Psychiatry Flashcards
A 76-year-old white woman is brought to her general practitioner by her children because she is becoming more forgetful. She used to pay her bills independently and enjoyed cooking but has recently received overdue notices from utility companies and found it difficult to prepare a balanced meal. She has lost 3.5 kg in the past 3 months, and left the water running in her bathtub and flooded the bathroom. When her children express their concerns, she becomes irritable and resists their help. Her house has become more cluttered and unkempt. On a past visit to her physician, she had normal laboratory tests for metabolic, haematological, and thyroid function. The current evaluation reveals no depressive symptoms and 2/15 on the Geriatric Depression Scale short-form. Her Mini-Mental State Examination score is 20/30.
Alzheimer’s dementia
A 54-year-old black woman is referred to the neurology clinic by her general practitioner for evaluation of memory problems. The patient is brought to the clinic by family members who are concerned that she has been forgetful in the past year. They report that she has difficulty in recalling birthdays and anniversaries and is not managing common household tasks such as cooking and paying bills. The patient’s sister had onset of dementia in her early 40s and was institutionalised because she was unable to care for herself. The patient was last seen by her primary care physician 3 months ago, when she had a routine work-up, which was reported to be unremarkable. Neurological examination revealed no significant abnormalities. Neuropsychological testing demonstrated severe impairment in executive function, deficits in visuo-spatial testing, and delayed speed of processing information. Mini-Mental State Examination score is 20/30.
Alzheimer’s dementia
A 65-year-old man presents with difficulty in decision-making and planning, which is of abrupt onset and occurs 3 months after a stroke. He has strong vascular risk factors, including smoking. Over time, there has been a fluctuating stepwise reduction in cognitive function. There is a history of nocturnal confusion and incontinence. On examination there is evidence of focal neurological deficit with pseudobulbar palsy and extrapyramidal signs. Neuroimaging indicates a probable vascular aetiology with white matter changes and infarction.
Vascular dementia
A 78-year-old woman presents with confusion, agitation, and visual hallucinations. She has become progressively confused over the past 2 years and has had trouble managing her affairs, including shopping and paying bills. It is unclear when her confusion started. Initially, she was having trouble following conversations and got lost on several occasions. Her memory, which was previously good, has begun to deteriorate. At night, she sees children playing in her house and has called the police on several occasions. She gets angry easily and has been paranoid about her relatives and their intentions. Her behaviour tends to fluctuate from day to day. She started to shuffle about 6 months ago and had difficulty getting out of chairs, and getting dressed to go out seemed to take hours. On one occasion, she fell and was taken to the emergency department but was subsequently discharged with no diagnosis given.
Lewy body dementia
A 45-year-old woman presents with a one-month history of poor sleep and irritable mood, in the setting of a recent divorce and ongoing custody battle with her former husband over their 2 teenage children. She has also just had a bad performance review at work due to her inability to meet deadlines and is fearful of losing her job. She explains that her work problems have arisen because she has been unable to keep her concentration focused on work. She expresses feelings of worthlessness and wonders sometimes what is the point of living. She has to force herself to stay engaged in her children’s activities and other interests that she used to enjoy; she feels she is ‘just going through the motions’. She had a similar episode after the birth of her second child, but pulled out of it after several months. There is a family history of suicide; her mother killed herself when the patient was 10 years old. Her examination is notable for poor eye contact and frequent tears. Her test results, including TSH, are normal.
Depression
A 43-year-old single woman presents after seeing a television advertisement describing depressive symptoms. She relates she has been depressed since childhood but has never been diagnosed or treated for depression. On questioning she says she has ‘sporadic’ depressive symptoms but, overall, more depressed days than well days. She describes chronic fatigue, ongoing low mood, rarely feeling pleasure or enjoyment, and is chronically socially avoidant. She has been evaluated by her primary care physician for annual check-ups but has never had a significant physical disorder. She is taking no medication except for vitamins, and her thyroid has been tested in the past and is normal. Her vital signs and physical examination are normal.
Depressive mood disorder
A 34-year-old white woman presents for evaluation of a persistent cough lasting 3 weeks after having symptoms of an upper respiratory tract infection. Her vital signs record indicates that she is currently smoking. Further information about her smoking indicates she smokes 1 pack per day and has her first cigarette within minutes of waking in the morning.
Substance abuse: smoking (tobacco)
A 60-year-old man with spirometry demonstrating airflow obstruction is seen for a follow-up appointment. He continues to smoke 1 pack per day, but he recently attempted to stop and stopped smoking for more than 2 days before relapsing. He expresses a strong interest, but little confidence, in trying to stop again. During the recent attempt to stop he tried nicotine gum, but used it only once or twice daily. Additional past history is significant for hypertension under control and a remote history of a seizure disorder.
Substance abuse: smoking (tobacco)
