach Inkblot test, digit span
Minnesota Multiphasic Personality Inventory-2 567 questions
Based on the principle that emotional dysregulation in inherent, which becomes pervasive with a invalidating environment.
?DBT, large group therapy, group analytic therapy, small group therapy, CAT, supporting psychotherapy, transactional analysis, interpersonal psychotherapy, brief insight-oriented therapy, psychoanalysis
DBT
- Mindfullness
- Interpersonal effectiveness
- Distress tolerance
- Emotion regulation
Uses cognitive therapy techniques with a psychodynamic framework. Focus on interpersonal behaviour. Target problem list is made. Patient has an active role
?DBT, large group therapy, group analytic therapy, small group therapy, CAT, supporting psychotherapy, transactional analysis, interpersonal psychotherapy, brief insight-oriented therapy
Cognitive analytical therapy
Anthony Ryle
Aims to increase the conscious recognition of the unconscious factors on current experiences and behaviour by free association, analysis of counter-transference and interpretation
?DBT, large group therapy, group analytic therapy, small group therapy, CAT, supporting psychotherapy, transactional analysis, interpersonal psychotherapy, brief insight-oriented therapy
Psychoanalysis
Role transitions and grief is addressed
?DBT, large group therapy, group analytic therapy, small group therapy, CAT, supporting psychotherapy, transactional analysis, interpersonal psychotherapy, brief insight-oriented therapy
Interpersonal psychotherapy
Receptor mechanism for zolpidem
?Muscarinic, D2, H1, 5HT3, 5HT 1A, sigma, Mu, 5HT2A, omega-1, NMDA
Omega-1
Agonist at GABA A 2 a 1 subunit->omega 1 R
Oxycodone receptor
?Muscarinic, D2, H1, 5HT3, 5HT 1A, sigma, Mu, 5HT2A, omega-1, NMDA
Mu
Fluvoxamine R
?Muscarinic, D2, H1, 5HT3, 5HT 1A, sigma, Mu, 5HT2A, omega-1, NMDA
Sigma R agonist
SSRI
Aripiprazole R
?Muscarinic, D2, H1, 5HT3, 5HT 1A, sigma, Mu, 5HT2A, omega-1, NMDA, partial DA agonism
Partial DA agonist, 5HT1A partial agonist, antagonist at 5HT2A
Bromocriptine R
?Muscarinic, D2, H1, 5HT3, 5HT 1A, sigma, Mu, 5HT2A, omega-1, NMDA
D2 agonist
Ketamine MOA
?GABA B agonist, butylcholinesterase inhibitor, MAO-B inhibitor, 5HT1A partial agonist, MAO A inhibitor, NMDA antagonis, 5HT2A R stimulation, , GABA A agonist, Alpha 2 agonist
NMDA R antagonist
Baclofen
?GABA B agonist, butylcholinesterase inhibitor, MAO-B inhibitor, 5HT1A partial agonist, MAO A inhibitor, NMDA antagonis, 5HT2A R stimulation, , GABA A agonist, Alpha 2 agonist
GABA B agonist
Buspirone
?GABA B agonist, butylcholinesterase inhibitor, MAO-B inhibitor, 5HT1A partial agonist, MAO A inhibitor, NMDA antagonis, 5HT2A R stimulation, , GABA A agonist, Alpha 2 agonist
5HT1A partial agonist- presynaptic R, acts as full agonist inhibiting synthesis of 5HT and firing. Post synaptic hippocampus and cortex as partial agonist
Selegiline
?GABA B agonist, butylcholinesterase inhibitor, MAO-B inhibitor, 5HT1A partial agonist, MAO A inhibitor, NMDA antagonis, 5HT2A R stimulation, , GABA A agonist, Alpha 2 agonist
MAO-B inhibitor
