Module 7 Flashcards
cortical structures
frontal, temporal, parietal, and occipital lobes
subcortical structures
fornix, cingulate cortex, basal ganglia, and basal forebrain
brainstem,
which consists of the midbrain, pons, and the medulla
Serotonin
Brainstem: raphe nuclei
Helps regulate mood, arousal, and cognition
Norepinephrine
Brainstem: locus coeruleus
Regulates mood, arousal, attention, and cognition
Dopamine
Brainstem: substantia nigra
Regulates mood, arousal, cognition, and motor control
Acetylcholine
Basal forebrain: basal nucleus of Meynert
Regulate sleep, arousal, and attention
Low levels of serotonin, norepinephrine, and dopamine have been associated with
depressive symptoms.
Low concentrations of serotonin with high levels of norepinephrine have been associated with
anxiety symptoms
Too much dopamine with low concentrations of serotonin in certain areas of the brain lead to symptoms of
psychosis and mania
Dementia is notable for low concentration levels of
acetylcholine
common comorbid conditions that accompany excessive or uncontrollable anxiety
Hyperthyroidism, cardiopulmonary disorders, and traumatic brain injury (TBI) are
Major depressive disorder (MDD) is characterized by
at least 2 weeks of depressed/irritable mood, with at least four of the following: anhedonia, insomnia or hypersomnia, decreased self-esteem, low energy, poor concentration or indecision, changes in appetite, feeling slowed or restless, and thoughts of death or suicide
Persistent depressive disorder (PDD) is characterized by
depressive/irritable mood lasting for at least 2 years with at least two of the aforementioned depressive symptoms.
Symptoms of manic episodes include
euphoric/irritable mood, grandiosity, decreased need for sleep, talkativeness, racing thoughts, distractibility, increased goal-directed behavior or agitation, and an increase in reckless pleasure-seeking (having unprotected sex, spending excess money, foolish investments
Diseases that mimic depression symptoms
Parkinson disease, traumatic brain injury (TBI), recent myocardial infarction (MI) or stroke, and hypothyroidism may mimic depressive symptoms.
If the patient affirms one-sided hand tremor or difficulty starting movements, consider
Parkinson disease.
In a younger adult patient with unusual limb movements, you should assess the family history for
Huntington disease.
The mental status examination consists of six components:
appearance and behavior; speech and language; mood; thoughts and perceptions; insight and judgment; and cognitive function.
Lethargy
The lethargic patient appears drowsy but opens the eyes when spoken to in a loud voice and looks at you, responds to questions, and then falls asleep.
Obtundation
The obtunded patient opens the eyes when tactile stimulus is applied and looks at you but responds to you slowly and is somewhat confused.
Stupor
The stuporous patient arouses only after painful stimuli. Verbal responses are slow or even absent. The patient lapses into an unresponsive state when the stimulus ceases.
Coma
A comatose patient remains unarousable with eyes closed. There is no evident response to inner need or external stimuli.
Circumlocutions
, in which phrases or sentences are substituted for a word the person cannot think of, such as “what you write with” for “pen”
Paraphasias
, in which words are malformed (“I write with a den”), incorrect (“I write with a bar”), or invented (“I write with a dar”)
expressive, or Broca aphasia
, with preserved comprehension with slow, nonfluent speech
receptive, or Wernicke aphasia
, with impaired comprehension with fluent speech
Blocking
Sudden interruption of speech in midsentence or before the idea is completed, attributed to “losing the thought.” Blocking occurs in normal people.
Circumstantiality
The mildest thought disorder, consisting of speech with unnecessary detail, indirection, and delay in reaching the point. Some topics may have a meaningful connection. Many people without mental disorders have circumstantial speech.
Clanging
Speech with choice of words based on sound, rather than meaning, as in rhyming and punning. For example, “Look at my eyes and nose, wise eyes and rosy nose. Two to one, the ayes have it!”
Confabulation
Fabrication of facts or events in response to questions, to fill in the gaps from impaired memory
Derailment (loosening of associations)
Tangential speech with shifting topics that are loosely connected or unrelated. The patient is unaware of the lack of association.
Echolalia
Repetition of the words and phrases of others
Flight of ideas
An almost continuous flow of accelerated speech with abrupt changes from one topic to the next. Changes are based on understandable associations, plays on words, or distracting stimuli, but ideas are not well connected.
Incoherence
Speech that is incomprehensible and illogical, with lack of meaningful connections, abrupt changes in topic, or disordered grammar or word use. Flight of ideas, when severe, may produce incoherence.
Neologisms
Invented or distorted words, or words with new and highly idiosyncratic meanings.
Perseveration
Persistent repetition of words or ideas
Delirium
, a multifactorial syndrome, is an acute confusional state marked by sudden onset; fluctuating course; inattention; and, at times, changing levels of consciousness
Parietal lobe
Involved in visuospatial sense, attention, and movement.1,64
Deficits in parietal lobe function have been associated with attention-deficit/hyperactivity disorder (ADHD), obsessive–compulsive disorder (OCD), and schizophrenia.
Temporal lobe: primary auditory cortex
Responsible for auditory processing.
In schizophrenia, the primary auditory cortex activates even in the absence of sound, which often result in the experience of auditory hallucinations
Temporal lobe: hippocampus
Critical to memory and learning.70–72 There is also high concentrations of cortisol receptors in the hippocampus.
Hippocampus dysfunction may contribute to cognitive impairment in Alzheimer disease (AD) and schizophrenia.73,74
Major depressive disorder (MDD) and posttraumatic stress disorder (PTSD) both cause significant increases of cortisol, which may cause memory and cognitive problems seen in these disorders.75–78
Hippocampus dysfunction is also thought to contribute to anxiety symptoms
Temporal lobe: amygdala
Involved in the cortical processes that cause emotions. The fight-or-flight response, or fear response, is activated through the amygdala.
In people with posttraumatic stress disorder (PTSD), the amygdala is often hyperactivated and cannot be easily turned off.78 People with PTSD often startle easily and struggle with anxiety or panic.
Excess amygdala activity is also seen in people with bipolar disorder, which is thought to contribute to irritability and labile mood
Frontal lobe
Vital to executive function (which includes memory, cognition, behavioral control, and attention) and emotions.
Dysfunction has been associated with most mental disorders, including bipolar disorder, schizophrenia, attention-deficit/hyperactivity disorder, major depressive disorder (MDD), obsessive–compulsive disorder (OCD), posttraumatic stress disorder (PTSD), and AD
Basal ganglia
Works with the nucleus accumbens to control reward.
Dysfunction seen in addiction,77,106 obsessive–compulsive disorder (OCD), major depressive disorder (MDD), attention-deficit/hyperactivity disorder (ADHD), schizophrenia, and bipolar disorder.
pineal gland
Produces melatonin, which regulates sleep.1
Contributes to sleep disturbances in major depressive disorder (MDD), obsessive–compulsive disorder (OCD), posttraumatic stress disorder (PTSD), and AD
Hypothalamus
Periods of increased stress are associated with increased activity of the hypothalamic–pituitary–adrenal axis and increased release of corticotropin-releasing factor, which causes cortisol (a steroid hormone) release.
Increased cortisol can cause depressive symptoms.
Cerebellum
Regulates motor coordination and motor learning
Alcohol use impairs cerebellar function, which can cause ataxia, or a loss of motor coordination.1
Somatic symptom disorder
Somatic symptoms are either very distressing or result in significant disruption of functioning, as well as excessive and disproportionate thoughts, feelings, and behaviors related to those symptoms. Symptoms should be specific if with predominant pain.
Illness anxiety disorder
Preoccupation with having or acquiring a serious illness where somatic symptoms, if present, are only mild in intensity
Conversion disorder
Syndrome of symptoms of deficits mimicking neurologic or medical illness in which psychological factors are judged to be of etiologic importance
Factitious disorder
Falsification of physical or psychological signs or symptoms, or induction of injury or disease, associated with identified deception. The individual presents himself or herself as ill, impaired, or injured even in the absence of external rewards.
Body dysmorphic disorder
Preoccupation with one or more perceived defects or flaws in physical appearance that are not observable or appear only slight to others.
Dissociative disorder
Disruption of and/or discontinuity in the normal integration of consciousness, memory, identity, emotion, perception, body representation, motor control, and behavior.
The most important geriatric syndromes in primary care are
falls, urinary incontinence, frailty, and cognitive impairment.
Primary aging reflects
changes in physiologic reserves over time that are independent of changes from disease.
BP in older adults
Tends to rise with aging, d/t large arteries stiffening and becoming atherosclerotic
actinic purpura
, that fade over time. These spots and patches come from blood that has leaked through poorly supported capillaries and spread within the dermis
presbycusis
Hearing loss associated with aging, known as ,
a fourth heart sound
As a person ages, decreased ventricular compliance and impaired ventricular filling result in this, often auscultated in otherwise healthy older people
auscultating a third heart sound,
is strongly suggestive of heart failure from volume overload of the left ventricle in conditions like heart failure and valvular heart disease
Calcium resorption from bone, rather than diet, increases with aging as
parathyroid hormone levels rise
Sarcopenia
is the loss of lean body mass and strength with aging
geriatric syndrome
is “a multifactorial condition that involves the interaction between identifiable situation-specific stressors and underlying age-related risk factors, resulting in damage across multiple organ systems
activities of daily living (ADLs),
which consist of six basic self-care abilities—bathing, dressing, toileting, transferring, continence, and feeding.
the instrumental activities of daily living (IADLs)
—using the telephone, shopping, preparing food, housekeeping, laundry, transportation, taking medicine, and managing money.
the single most common modifiable risk factor associated with falls
Medications
Older adults should have no more than
2 drinks on any one day or 7 drinks a week.
Palliative care
encompasses the alleviation of pain and suffering and the promotion of optimal quality of life across all phases of treatment, including curative interventions and rehabilitation
orthostatic or postural hypotension
, defined as a drop in SBP of ≥20 mm Hg or DBP of ≥10 mm Hg within 3 minutes of standing
entropion
the eyelashes in the lower lids to see whether they are directed toward the eye
ectropion
sagging and outward turning of the lower eyelid and eyelashes
Get Up and Go Test
Performed with patient wearing regular footwear, using usual assistive device if needed, and sitting back in an armless chair. After instructing the patient on what to do, on the word “Go,” the patient should:
Get up from the armless chair
Walk 3 m (in a line)
Turn around
Walk back to the chair
Sit back down
Time the second effort. Observe patient for postural stability, steppage, stride length, and sway.
Scoring:
Normal: completes task in <10 seconds
Abnormal: completes task in >20 seconds
Parkinson evidence
Tremor, Rigidity, Akinesia, and Postural instability, or TRAP
