JOINT NEUROPSYCH CONFERENCE

1. JOINT NEUROPSYCH CONFERENCE BLOCK 5B

2. The patient is LM, a 31/M, a heavy alcoholic drinker, but otherwise a previously healthy individual with no known comorbidities. • Typhoon Ondoy occurred and flooded the streets a week prior to admission.

3. 3 days PTA, • Patient had history of undocumented fever, dyspnea, weakness, pain on the lower back, chest, RUQ, right flank and lower extremity, loose yellowish stool 4x a day, cough and colds with whitish sputum, oliguria, tea colored-urine and vomiting. (+) History of wading in the flood. Patient self-medicated with paracetamol with no relief of symptoms.

4. Days prior to admission, • The patient did not have any change in behavior or consciousness. He also reported to be constantly intoxicated on previous days, before or even after the typhoon

5. On the day of admission: • Patient was seen at the ER and found to have persistence of symptoms, with BP of 90/60, heart rate of 112, respiratory rate of 22 and afebrile.

6. HISTORY • 1st MICU Day (Thursday) • On interview, the patient was agitated and kept on calling names of people he knows, but are not present in the room • He kept on saying “kamukhani…” or “hawigni…” • He was very agitated, and had a short attention span as he kept on reiterating that he wanted to go to the bathroom, even when he was reminded constantly that he already had a catheter

7. HISTORY Underwent dialysis • During neck and femoral fistula placement, when asked by the fellow if he was in pain, he would just shrug his head and appeared passive to any sensation of pain • (+) hypotensive episodes (80/50) while on dialysis, dopamine drip increased • (+) waxing and waning of consciousness • He would ask about his blood pressure, and he would ask if the IVF were running • (+) regard, but started talking gibberish with right intonation --> Felt frustrated when he was not understood, sighed and looked exasperated • After 30 minutes, he was comprehensible again, and recognized his father, repeated his need to urinate

8. Would become irritable at times, complaining to his watchers about his clothes • “yung shorts ko” which he was wearing prior to the dialysis, and insisted on wearing them in spite that the nurse already told him to wait for awhile because the fistula was going to be cleaned and bandaged • Remembered his “missing” shirt, and said that it was ok if it was lost because it was already old, but the patient came to dialysis already shirtless

9. Pt was also seen talking/mumbling to himself loudly and saying incoherent phrases like “may buhangin ka samukha” • Pt is sometimes awake, and would tug at his IV lines, and attempt to start conversations with those passing by • Pt has also some lucid moments and was inquisitive • Would ask those who would monitor when they went home, where they lived

10. 2nd MICU day (Friday) • Patient wanted to drink water, and his father assisted him. After taking a sip, he turned the bottle over the side and spilled all the water on the floor. During this time he recognized his father • Patient would try to attract the attention of passers-by, “psst…psst” even if he doesn’t know them • At times, he himself would cooperate and raise his arm when the monitoring team would come • He would sometimes reach through air, as if grabbing some objects, and picking at imaginary things

11. 3rd MICU day (Saturday) • Patient was noted to be tachycardic, febrile, nauseated, with myoclonic seizures, and tremors • Patient started to sing loudly • He said “mayroonakongpusasadibdib” and he would place his hands over his chest in an attempt to remove it • Patient asked “nasaang beer house ako?”

12. 4th MICU Day • The following morning, the patient was observed to be more subdued, and not as loud as the previous days. • CODE

13. Past Medical History: unremarkable • Past Family Medical History: • (+) heart disease and hypertension, father • (+) occasional alcoholic beverage drinkers • Past Psychiatric History • unremarkable

14. Personal and Social Profile • The patient finished High school • Currently works as a pedicab driver • (+) smoking, 5 pack years • (+) heavy alcoholic drinker, drinks everyday until he passes out

15. ANAMNESIS • Prenatal & Perinatal • Pt was born via SVD to a then G5P4 mother, with no reported FMC. He was a product of a wanted pregnancy and is the youngest of 5 siblings • Early Childhood • Pt was breastfed for three months and then was shifted to bottle feeding. Father reports that pt was at par with children of his age. No developmental delays were noted. As a young boy, he was fond of playing with his siblings. • Middle Childhood • Pt started schooling at age 6. He was an average student until elementary. He had to stop studying when he was in grade 5 due to financial constraints. He then had to help with his mother and siblings sell fruits to provide added income to the family. He was always picked upon by his siblings during this time and would come to his mother for comfort. He had some friends and wasn’t able to play because he had to help earn income.

16. Late Childhood • Pt started to have a barkada whom he would always spend time with. This was when he started to have habits of drinking and smoking. He started to become aloof from his siblings. He confided his family problems with his friends. • Adulthood • His drinking habits persisted and even worsened getting him mostly into trouble with the other drunkards of the neighborhood. He tried to do different jobs to earn a living, but he had the most success as a pedicab driver. He had several relationships with women but was not able to keep them due to his drinking problem. He still lived with his parents.

17. PHYSICAL EXAMINATION General Survey: • Awake, conscious, conversant, weak-looking, not in respiratory distress. Vital Signs: • BP 90/60 • HR 104 • RR 22 • TempAfebrile

18. PHYSICAL EXAMINATION HEENT: • Pink conjunctivae, ictericsclerae, pupils EBRTL, (+) subcojunctival suffusion, (-)NVE, (-) CLAD, (+) sunken eyeballs, dry lips and buccal mucosa Chest/Lungs: • ECE, CBS, (-) alar flaring, (-) use of accessory muscles on respiration, (-) wheezes, (-) crackles CVS: • DHS, AP, tachycardic, regular rhythm (-) heaves, (-) thrills, (-) adventitious heart sounds Abdomen: • Soft, non-tender, NABS, (+) abdominal pain on direct palpation on RUQ, (+) CVA tenderness right side Skin/Extremities: • Pink nail beds, full and equal pulses, (-) cyanosis, (-) edema, (+) calf pain, (-) bleeding, (+) jaundice

19. MSE • General Description: Patient has unkempt hair, and long and dirty nails, shirtless, with soiled maong shorts and was seen lying on his bed. He had no distracting mannerisms, gestures, and pschymotor activity. However, he appeared agitated and would occasionally scan his environment. He has good eye contact, with ability to follow commands and requests and cooperative . Patient has episodes of talking gibberish, but with inflections and change in tone. But he still could talk spontaneously, in a normal rate, and normal tone, with clear and at appropriately placed inflections. Patient is cooperative.

20. MSE • Functional assessment : Patient could still feed himself • Mood, feeling, and affect: patient was noted to have an over all blunted affect and constricted response, or a limited range of emotions • He answers in a logical,cohesive manner when asked, and gives relevant answers.

21. MSE • Perceptual Disturbance: There were preoccupations with his need to urinate and clothes. Aside from his confusion in identifying other people and calling out to them, there were hallucinations of seeing sand on faces, delusions of being inside a beer house. There were no suicidal and violent tendencies towards others and unusual dreams and fantasies expressed.

22. MSE • General Description: Patient has unkempt hair, and long and dirty nails, shirtless, with soiled maong shorts and was seen lying on his bed. • He was cooperative to the examiner and those who were monitoring. • The patient‘s speech was normally responsive to cues from the interviewer, he has normal quantity, and rate of production. However, he would occasionally utter gibberish. • He had no distracting mannerisms, gestures, and psychomotor activity. However, he appeared agitated and would occasionally scan his environment. He has good eye contact.

23. When the patient is asked, “kamusta ka na kuya?”, the patient answered: Ok lang. • The patient was irritable, and anxious.

24. MSE • Perceptual Disturbance: Aside from his confusion in identifying other people and calling out to them, there were hallucinations of seeing sand on faces, delusions of being inside a beer house.

25. Thought Content and Process • There were preoccupations with his need to urinate and clothes. • There were no tangentiality, circumstantiality, rambling, or evasiveness. • There were no suicidal and violent tendencies towards others and unusual dreams and fantasies expressed.

26. The patient is alert, but only oriented to self, has poor concentration, poor memory and poor fund of knowledge • Poor insight to illness • When asked why the patient was in the hospital: “Nagtatae kasi ako”

27. Laboratory Results ABG • 10/15 FiO2 21% Hgb 100 Tem 37 pH 7.394 pCO2 37.8 pO2 49.5 HCO3 23 TCO2 24.2 BE -1 O2 Sat 84.3% Urinalysis • 10/15 dark yellow/hazy/1.015/5.5/CHO neg/CHON 1+/RBC 10-12/WBC 0-4/Cast waxy 0-1/EC neg/Bac 1+/MT rare/Crystals Bilirubin rare/Bil 2+/Urobil normal/Ketone trace/Leuco neg/Nitrite neg/Hgb 3+ 12L ECG • 10/15 Sinus Tachycardia, Normal axis, NSSTTWCs BT : O+ CBC • 10/15 WBC 18.04 RBC 4.54 Hgb 140 Hct 0.374 MCV 82.4 MCH 30.8 MCHC 374 RDW 12.9 Plt 48 N 0.890 L 0.048 Electrolytes • 10/16 crea 136 K 2.2 • 10/15 HCV neg HbsAg neg BUN 13.07 (high) Crea 236 (high) AST 154 (high) ALT 75 (high) Na 126 (low) K 1.8 (low)

28. What does our patient have?

29. What other things will we consider in our patient?

30. MULTIAXIAL DIAGNOSIS

31. DSM-IVDIAGNOSTIC CRITERIA Alcohol Withdrawal Delirium

32. DSM-IV-TR Diagnostic Criteria for Alcohol Withdrawal • Cessation of (or reduction in) alcohol use that has been heavy and prolonged. • Two (or more) of the following, developing within several hours to a few days after Criterion A: • autonomic hyperactivity • increased hand tremor • insomnia • nausea or vomiting • transient visual, tactile, or auditory hallucinations or illusions • psychomotor agitation • anxiety • grand mal seizures • The symptoms in Criterion B cause clinically significant distress or impairment in social, occupational, or other important areas of functioning. • The symptoms are not due to a general medical condition and are not better accounted for by another mental disorder.

33. DSM-IV-TR Diagnostic Criteria for Substance (Alcohol) Withdrawal Delirium • Disturbance of consciousness with reduced ability to focus, sustain, or shift attention. • A change in cognition or the development of a perceptual disturbance that is not better accounted for by a preexisting, established, or evolving dementia. • The disturbance develops over a short period of time (usually hours to days) and tends to fluctuate during the course of the day. • There is evidence from the history, physical examination, or laboratory findings that the symptoms in Criteria A and B developed during, or shortly after, a withdrawal syndrome.

34. Diagnostic Criteria for Delirium Due to Multiple Etiologies • Disturbance of consciousness with reduced ability to focus, sustain, or shift attention. • A change in cognition or the development of a perceptual disturbance that is not better accounted for by a preexisting, established, or evolving dementia. • The disturbance develops over a short period of time (usually hours to days) and tends to fluctuate during the course of the day. • There is evidence from the history, physical examination, or laboratory findings that the delirium has more than one etiology (e.g., more than one etiological general medical condition, a general medical condition plus substance intoxication or medication side effect).

35. DELIRIUM • Delirium is a medical emergency. • Greater morbidity and mortality. • Often referred to a psychiatrist because of presenting psychiatric symptomatology.

36. CLINICAL SYMPTOMS OF DELIRIUM • Intermittent disorientation to time or place • Easy distractibility by irrelevant stimuli • Mumbling or muttering (dysarthric speech) • Hyper- or hypoactivity(agitation or hypersomnolence) • “Sundowning” (increased confusion in the early evening), or a subjective feling of confusion • Illusions and misperceptions or a predominance of visual hallucinations • Extreme emotional lability • Sudden inability to remember the events of the previous day • Transient difficulties in word-finding or disorganized speech

37. Differences in Pyschotic Symptoms in Psychiatric and Neurologic Disease

38. Differences in Pyschotic Symptoms in Psychiatric and Neurologic Disease

39. DISCUSSION Typhoid Encephalopathy

40. Typhoid Fever • AKA Enteric fever • Potentially fatal multisystemic illness caused primarily by Salmonella typhi • Caused by ingesting food or water contaminated with feces or urine containing the bacterium. • Classic Presentation: fever, malaise, diffuse abdominal pain, and constipation • Untreated typhoid fever may progress todelirium, obtundation, intestinal hemorrhage, bowel perforation, and death within one month of onset.

41. Typhoid Encephalopathy • Typhoid state, muttering delirium, coma vigil • Diffuse encephalopathy is a well-recognized entity in typhoid fever • Occurs in 10-15% of typhoid fever cases • Typically occurs in the third week of illness • Exact cause is unclear, but may be due to release of endotoxins

42. Typhoid Encephalopathy • Clinical Manifestations: decreased sensorium, usuallyapathetic but arousable, may be severely agitated,delirious, or obtunded • Prognosis: decreased sensorium with shock is associated with high mortality. Survivors may be left with long-term or permanent neuropsychiatric complications.

43. 1980’s Case Narrative The ‘typhoid state’ or ‘coma vigil’ supervenes and the prognosis is now grave. The patient lies on his back, too weak to move, unconscious of his surroundings, his trembling hands picking endlessly at the bedclothes, his eyes deceptively bright, but seeing little. He may continually whisper to himself until the coma deepens, his movements cease, and the death rattle heralds the final stage’.

44. Treatment of Typhoid Fever • With antibiotics, usually fluoroquinolones. • Alternatives: chloramphenicol, amoxicillin and trimethoprim–sulfamethoxazole • Unfortunately, resistance of S. typhistrains to all of these drugs is becoming more common, particularly in Asia, the Middle East and Latin America. • In resistant cases, consideration is given to a longer duration of quinolone therapy or to treatment with azithromycin or a third generation cephalosporin.

46. DISCUSSION Alcohol Withdrawal

47. Ethanol • Enhance inhibitory effects of GABA at GABA-A receptors • Blocks the NMDA subtype of glutamate, an excitatory amino acid (EAA) receptor • Chronic Exposure: tolerance to ethanol by enhancing EAA neurotransmission and NMDA receptor upregulation

48. Effects of Chronic Alcoholism on the Brain • Neurotoxic • Shrinkage of the brain owing to loss of both white and gray matter (Kril & Halliday, 1999) • Reduces brain metabolism and this hypometabolic state rebounds to a level of increased metabolism during detoxification

49. DSM-IV-TR Diagnostic Criteria for Alcohol Withdrawal • Cessation of (or reduction in) alcohol use that has been heavy and prolonged. • Two (or more) of the following, developing within several hours to a few days after Criterion A: • autonomic hyperactivity • increased hand tremor • insomnia • nausea or vomiting • transient visual, tactile, or auditory hallucinations or illusions • psychomotor agitation • anxiety • grand mal seizures • The symptoms in Criterion B cause clinically significant distress or impairment in social, occupational, or other important areas of functioning. • The symptoms are not due to a general medical condition and are not better accounted for by another mental disorder.

50. DSM-IV-TR Diagnostic Criteria for Substance (Alcohol) Withdrawal Delirium • Disturbance of consciousness (i.e., reduced clarity of awareness of the environment) with reduced ability to focus, sustain, or shift attention. • A change in cognition (such as memory deficit, disorientation, language disturbance) or the development of a perceptual disturbance that is not better accounted for by a preexisting, established, or evolving dementia. • The disturbance develops over a short period of time (usually hours to days) and tends to fluctuate during the course of the day. • There is evidence from the history, physical examination, or laboratory findings that the symptoms in Criteria A and B developed during, or shortly after, a withdrawal syndrome.