delirium or psychosis 09.14.2011

8/4/2019 Delirium or Psychosis 09.14.2011

1/21

S E P T E M B E R 1 4 , 2 0 1 1

A N N I E P O W E R S

Morning Report


2/21

Case Presentation

Chief Complaint: She is spacing out

HPI:

18 year old female with four days of decreased need for sleepand decreased appetite

Difficulty with memory (couldnt spell her name, rememberwhat she ate for dinner)

Was more defiant at school

Talking on the home phone at school about making a moviewith Charlie Scheen

Believes she is 25, pregnant and it is her birthday (which is inMarch)


3/21

History

PMHx: Developmental Delay

ADHD

Wisdom teeth removed 2 weeks prior

SocHx: Lives with parents, stays with sister on occasion

Recently started new vocational rehabilitation school

Has a boyfriend, reports being sexually active

Denies drug and alcohol use FamHx: Paternal uncle with Bipolar Disorder


4/21

History

Development: Walked and talked after 2 years, mild intellectual disability,

functions at level of 12-13 year old

Immunizations: UTD

Allergies: NKDA

Medications: Ritalin

Lortab

ROS: Negative for fever, cough, dysuria, weight loss, rash, known

trauma, known ingestion


5/21

Exposures:

Travel: Camping 2 weeks ago in Little Cottonwood Canyon, noinsect or tick bits; hiking in Millcreek on Saturday

Animals: Two cats, no scratches or bites. No other animal

exposures

Water: Drinks only tap or bottled water, no recent swimming

Contacts: No sick contacts, no recent visitors.

Toxins: Father takes Aleve, Colon Care, Prostate 600, and

GAC. She has not had anymore Lortab.


6/21

Physical Exam

VS: T 36.7. HR 78. RR 24. BP 97/75. O2 96% on RA

Weight: 85.2 kg.

Gen: Alert, answers some questions appropriately, triesto cooperate with exam

HEENT: PERRL, EOMI, MMM, OP clear, TMs normallandmarks

CV: RRR, no murmur, distal pulses 2+ symmetric

Lungs: CTAB

ABD: Soft, non-tender, non-distended, no masses


7/21

Physical Exam

Neuro: CN II-XII intact, normal strength and tone,sensation intact, reflexes 2/4 in upper and lowerextremities, normal gait, no ataxia

Psych: Appearance: endomorphic, younger than her age, tired

Attitude/ Behavior: maintained eye contact, cooperativeSpeech articulation: fair, high pitchMood: labile; Affect: exaggerated, excitedThought Process: disorganized, confusedThought Content: bizarre delusions, no SI/HI

Perception: auditory hallucinationsAttention / Concentration: inattentiveCognition: intellectual delay, not oriented, limited memoryInsight / Judgment: poor; Motivation: cooperative


8/21

Differential Diagnosis

18 year old female with mild

developmental delay and acute alteredmental status


9/21


Metabolic:

Urea cycle defects

Acute intermittent porphyria

Wilsons disease

CNS Abnormality

Brain tumor

Abscess or infection

Stroke Temporal lobe epilepsy

Subacute sclerosing panencephalitis


10/21


Electrolyte disturbances

Hepatic failure

Thyroid storm

Antiphospholipid syndrome Hashimotos

SLE

Substrate deficiency (hypoglycemia, cerebralhypoxia)


11/21


Drug overdose or abuse

Withdrawal from medications (baclofen, benzos)

Drug related syndromes (serotonin, NMS)

Drug-induced psychosis Antibiotics

Steroids

Anticonvulsants


12/21

Laboratory

Drug Screens (serum and urine): negative

CBC: WBC 10.4 (1B/58N/34L), Hct 39, Plts 416

CMP: WNL

CSF: WBC


13/21

Imaging

Head CT: Normal

Brain MRI: Normal

EEG: Normal awake only EEG


14/21

What remains on your differential?


15/21

Further Evaluation

Neurological Consultation

EEG to rule out NCSE: Normal awake EEG

Psychiatric Consultation

Primary psychotic disorder Manic episode with psychotic features

PTSD

Stress-adjustment disorder

Delirium


16/21

Psychosis

Disruptions in thinking, accompanied by delusionsor hallucinations

Orientation and concentration are preserved in

functional psychosis Primary psychotic disorders may be suggested by

family history of psychiatric illness, subacute orchronic symptoms, coexistent mood disorder or

emotional trauma


17/21

Delirium

Diffuse cognitive dysfunction, perceptualdisturbances, altered sleep-wake cycles, thought andlanguage disturbances, altered mood and affect andpsychomotor changes

Onset of symptoms is acute and fluctuates over thecourse of the the day


18/21

Delirium

Delirium among pediatric patients remainsunderstudied and under recognized

Symptoms similar to adults:

Impaired alertness Apathy

Anxiety

Disorientation

Hallucinations


19/21

Delirium

Symptoms more common among children:

Sleep-wake cycle disturbances

Fluctuating symptoms

Impaired attention

Irritability

Agitation

Affective liability

Confusion


20/21

Patient Follow-Up

Discharged on Zyprexa

Seen by outpatient Psychiatry one week afterdischarge

Parents report mental status is 50% resolved Continued to have some waxing and waning

No delusions

Patient able to communicate that starting GATESprogram was very stressful for her

Back to baseline at two week follow up


21/21

References

Turkel et al. The delirium rating scale in children and adolescents.Psychosomatics. 2003;44:126-129.

Turkel et al. Comparing symptoms of delirium in adults and children.Psychosomatics. 2006;47:320-324.

Karnik et al. Subtypes of pediatric delirium: a treatment algorithm.Psychosomatics. 2007;48:253-257.

Adolescent adjustment disorder: Precipitant stressors and distresssymptoms of 89 outpatients.European Psychiatry.2007;22:288-295.

delirium or psychosis 09.14.2011

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