Plgh ?

leld sychlaLry
Shelf Lxam 8evlew
Lmma Polllday 8amahl
A paLlenL ls broughL ln by hls ldenLlcal Lwln
broLher sLaLlng he has been sleeplng llLLle for
Lhe pasL 8 days, had sex wlLh 13 dlfferenL
women, and Lalked ln a pressured manner abouL
maxlng ouL hls credlL cards starting a business
LhaL couldnt fail.
ulagnosls?
lncldence ln Lhe populaLlon?
8lsk for same ux ln broLher?
lf Lhese sxs occurred for Lhe
1
sL
Llme ln a 73 y/o paLlenL?
MedlcaLlons Lo AvClu?
MedlcaLlons Lo sLarL ln Lhls
paLlenL?
Manlc Lplsode blpolar l lf cycled w/ depresslve eplsodes
~1
80-90
Look for a medlcal cause. *8lghL
fronLal hemlsphere sLroke*
SS8ls and 1CAs (can Lrlgger manla)
Paloperldol or clonazepam for acuLe
aglLaLlon or deluslons.
LlLhlum, valprolc acld or carbamazeplne for malnLenance.
aLlenL Laklng Advll
develops n/v/d, coarse
Lremor, aLaxla, confuslon,
slurred speech.
osslble LkC flndlngs?
1x?
Ma[or Slde LffecLs?
MCA?
1herapeuLlc levels?
Medlcal monlLorlng?
ConLralndlcaLlons for
use?
roblems ln preggos?
!"#$"%& ()*"+"#,
reclp by nSAlus.
8eLLer paln meds are asplrln
or sullndac.
1-wave flaLLenlng or lnverslon + u waves
lluld resusclLaLlon. LmergenL dlalysls lf >4 or kldney dz
WelghL galn and acne, Cl lrrlLaLlon, cramps
Suppresses lnoslLal LrlphosphaLe
0.6-1.2
Ll level q4-8wks, 1l1s q6mo, Cr, uA, C8C, LkC
Severe 8enal uz, Ml, dlureLlcs or dlgoxln,
MC, pregnancy or breasLfeedlng.
Ebsteins anomaly = malformed tricusp,
aLrlallzes parL of 8v. lf Laken durlng 1
sL
Lrl
referred LreaLmenL for blpolar ln
preggos?
8lpolar + elevaLed Ll1s and
hepaLlLls?
Bipolar + Stevens Johnson
Syndrome?
8lpolar + agranulocyLosls?
lf AnC <2000?
lf AnC <1000?
Bipolar + AFP in a 20wk
preggo?
MosL common compllcaLlon of
carbamezaplne?
1herapeuLlc levels of valproaLe?
1herapeuLlc levels of
carbamezaplne?
Clonazepam. Lsp 1
sL
LrlmesLer
valproaLe. Also can cause n/v/d, skln rash
LamoLrlglne
(less llkely carbamazeplne
Carbamazeplne. Check C8C regularly
MonlLor closely w/ weekly C8C
u/C Lhe med
Could be valproaLe or Carbamazeplne
n1u. 8epro-age l should Lake 4g dally
8ash.
6-12
60-120
A woman comes ln complalnlng of decreased
appeLlLe and 3lb welghL loss, no longer en[oys
knlLLlng, lnsomnla and decreased energy, unable
Lo concenLraLe and feellng gullLy for 2 weeks.
MosL lmporLanL 1
sL
quesLlon?
8l for Lhls?
Seen on polysomnogram?
ALyplcal lab LesL?
MedlcaLlons LhaL mlghL cause
Lhls?
Medlcal dlseases LhaL mlghL
cause Lhls?
Assess for sulcldal ldeaLlon.
*rlor aLLempL*, >43, whlLe, male, serlous lllness,
deLalled plan, no supporL, lack of supporL, L1CP/drugs
ShorLened 8LM laLency, more freq 8LM
uexameLhasone suppresslon LesL fallure Lo suppress
lln, beLa-blockers, meLhyldopa, L-dopa, CCs, L1CP, cocalne
/amph wlLhdrawal, oplaLes.
Plv, Lyme, PypoLhyroldlsm, orphyrla, uremla, Cushlngs uz,
Liver disease, Huntingtons, MS, Lupus, L-MCA sLroke
aLlenL who ls eaLlng
more, galnlng welghL,
sleeplng more and has
!"#$"% '#(#!)*+* ln Lhe
mornlng.
1 monLh afLer deaLh of
her chlld, a moLher feels
guilty, cant sleep,
concenLraLe, eaL, or en[oy
her lnLeresLs.
4 monLhs afLer Lhe deaLh
of her chlhuahua, a
woman sLlll feels gullLy,
cant sleep, concentrate,
eaL, or en[oy her lnLeresLs.
-#,."+/0 12.3244")5.
Are hypersenslLlve Lo re[ecLlon, can
affecL soclal fxnlng.
*8esL LreaLed w/ MACls.
65+)&.0"+/#27 8232/92&25#.
*v-code on uSM-lv*
no sulcldal ldeaLlon (oLher Lhan
LhoughLs of wanLlng Lo be w/ loved
one). no psychosls (oLher Lhan
hearlng/seelng loved one)
*8arely Lx w/ anLldepressanLs for sxs
-7:%4#&25# 1"4)3723.
Sxs w/ln 3mo of sLressor ouL of
proportion. Cant persist longer than
6mo.
*8esL LreaLed w/ psychoLherapy.
1
sL
llne for Muu-
Pas mosL drug-drug lnLeracLlons
Dont have to taper when stopping
lewesL drug-drug lnLeracLlons
PA, n/v/d, dlzzlness and faLlgue when
sLopplng suddenly.
Myoclonlc [erks, Lachycardla, hlgh
8, hyperreflexla, n/v/d.
WhaL lf loss of erecLlon, e[aculaLlon?
ConLralndlcaLlons Lo use?
LrecLlon lasLlng >3 hours?
Cood for old, sklnny, sad ladles?
Avold ln hyperLenslve paLlenLs?
oundlng head, flushlng, nausea,
myoclonus afLer eaLlng cheese,
drlnklng red wlne, Laklng
decongesLanL or merperldlne?
;;<=4. Also lndlcaLed for CCu, bulemla, anxleLy, 1Su
or premaLure e[aculaLlon
aroxeLlne
lluoxeLlne
Venlafaxine (SNRI). Dont take w/ St.
!ohns WarL
>?( 7"4+)5#"5%/#")5 4,573)&2. MosL
common w/ serLrallne and fluvoxamlne
>?( 4,573)&2. lf SS8l + MACl
SwlLch Lo buproprlone (uA/n-8l)
8ulemla, alcohollcs, epllepLlcs
Llkely caused by Lrazodone.
Mirtazepine. appetite and sleep
ClLalopram
PyperLenslve crlsls w/ MACl.
1x w/ 3mg lv phenLolamlne
A kid ate some unidentified pills out of grandmas
purse. Crandma has P1n, PL, flbromyalgla, lnsomnla
and pepLlc ulcer dlsease. Pe now has dry mouLh,
Lachycardla, vomlLlng, urlnary reLenLlon, and selzures.
Widened QRS
complexes and
prolonged C1
interval
WhaL dld Lhe kld lngesL?
MosL common cause of deaLh?
1reaLmenL?
1rlcycllc AnLldepressanL
ArrhyLhmla Lorsades, v-flb, deaLh
AcLlvaLed charcoal lf lngesLlon w/ln 1-2hrs. Clve lv sodlum
blcarbonaLe. (helps meL acldosls and cardloproLecLlve)
A smelly 20 y/o college kids grades have been declining
over Lhe pasL 2 semesLers as he keeps Lo hlmself, has
flaLLened affecL and no moLlvaLlon. lor Lhe pasL 6wks, he
has locked hlmself ln hls dorm room sLaLlng resldenL
Obama puL a hlL on hlm. He was told this by 2 volces
havlng a dlscusslon ln hls head.
ulagnosls?
revalence?
8lsk for MZ Lwln?
Slbllng?
neuroblology?
Schlzophrenla, aranold Lype (MC and besL prog)
0.3-1
30
10
oslLlve Sxs-excess uA ln llmblc area blndlng u2 recepL.
neg Sxs- decr uA ln prefronLal corLex/meso-corLlcal LracL
*1hls ls why Lyplcal anLlpsychoLlcs make negaLlve sxs
worse.
A paLlenL has deluslons,
halluclnaLlons, and flaLLened
affecL for 3 weeks.
lor 3 monLhs?
A paLlenL has had persecuLory
deluslons for Lhe pasL 3 years.
6 monLhs ago he sLarLed
havlng sadness, gullL,
insomnia, concentration, SI.
A paLlenL has had Muu for 3
years and reporLs hearlng
volces Lelllng hlm he ls
worLhless and Lo klll hlmself.
A man ls convlnced Mlley
Cyrus ls ln love wlLh hlm buL ls
oLherwlse funcLlonal.
8rlef sychoLlc ulsorder
(>1wk, <1mo)
Schlzophrenlform ulsorder (>1m, <6mo)
SchlzoaffecLlve ulsorder.
(deluslons/halluclnaLlons for >2wks
ln absence of mood ss)
*1x w/ ALyplcal anLlpsychoLlcs + SS8l
lf depresslon and + Ll lf manlc.
Muu wlLh sychoLlc leaLures.
ueluslons are Lyplcally mood
congruenL.
* 1x w/ ALyplcal anLlpsychoLlc + SS8l
or LC1 (esp ln preggos)
ueluslonal ulsorder.
LroLomanlc Lype. non-blzzare.
1x w/ LherapeuLlc relaLlonshlp + meds
uCC for acuLe aglLaLlon
or psychosls?
MCA?
Low oLency?
Plgh oLency?
lf paLlenL has a hlsLory
of medlcaLlon non-
adherence?
urple grey meLalllc rash
over sun-exposed areas
and [aundlce?
rolonged C1c and
plgmenLary reLlnopaLhy?
lM haloperldol.
u2 recepLor anLagonlsL. [ mesollmblc LracL helps + sxs.
Causes hyperprolacLlnemla and LS.
Chlorpromazlne and 1hlorldazlne. Less LS more anLl-Ach
Paloperldol and lluphenazlne. More LS.
Can glve decanoaLe forms ever 2-4wks.
Chlorpromazlne
1hlorldazlne
L wakes up wlLh eyes
stuck looking up or head
stuck turned to the side.
L reporLs feellng llke Lhey
always have to move.
Coarse resLlng Lremor,
masked facles, unsLeady
galL, bradyklnesla.
AfLer 10 years on
fluphenazlne, Longue
movmenLs and glmaclng.
W/ln hours of a haloperldol
ln[ecLlons, pL has CPK, T =
103l, rlgldlLy, auLonomlc
lnsLablllLy, and dellrlum.
AcuLe uysLonla. (<12hrs).
1x w/ benzLroplne or
dlphenhydramlne
AkaLhesla. (30-90 days).
1x w/ propranolol (1
sL
llne) or benzo
arklnsonlsm. (>6mo)
1x w/ benzLroplne/dlphenhydramlne,
amanLldlne or bromocrlpLlne. nC1 L-dopa!!
1ardlve uysklnesla. (>years)
1x by sLopplng anLlpsychoLlc and
swlLchlng Lo and aLyplcal or clozaplne.
neurolepLlc MallgnanL Syndrome.
1
sL
- d/c Lhe offendlng med.
2
nd
- coollng blankeLs and danLrollne na
or bromocrlpLlne (2
nd
llne).
8emember LhaL meLoclopramlde,
compazlne and droperldol can cause.
ALyplcal agenL w/ hlghesL rlsk
for EPS and prolactin?
WelghL neuLral buL prolongs
Lhe C1c?
WelghL neuLral buL lncreases
akaLhesla?
MosL assoc w/ welghL galn?
(buL #1 S/L ls sedaLlon.)
Causes orLhosLasls and
caLaracLs?
Cood for Lx-refracLory
schlzophrenla?
MosL Common S/L-
MosL uangerous S/Ls-
MonlLorlng?
8lsperldone. 8uL comes ln depo shoL
Zlprazodone.
Arlplprazole.
Clazeplne
CueLlaplne (alpha blocklng properLles)
Clozaplne
Sedation, weight gain, blood sugar and lipids
AgranulocyLosls, decreased selzure Lhreshold.
C8C AnC qweek for 6mo and x2wks for nexL 6mo.
u/c lf W8Cs<3000 or AnC<1300
A 28 y/o female ls broughL ln by LMS complalnlng of
shorLness of breaLh, palplLaLlons and chesL paln. She
smokes 1 u and her only medlcaLlon ls CCs. She
had one of Lhese aLLacks prevlously whlle grocery
shopplng. She shares wlLh you LhaL she ls so afrald of
havlng anoLher one she rarely leaves her house.
WhaL ls your nexL sLep?
urug reglmen of cholce?
She ls broughL ln 3mo laLer wlLh
sxs of a Lemp of 101,
convulslons, confuslon and
hyperLenslon. She recenLly losL
her perscrlpLlon drug coverage.
LkC, cardlac enzymes, echocardlogram,
1SP or 14, urlne drug screen,
Alprazolam or clonazepam low dose 8n
shorL Lerm, buL SS8ls are Lhe preferred drug
*Dont give benzos to drug addicts, COPDers, or restrictive lung disease.
AcuLe benzo wlLhdrawal reacLlon.
Slmllar Lo u1s.
1x w/ dlazepam or
chlordlazepoxlde + haloperldol lf
psychoLlc.
MS4 w/ deaLhly fear of flylng
LhaL lnhlblLs her from
lnLervlewlng aL Lhe program
of her dreams.
MS3 w/ deaLhly fear of
presenLlng a case ln grand
rounds b/c she ls afrald Lhe
surgeons wlll laugh aL her.
MS2 keeps Lo herself and
doesnt talk with peers b/c
she ls afrald Lhey wlll laugh aL
her.
MS1 ls havlng dlfflculLy falllng
asleep b/c she keeps Lhlnklng
abouL falllng blochem. ln class
she cannoL concenLraLe b/c
she worrles her boyfrlend wlll
leave her. Sxs lasLlng >6mo
;.2+"@"+ A$)B"/.
8esL 1x ls C81 w/ floodlng or
exposure/exLlncLlon.
Can glve benzos for slLuaLlonal use.
;)+"/0 A$)B"/.
8esL 1x ls propranolol Lo sLop
hyperarousal and benzo.
-9)"7/5# A234)5/0"#, 1"4)3723.
8esL 1x ls C81
C2523/0"D27 -5*"2#, 1"4)3723.
8esL 1x ls 8usplrone (3P1 1a parLlal
agonlsL), buL musL glve benzos Lo
brldge b/c lL Lakes >3wks Lo work.
18y/o who [usL sLarLed college has decllnlng grades.
He states he cant make it to class on time because he
spends 2-3 hours scrubblng ln Lhe shower each
mornlng. Pe knows Lhls ls excesslve buL on days he
takes shorter showers, he states he can feel the
bacteria and worrles abouL conLracLlng an lllness.
ux?
Comorbld CondlLlon?
1x?
Cbsesslve Compulslve ulsorder
Plgh prevelance of vocal-moLor
Llcks and 3-7 of CCu pLs have
full blown 1oureLLes.
Clomlpramlne ls gold sLandard
SS8ls are flrsL llne.
A 23 y/o sexual assaulL survlvor comes Lo you wlLh a
6wk hlsLory of recurrenL nlghLmares of when she was
raped aL knlfepolnL. She now avolds slLuaLlons where
unknown men wlll be presenL, Lo Lhe polnL LhaL she
had Lo qulL her [ob aL a bank. She reporLs belng
jumpy anyLlme she hears fooLsLeps behlnd her.
ux?
1x?
lf same sxs, buL only
presenL for 3wks?
lf same sxs, buL ln
response Lo a bad
breakup?
osL 1raumaLlc SLress ulsorder
SerLrallne or paroxeLlne. Comblned w/ C81. razosln for nMs
AcuLe SLress 8eacLlon
Ad[usLmenL ulsorder
A 34 y/o 8n presenLs w/ a hlsLory of
2mo of dlarrhea and abd paln. Pe
has presenLed Lo 4 oLher hosplLals
w/ Lhe same complalnL.
Colonoscopy reveals plgmenLaLlon
ln Lhe wall of Lhe colon
A concerned moLher presenLs wlLh
her 13mo baby who ls havlng
recurrenL selzures. She requesLs an
M8l, sleep deprlved LLC wlLh
lnLracranlal leads.
A 43 y/o unemployed man ls
lnvolved ln a car accldenL. Pe sues
Lhe drlver sLaLlng he has nerve
damage Lo hls legs LhaL keeps hlm
from walklng. vldeo evldence
shows hlm danclng aL a club Lhe
nlghL before.
E%5+$/%425 ;,573)&2.
More severe Lhan slmple
facLlLlous d/o b/c Lhey
acLually lnduce sxs. (ln Lhls
case, w/ laxaLlve abuse).
1hey do lL for '(+,#() -#+%.
E%5+$/%425 ;,573)&2 B, .3)*,.
A form of chlld abuse!
10 of chlldren dle before reachlng
adulLhood.
E/0"5F23"5F.
Coes as a v-code
AssoclaLed w/ anLlsoclal
personallLy dlsorder
1hey do lL for *"./%$#() -#+%.
A 18 y/o l presenLs wlLh no mensLrual cycle for
3mo. A pregnancy LesL ls negaLlve buL her 8Ml ls
calculaLed Lo be 17. Per LeeLh are eroded and
she has calluses on her knuckles (8ussel slgn).
LaboraLory abnormallLles-
vlLal slgns
C8C
ChemlsLry
1l1s
lasLlng Llpld roflle
Pormones
Long Lerm compllcaLlons-
MosL common cause of deaLh-
1reaLmenL-
CompllcaLlons of 1reaLmenL-
PypoLenslon, 8radycardla, PypoLhermla
Leukopenla
Plgh PCC3, low Cl, low k, hlgh caroLene, hlgh Ll1s and amylase
normal
Plgh cholesLerol
Plgh corLlsol, low LP/lSP, low esLrogen
CsLeoporosls
PearL dlsease. 1hen sulclde.
Admit them to maximize nutrition. SSRIs help bulemia, anoexia
needs lnLenslve counsellng.
8e-feedlng syndrome = low C4, low Mg, low Ca and fluld reLenLlon.
Sleep LLCs
Awake
SLage 1
SLage 2
Slow wave sleep-
SLage 3 <30 delLa, SLage 4 >30
Sleep walklng/Lalklng/nlghL Lerrors
8LM.
SkeleLal muscle
paralysls
1rouble falllng asleep or
sLaylng asleep causes
lmpalrmenL ln fxn >1mo.
As falllng asleep, feel
creepy-crawlles on legs,
beLLer when Lhey geL up
and move.
uayLlme sleeplness and
depresslon ln a blg faL guy
wlLh a blg neck.
lrreslsLlble aLLacks of
refreshlng (8LM) sleep.
upon lnLense emoLlon,
Lhey lose muscle Lone or
have halluclnaLlons as
waklng of falllng asleep.
=54)&5"/.
LducaLe abouL sleep helgyne 1
sL
, Lhen Lry
benzos (reduce sleep laLency and lncr
SWS and 8LM). Zolpldem, zaleplon,
escoplclone are CA8Aa recp
1,44)&5"/ GH;.
8/o medlcal causes 1
sL
le-def anemla
or chronlc kldney dz. neuropaLhy.
1x w/ roplnlrole or pramlpexole (ua-ag)
HB4#3%+#"92 ;022. -.52/.
Goes on axis III, breathing related sleep
d/o goes on axis I.
need polysomnogram Lo dlagnose >10
hypopnelc/apneas per hour. need CA
Lo reduce pulmonary P1n.
G/3+)02.4,.
1x w/ scheduled naps and Modaflnll.
30 y/o man and ls wlfe presenL for couples
counsellng. Pe consLanLly accuses her of
cheating. Hes in a feud w/ the neighbor b/c
he feels Lhey are aLLacklng hls characLer
when Lhey say Lhey llke hls flowerbeds.
30 y/o man, never been marrled or have
any close frlends. Works as a nlghL securlLy
guard and ln hls free Llme works on hls
model shlps ln hls basemenL.
30 y/o man, never been marrled or have
any close friends because people make him
uncomfortable. He is unemployed because
he spends hls Llme readlng books on how Lo
communicate with animals so he can be at
one with nature.
A/3/5)"7 A1
Low dose anLl-
psychoLlcs can
help paranold
behavlor.
;+$"D)"7 A1
ulsLlngulsh from
AvoldanL b/c Lhey
dont WANT
relaLlonshlps
;+$"D)#,./0 A1
ulsLlngulsh from
Schlzold by
maglcal Lhlnklng/
lnLeresLs.
ulsLlngulsh from
Schlzophrenla by
lack of delus/hallu
23y/o man comes Lo courL mandaLed counsellng
for beaLlng hls glrlfrlend. Pe was klcked ouL of
hlgh school for flghLlng & [usL goL ouL [all for
sLeallng a car.
Pls glrlfrlend has a hx of unsLable relaLlonshlps,
has superflclal cuLs on boLh wrlsLs, ls lmpulslve
ln her spendlng and sexual pracLlces.
26 y/o MS2 ls asked by nan Clare Lo seek
counsellng. Per classmaLes complaln LhaL she
dresses Loo provocaLlvely Lo class. She recenLly
Lrled Lo seduce a professor.
A 22 y/o MS1 doesnt feel like he needs to come
to any classes or labs because he already has
Lhe brllllance Lo be a docLor. Pe refuses Lo Lalk
Lo nan Clare abouL Lhls, lnsLead lnslsLlng Lo deal
dlrecLly wlLh resldenL Penrlch.
-5#"4)+"/0 A1.
2/3 have
subsLance
abuse.
8)37230"52 A1.
Commonly use
spllLLlng.
?"4#3")5"+ A1.
Look for
subsLance abue
or eaLlng d/o
G/3+"44"4#"+ A1.
Can be confused
w/ hypomanla b/c
of grandloslLy.
Clve lndlvldual
Lhearpy
30 y/o woman has no frlends and avolds
happy hours wlLh her coworkers b/c she
fears ridicule and rejection. She feels no
one would want to be friends with me.
30 y/o woman has [umped from one
relaLlonshlp Lo anoLher because she
doesnt do well alone. She calls her
frlends and famlly >20x a day Lo geL Lhelr
lnpuL on her dally declslons.
23 y/o MS4 spends more Llme color codlng
her noLes and LexLbook hlghllghLlng Lhan
acLually sLudylng. She makes llsLs and sLudy
schedules 3 times per day. People dont like
to work with her because she is so anal.
-9)"7/5# A1.
Can Lx soclal
phobla sxs w/ b-
blocker or SS8l
12.25725# A1.
Look for co-
morbld
depresslon and
anxleLy. SS8l
HB4244"92
I)&.%04"92 A1.
ulfferenL from
CCu b/c Lhe
acLlons are
ego-syntonic
78 y/o lady ls broughL ln from her nurslng home
for alLered menLal sLaLus. She sleeps more
durlng Lhe day and becomes aglLaLed aL nlghL-
reporLlng seelng green men ln Lhe corner. She
also complalns of paln upon urlnaLlon.
llrsL sLep?
8lggesL rlsk facLor?
CLher common causes?
LLC flndlngs?
1reaLmenL?
ln her case, uA and culLure.
Work up also lncludes glc, na, blood culLures, 812, 88
Make sure Lo look aL med llsL- benadryl, oplaLes, 8zs
Age. underlylng demenLla ls Lhe 2
nd
blggesL
AcuLe subsLance wlLhdrawal. Look for lL on
Lhe 2
nd
or 3
rd
posL-op day ln alcohollc.
ulffuse background slowlng of background rhyLhm.
sychosls has normal LLC.
8educe excesslve sLlmull, calendar and clock Lo orlenL
paLlenL. SLop unnecessary meds. Clve haloperldol lf
aglLaLed.
A 78 y/o female presents with memory loss
Aphasla, apraxla, geLs losL
whlle drlvlng?
aLhology?
Cenes?
1reaLmenL?
8ecomes more sexually
expllclL, apaLhy.
aLhology?
1reaLmenL?
llucLuaLlon ln consclousness,
vlsual halluclnaLlons and
shuffllng galL.
aLhology?
1reaLmenL?
Alzheimers Dementia. MC Lype.
On MMSE, prompting does not recall
Clobal braln aLrophy. 8-amylold plaques or Lau Langles
A (on chr 21), ApoL L2
uonepezll, rlvasLlgmlne, galanLamlne (dlarrhea). MemanLlne
J3)5#)#2&.)3/0 12&25#"/. (Picks Dz).
Lobar aLrophy. lnLra-neuronal sllver sLalnlng lncluslons.
Clanzeplne for severe dlslnhlblLlon.
lnLra cyLoplasmlc Alpha-synucleln lncluslons ln neocorLex
Clve Ach-Lase lnhlblLors. nC1 L-dopa. Avold neurolepLlcs.
!2K, 8)7, 12&25#"/
A 78 y/o female presents with memory loss
Sudden, sLep-wlse decrease ln
memory/cognlLlons.
Loss of vlbraLlon sense, lablle
affecL. upll LhaL accommodaLes
but doesnt react.
ux?
1x?
Myoclonus, sLarLle response,
selzures. 8ecenLly had a corneal
LransplanL.
aLhology?
LLC flndlngs?
lnconLlnence, galL dlsLurbance/freq
falls, and rapldly developlng
demenLla.
ux?
1x?
L/4+%0/3 12&25#"/.
(23#"/3, ;,.$"0"4.
I32%#D@207# M/N)B.
G)3&/0 A3244%32 ?,73)+2.$/0%4.
+88, vu8L. uo splnal Lap Lo look for splrocheLes.
lv penlclllln. lf en-allerglc, musL desenslLlze.
Sponglform encephalopaLhy
*1rlphaslc bursLs*
C1/M8l shows hydrocephalus, splnal Lap shows nl openlng pressure
venLrlculoperlLoneal shunL lmproves cognlLlve fxn ln 30-67 of pLs
A 30 y/o known alcohollc presenLs Lo Lhe L8
wlLh Lonlc clonlc selzures. 8 180/110, P8 118, 1
100.1.
Pow long slnce hls lasL drlnk?
Pow long Llll he develops confuslon,
flucLuaLlons ln consclousness and Lhe
feellng of anLs crawllng on hlm?
Pls blood alcohol level ls 223mg/mL.
Pow long Llll lLs ouL of hls sysLem?
lf hls medlcaLlons lncluded
propranolol, lacLulose, and
allopurlnol, whaL would be Lhe besL
slgn Lo monlLor for hls wlLhdrawals?
~12-24hrs. (blmodal peak aL 8 and 48hrs)
~48-72hrs slnce lasL drlnk ls
when dellrlum Lremens usually
sLarL.
~9hrs, Alcohol ls meLabollzed
by zero order klneLlcs (same
amL/unlL Llme = 23mg/hr)
8eLa-blockers mask Lhe slgns of
auLonomlc hyperacLlvlLy, buL you
can follow hyperreflexla Lo dose
Lhe benzos durlng w/drawal.
8esL lnlLlal LreaLmenL of our
paLlenL?
What if hes a Childs class C
clrrhoLlc?
MosL speclflc LesL for L1CP
consumpLlon ln Lhe pasL 10
days?
Cur nexL paLlenL comes ln
w/ confuslon, aLaxla, and
you flnd Lhls on physlcal
exam: ux?
8esL 1
sL
sLep?
commons.wlklmedla.org
ulazepam or chlordlazepoxlde b/c
Lhey have 80 & 120hr x-llves
respecLlvely.
Lorazepam, oxazepam or Lemazepam
b/c Lhey are glucuronldaLed prlor Lo ellm
CarbohydraLe-deflclenL Lransferrln.
Less speclflc- elevaLed CC1 and AS1
more Lhan Lwlce AL1.
O235"+N2 P5+2.$/0)./#$,.
Caused by Lhlamlne deflclency
Clve Lhlamlne 1sL, Lhen glucose
conLalnlng flulds.
Can progress to Korsakoffs
syndrome (lrreverslble damage Lo
mamlllary bodles, eLc)- apaLhy,
anLer/reLrograde amnesla and
confabulaLlon. Can see M8 aLrophy
on M8l
A paLlenL ls broughL lnLo Lhe L8 ln a non-
responslve sLaLe. Pls 8 ls 100/60, P8 ls 30, 88 ls
6. Pe has mulLlple Lrack marks on hls arms.
8esL flrsL sLep?
?ou reallze hls puplls are dllaLed.
uoes LhaL change your dx?
WhaL sxs Lo you expecL as he
sLarLs Lo wlLhdraw?
1reaLmenL?
lnLubaLe Lhe paLlenL. 1hen glve lv or lM naloxone
(full mu-oplaLe anLagonlsL)
no. 1he hypoxla 2/2 resplraLory
depresslon can cause hypoxla
!olnL and muscle paln, phoLophobla,
goosebumps, dlarrhea, Lachycardla,
P1n, Cl cramps, dllaLed puplls,
anxleLy/depresslon
Clonldlne for auLonomlc sxs, lbuprofen for muscle cramps,
loperlmlde for dlarrhea.
MeLhadone, buprenorphrlne or nalLrexone can be used for
long-Lerm dependence.
L presenLs wlLh horlzonLal
nysLagmus, dllaLed puplls,
aLaxla and acuLe psychosls.
L presenLs s/p MvC wlLh
ln[ecLed con[uncLlva, sedaLlon
and ls asklng for uorlLos (cool
ranch plz).
L presenLs wlLh Sl,
hypersomnla, depresslon and
anergla.
L presenLs wlLh dllaLed
puplls, selzure, Lachycardla
and P1n.
8esL 1
sL
LesL?
1x of P1n and Lachycardla?
Palluclnogen (C) lnLoxlcaLlon.
Can use haloperldol for acuLe
psychosls.
Cannabls lnLoxlcaLlon.
Cocalne/AmpheLamlne
wlLhdrawal.
Cocalne/AmpheLamlne lnLoxlcaLlon
LkC Lhen urlne Lox screen. 1x selzure w/ lorazepam
Calclum channel blocker.
8eLa-blockers are CCn18AlnulCA1Lu!
Chlldhood uevelopmenL
P3"N4)5 A"/F2# J32%7
8lrLh 1 year
1 year-3 years
3 years-3 years
6 years- 11 years
11 years-
adolescence
21 years 40 years
40 years- 63 years.
> 63 years
1rusL vs MlsLrusL
AuLonomy vs Shame
lnlLlaLlve vs CullL
lndusLry vs
lnferlorlLy
ldenLlLy vs role
dlffuslon
lnLlmacy vs lsolaLlon
CeneraLlvlLy vs
sLagnaLlon
lnLegrlLy vs
ulspalr
;254)3"&)#)3-
conLrol moLor
funcLlon- ob[ecL
permanence
A32).23/#")5/0-
LgocenLrlc
I)5+32#2 H.23/#")5/0-
ueaLh ls permanenL
J)3&/0 H.23/#")5/0-
1hlnk absLracLly,
deducLlve
reasonlng,
hypoLheLlcal
Lhlnklng.
Cral
Anal
halllc
LaLenL
CenlLal
An 11 year old boy ls evaluaLed for developmenLal
delay, poor school and soclal performance. lormal lC
LesLlng reveal hls lC Lo be 30. Pe has a macrocephaly,
long face and macroorchldlsm
WhaL degree of menLal
reLardaLlon?
WhaL ls average and
sLandard devlaLlon for lC?
Where does lL go ln Lhe
uSM-lv?
WhaL ls Lhe mosL llkely
cause ln Lhls case?
ModeraLe.
Mlld- 33-70
ModeraLe- 40-33
Severe- 23-40
rofound- <23
Average ls 100, SLandard devlaLlon ls 13
Axls ll
lraglle x
x-llnked domlnal lnherlLance
CCC repeaLs w/ anLlclpaLlon
Cx = Selzures, Mv, dllaLlon of Lhe aorLa,
Lremors, aLaxla, AuPu-llke behavlor.
MC cause of lnherlLed M8.
A newborn baby has decreased Lone, obllque
palpebral flssures, a slmlan crease, blg Longue,
whlLe spoLs on hls lrls
WhaL can you Lell hls
moLher abouL hls expecLed
lC?
Common medlcal
compllcaLlons?
PearL?
Cl?
Lndocrlne?
Msk?
neuro?
Cancer?
Downs Syndrome
Pe wlll llkely have mlld-moderaLe M8.
Speech, gross and flne moLor sklll
delay
vSu, endocardlal cushlon defecLs
Hirschsprungs, intestinal atresia, imperforate anus, annular pancreas
PypoLhyroldlsm
ALlanLo-axlal lnsLablllLy
Incr risk of Alzheimers by 30-33. (A ls on Chr21)
10x lncreased rlsk of ALL
Cafe-au-lalL spoLs, selzures large head.
AuLosomal domlnanL
Coarse facles, shorL sLaLure, cloudy
cornea. AuLosomal recesslve.
8road, square face, shorL sLaLure, self-
ln[urlous behavlor. ueleLlon on Chr17
PypoLonla, hypogonadlsm,
hyperphagla, skln plcklng, agresslon.
ueleLlon on paLernal Chr13.
Selzures, sLrablsmus, soclable w/
eplsodlc laughLer. ueleLlon on
maLernal Chr13.
Llfln-appearance, frlendly, lncreased
empaLhy and verbal reasonlng ablllLy.
ueleLlon on Chr7.
neuroflbromaLosls
Purler Syndrome
SmlLh Magenls
rader-Wllll
Angelman
Wllllams
AuPu-llke sxs, mlcrocephaly, smooLh
phllLrum. MosL common cause of
menLal reLardaLlon.
Selzures, chorloreLlnlLls, hearlng
lmpalrmenLs, perlvenLrlcular
calclflcaLlons, peLechlae [ blrLh,
hepaLlLls.
Selzures, hearlng lmpalrmenLs, cloudy
cornea/reLlnlLls, hearL defecLs, low
blrLh welghL.
Abnormal muscle Lone, unsLeady galL,
selzures, menLal reLardaLlon or
learnlng dlsablllLy.
leLal Alcohol Syndrome
CongenlLal CMv
lnfecLlon.
CongenlLal 8ubella
Syndrome
Cerebral alsy from
blrLh asphyxla.
luC8, hyperLonla, dlsLlncLlve facles,
llmb malformaLlon, self-ln[urlous
behavlor, hyperacLlve.
Coloboma, hearL defecLs, choanal
aLresla, growLh reLardaLlon, Cu
anomalles, ear deformlLy and
deafness. Chr 8.
AuLlsm specLrum sxs, hearL dlsease,
palaLe defecLs, hypopasLlc Lhymus,
hypoCa. Chr 22 deleLlon.
vomlLlng, selzures, leLhargy, coma.
Acldosls w/ sLress, lllness. Causes
neurologlcal damage.
psychneL-uk.com
Cornella de Lange
CPA8CL
ulCeorge
Maple Syrup urlne
ulsease
Lxcluslvely ln glrls, normal
developmenL for 6-8mo, Lhen
regresslon, handwrlnglng, loss of
speech and use of hands. x-llnked
domlnanL deleLlon of MLC2.
normal developmenL unLll age 2 Lhen
ma[or loss of verbal, soclal skllls w/
auLlsLlc llke behavlor.
Lack of moLher-chlld eye conLacL,
language delay/repeLlLlve language,
peroccupation w/ parts of toys
before age 3.
roblems wlLh soclal skllls (usually
recognlzed ln preschool) w/ reserved
verbal ablllLy.
8eLL Syndrome
Chlldhood
ulslnLegraLlve
ulsorder
AuLlsm
Asperger
A 7 year old boy ls broughL ln by hls parenLs.
1hey reporL he musL be Lold several Llmes Lo
compleLe hls chores, Lhey cannoL geL hlm Lo
focus on compleLlng hls homework (he ls easlly
dlsLracLed), and LhaL he ofLen loses hls shoes,
penclls, books, eLc.
ulagnosls?
nexL besL sLep?
8lsk facLors for AuPu?
Comorbld condlLlons?
1reaLmenL?
normal, age approprlaLe behavlor.
Get information from the childs school/teacher
77 herlLablllLy. L8W, Lobacco/L1CP exposure
Cuu/Cu ln 30-30
MeLhylphenldaLe-
AmpheLamlne-
ALomoxeLlne-
8andoms-
AuPu Meds
E27"+/#")5 EH- ;"72 P@@2+#4
MeLhylphenldaLe
(ConcerLa, 8lLalln)
AmpheLamlne
(Adderall)
ALomoxeLlne
(SLraLLera)
8 meds
(clonldlne, guanfaclne)
AnLldepressanLs
(Sn8ls, 1CAs, MACls)
8locks uA reupLake Nausea, appetite,
lncr P8 and 8,
sLunLed growLh
8locks uA/nL reupLake
& sLlmulaLes release
nL reupLake lnhlblLor.
non sLlmulanL
ury mouLh, lnsomnla,
decreased appeLlLe
Alpha 2 agonlsLs,
reduce perlpheral SnS
uecreased 8. Causes
sedaLlon
revenLs nL reupLake and
lncreases ln synapse
uleLary resLlcLlons w/ MACl.
ArrhyLhmlas ln 1CAs
A 14 year old boy ls senL for courL mandaLed
counseling. He stole his neighbors lawn mower and
Lhen seL flre Lo hls Lool shed. Pe has a 3 year hlsLory
of Lruancy from school and assaulLed a 13 year old
school maLe.
A 14 year old boy ls broughL ln by hls grandmoLher.
lor Lhe pasL year, he has been geLLlng ln Lrouble aL
school for belng argumenLaLlve and dlsrespecLful Lo
hls Leachers. Pe defles Lhe rules she seLs for Lhe
house and ofLen dellberaLely annoys her.
I)57%+# 1"4)3723. need sxs for 6mo.
Comorbld subsLance abuse.
May progress Lo anLl-soclal personallLy dlsorder.
H..)4"#")5/0 12@"/5# 1"4)3723. need sxs for 12mo.
SLops [usL shorL of breaklng Lhe lay or physlcally harmlng
oLhers.
A 9 year old boy ls senL Lo counsellng aL Lhe
recommendaLlon of hls Leacher. She sLaLes LhaL aL
leasL once a day he makes loud grunLlng nolses and
hand movemenLs LhaL are dlsrupLlve Lo Lhe class.
ux?
Comorbld condlLlons?
1x?
llrsL llne?
MosL LffecLlve?
lor Llcs Lo quallfy as 1oureLLes Lhey musL occur aL
leasL once a day for 1 year w/o a Llc-free perlod
longer Lhan 3mo.
Look for Lhe compulslons of CCu
Clonldlne 2/2 relaLlvely benlgn S/L proflle
Paloperldol or plmozlde- uA-recepLor anLagonlsLs.
7 year old complalns of frequenL abdomlnal
paln resulLlng ln many mlssed school days. Pe
never geLs Lhe paln on Lhe weekends or ln Lhe
summer.
6 year old adopLed chlld ls broughL ln because
she has noL formed a relaLlonshlp wlLh her
adopLlve parenLs. She ls lnhlblLed and hyper
vlgllanL.
An 18mo old baby has recenLly been
regurglLaLlng and re-chewlng her food. She had
prevlously been eaLlng normally.
6y/o sLools ln her cloLhes once every 2 weeks.
nexL besL LesL?
1x?
6 y/o urlnaLes ln her cloLhes once a day.
nexL besL LesL?
1x?
SeparaLlon AnxleLy
ulsorder
8eacLlve
ALLachmenL
ulsorder
8umlnaLlon
ulsorder.
Check lead levels.
Check for fecal reLenLlon.
8ehavloral modlfcaLlon LhaL only rewards
uA and urlne culLure.
Alarm and pad for 6wks. 1CAs reduce bed weLLlng buL relapse ls
common. uuAv has Lhe same prob + S/L = headaches, nausea,
and hyponaLremla.