Examen fisica, examen neurologico, mini mental: contra por 7, orientation, memory, follow directions (read oracion, copia un reloj)




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Neuropsychiatry

07/29/02 1-5PM

Delirium and Dementia, Parkinson’s Disease and Other Movement Disorders

Dr. Vera Ramirez, MD

  1. Delirio: subito

  2. Dementia

    1. Deterioro progresiva de cognicion, memoria, manera de que razonamos, hablar

    2. Progressive cognitive and emotional impairment severe enough to interfere with daily function and quality of life

    3. In evaluating the patient with dementia the most important goal is to rule out treatable causes of dementia

    4. Varios tipos de dementia: Alzheimer’s es mas comun, pero lo mas importante es descartar todas causas

    5. Treatable causes of dementia

      1. Hypothyroidism

      2. B12 deficiency

      3. Cerebral vasculitis

      4. Neurosyphilis: hace 2 semanas atras, paciente 75 anos, todo workup fue negativo excepto, un screening para syphilis

      5. HIV

      6. Depression

    6. Work-up

      1. History

      2. Physical and neurological examination

      3. Mini-mental state exam

      4. Review of medication and drug levels

      5. Serum chemistry, CBC, U/A, TSH, serum B12, VDRL, HIV, ABG’s, EKG, EGG, CT or MRI of the head, SPECT, lumbar puncture

  3. Case dementia

    1. Father and son visit dr, father has dementia 3 months duration

    2. To precisely find date when dementia began, can ask if lives alone, pays bills for water on time, or if hasn’t paid and has had the water shut off, poor memory

    3. Ask if works or not, maybe patient needs to be living with people

    4. Historia social, si fuma, si bebe, historia familial, toma drogas, si tiene amiguita steady o si cuando coge el cheque de seguro social si tiene muchas amiguitas

    5. Hijo puede decir que tomaba cuando era joven, o que hay latas tirades en la casa

    6. Examen fisica, examen neurologico, mini mental: contra por 7, orientation, memory, follow directions (read oracion, copia un reloj)

    7. Tratamiento: supervision, no debe dejar plancha prendida, deja notitas en nevera para acordarse de hacer quehaceres, aprenden cosas, viejitos son religiosas, la proximas cita quiero que aprendas un psalm que gusta mucho, compra rompecabeza y hacerlo, los sopas de letras

  4. Alzheimer’s dementia

    1. Epidemiology

      1. family history of alz dis (AD), parkinson’s (PD) or Down

      2. Age: >75

      3. Female mas comun

      4. Low education

      5. head injury: boxers

      6. link between cholesterol and beta amyloid?

      7. diabetes?

      8. depression?

    2. Pathology

      1. Gross pathology: atrofia de hipocampus

      2. Microscopic

        1. senile plaques

        2. neurofibrillary tangles

        3. granulovacuolar degeneration

    3. Neurochemistry: Choline acetylstranferase is diminished

    4. Genetics

      1. Late onset AD: chromosome 19 (ApoE)

      2. Early onset AD

        1. Chromosomes 1 (presenilin 2 mutation)

        2. Chromosome 14 (presenilin 1 mutation)

        3. Chromosome 21 (amyloid precursor protein): tiene que ver con down’s syndrome

    5. work-up: alz dis can be clinically diagnosed with an 85-95% accuracy

    6. pharmacologic treatment

      1. cholinesterase inhibitors

        1. tacrine: hepatotoxico, dar 4 veces al dia

        2. donepezil: 1 vez al dia

        3. rivastigmine: mecanismo adicional

        4. galantamine: mecanismo adicional

      2. disease-modifying drugs

        1. antioxidants: Vitamina E: ayuda memoria, mas corazon, dosis es alta, a veces paciente no lo tolera, 400mg/dia, aumenta 400mg/2 veces al dia, poco a poco tolera, 1000mg/dia, dosis recomendado es hasta 2000UI

        2. estrogen: en mujeres, se ha visto en laboratorio que ayuda a hacer que dendrites se mantengan, no se degeneren

        3. anti-inflammatory drugs

        4. nicotine?: no aceptado

        5. statins?

        6. Gingko biloba: ayuda memoria

  5. Vascular dementia

    1. Multiple large infarctions

    2. Multiple small infarctions

    3. Diffuse chronic vascular processes such as binswanger’s disease

    4. Examen fisico le va a tener idea que le paso algo porque tiene un hemiparesis

    5. factores de riesgo, diabetes

  6. frontotemporal dementia

    1. characterized by disordered initiation, goal-setting and planning with apathetic or uninhibited behavior

    2. most patients are unaware of their behavioral changes

    3. pathologic accumulation of hyperphosphorylated tau proteins in brain cells?

    4. Pick disease

  7. dementia associated with movement disorders

    1. huntington’s disease

    2. progressive supranuclear palsy: problema mirando hacia abajo en plano vertical, no responde a tratamiento levodopa

    3. parkinson’s disease: tratamiento levodopa, 30-60% desarrolla tipo alz

  8. hydrocephalus

    1. por trauma, puede causar dementia

    2. normal pressure hydrocephalus

    3. triada

      1. apraxia a caminar: como si tuviera pies pegado a suelo

      2. urinary inconteintein

      3. cognitive decline

  9. other dementia

    1. post traumatic dementia

    2. infections

      1. HIV

      2. Creutzfeldt-Jacob disease: onset rapid, EEG, va a deteriorar bien rapido, 3-4 meses muerto, si va a inglaterra no come mucho carne

      3. meningitis

    3. neoplasm

    4. drugs/toxins

  10. MOVEMENT DISORDERS

  11. Bradykinetic: parkinson’s

  12. Hyperkinetic

    1. Tremors

    2. Chorea

    3. Athetosis

    4. Dystonias

    5. Myotonias

    6. tics

  13. Multiple movement types in a single diagnosis

    1. Parkinson’s disease

    2. Huntington’s disease: AD, chrom 4, caudate nucleus, suicidio, anticipation, CAG nucleotides, mas repiticiones de nucleotides es peor pronostico, si hereda de padre son mas severo mas joven, si hereda de madre son severa mas tarde

    3. Wilson’s disease

      1. problema de metabolismo de copper metabolism, cirrhosis, chrom 13

      2. distonic features of left hand

  14. Parkinson’s disease

    1. Incidence and epidemiology

      1. Prevalence rates: 200 per 1,000,000

      2. rare for individuals <40 years of age

      3. 1% for individuals >60 years of age

      4. 2% for individuals >85 years of age

      5. Males>females

      6. Incidence rate: 20 per 100,000 (annually)

    2. Symptoms

      1. Tremor: pill rolling resting tremor

      2. Rigidity: pierda movimiento de brazo cuando camina, con espasmo muscular, duele el hombro porque esta rigido

      3. Bradykinesia: movimientos lentos, lento procesar la informacion, si no deja paciente pensar, la esposa habla por el

      4. Loss of postural reflexes: tell patient to close eyes, then pull patient backwards and see if they fall

      5. sialorrhea: no tiene reflejo de tragarlo, concientemente hay que tragarlo

      6. hipomimia: falta de expression facial, mira a la papa que no tiene expression facial, como si tuviera una mascara

    3. Classification

      1. Primary (idiopathic) parkinson’s disease: ver si tuvo medicamento neurolepticos, responde a medicamentos

      2. Parkinson plus syndromes: progressive supranuclear palsy

      3. Drug induced

        1. Phenothiazines/butyrophenones

        2. Metoclopramide (reglan)

        3. MPTP

        4. Calcium-channel blockers (Diltiazem)

        5. Alpha methyl dopa (Aldomet)

      4. Toxic

        1. Carbon monoxide

        2. manganese

      5. Vascular

        1. Multi-infarct

        2. Binswanger’s disease

      6. Trauma: pugilistic parkinsonism (ali)

      7. Infectious: post encephalitic parkinsonism (von economo’s): no responde a levo dopa

    4. pathology

      1. depigmentation and loss of neurons in the substantia nigra and other pigmented nuclei (that have dopamine)

      2. lewy bodies

      3. neurochemistry: loss of striatal dopamine

    5. therapy: levodopa

      1. benefits

        1. precursor of dopamine

        2. most effective therapy

        3. significantly extends life expectancy

      2. limitations

        1. nausea, constipation

        2. sleep disturbances

      3. usa con carbidopa

    6. therapy: dopamine agonists

      1. nos da mas tiempo, aunque no funciona tan efectivo para sintomas

      2. on-off phenom

      3. dyskinesia

    7. surgery

      1. pallidotomy

      2. thalamotomy

      3. deep brain stimulation

      4. autologous tissue transplant

      5. fetal mesencephalic tissue transplant

    8. tremor

      1. involuntary, rhythmic oscillating movement (parkinsons is resting tremor, versus cerebellar intention tremor)

      2. it may occur at rest (PD), on posture holding (physiologic and drug induced) or action (benign essential tremor)

      3. intention tremor, a type of action tremor is characteristic of cerebellar disorders, como en paciente con esclerosis multiple con finger pointing to nose

      4. no todo que tiene temblor es parkinson’s

    9. causes of tremor

      1. drugs

        1. amphetamines

        2. alcohol withdrawal

        3. valproate

        4. caffeine

      2. toxic/metabolic

        1. uremia

        2. thyrotoxicosis

        3. hypocalcemia

        4. heavy metals

    10. treatment

      1. propranolol (inderal)

      2. primidone (mysoline)

      3. BDZ

  15. Chorea

    1. Irregular, unpredictable, brief movements that flow from one body part of another in a non-stereotyped fashion, trata de esconderlo

    2. Causes

      1. drugs

      2. infections

      3. toxins

    3. conditions associated with chorea

      1. hunt

      2. Wilson

      3. syndenhams’ (rheumatic fever)

      4. lupus

      5. chorea gravidorum

      6. polycythemia vera

      7. hyper/hypothyroidism

  16. Dystonia

    1. Movimientos mas lentos

    2. Slow twisting movements usually with the peak of the movement sustained for a second or longer

    3. Dystonia may be generalized as in idiopathic torsion dystonia or focal (segmental)

    4. Torticolis (movement neck)

    5. Writer’s cramp, se queja que no puede escribir ni coger el lapis

    6. Focal dystonias

      1. blepharospasm

      2. torticolis

      3. writer’s cramp: thumb extends, elbow abducted during writing, during typings the fingers spontaneously flex

      4. oromandibularlingual distonia: tardive distonia, exposure to neuroleptics, jaw opening and closing, tongue protrusion and contortion

      5. breathy disfonia: causes abductor disfonia, patients vocal cords allow sounds to escape easily, whisper disfonia

    7. conditions associated

      1. parkinson’s

      2. huntington’s

      3. wilson’s disease

    8. motor cortex affected

    9. treatment: botulinum toxin, can have complete remission

  17. myoclonus

    1. very rapid, brief, almost shocklike jerks

    2. may involve very small muscles

    3. combing hair, then throws comb, can be prominent intention myoclonus seen trying to touch the finger to another finger and nose

    4. essential palatal myoclonus: rhythmical contraction of soft palate and associated with clicking in left ear

    5. causes

      1. infection: herpes

      2. metabolic

        1. uremia

        2. hypoglycemia

      3. trauma

      4. anoxia

    6. conditions associated

      1. wilson’s disease

      2. hunt

      3. creutzfeldt Jacob

  18. tics

    1. stereotypic, repetitive, intermittent, movements or sounds that characteristically is suppressible for some time but gets to a moment where they have to do it

    2. touch things, smell fingers, hit themselves, grind teeth, swing out arms, kick legs, shake head, if someone puts a thought into your mind like saying the word tongue they will stick out their tongue, grimace

    3. usually preceded by an urge to make the tic and followed by relief

    4. if vocal tic, patient will repeat word sthat others say, like in class will repeat what teacher says and yell it out

    5. volitional control, suppression by concentration if concentrate on counting and touching fingers

    6. treatment: haloperidol, pomozide

  19. pelicula

    1. tremor

      1. handwriting tremor: can’t draw spiral

      2. task specific tremor: can’t write certain numbers such as

      3. position specific tremo: hold glass with left hand close to mouth has tremor, not with right hand, nor with left hand far from mouth

      4. familial hand tremor: transiently relieved with alcohol

      5. puede tambien tener PD asociado

      6. head trauma complicated right 3rd nerve palsy and left hemiparesis, pronation supination tremor left arm while at rest and holding arm in outstretched position

      7. sicogenic tremor: also diagnosed as pseudoseizure, acute onset right hand tremor after she forgot to pick up daughter from school, spontaneously resolved, but recurred associated with stress, mas sicologico

    2. tardive dyskinesia syndrome

      1. 68 year old women touches scalp, complains of nervousness, squirms, can medically suppress akathesia

      2. tardive distonia and diskinesia: oral diskinesia, jaw opening distonia, no akathesia

      3. cocaine abuser took neuroleptics, diskinesias in cranial, cervical, and brachial regions, treatment with tetrabenazine has improvement but not complete

  20. group cases on thursday

    1. examen de importante

    2. diagnostico importante, donde esta lesion, diagnostico patologico, que haria

  21. class info

    1. chili’s 6 veronica

    2. election: wed

    3. meeting: wed

    4. comite graduacion: wed

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