Nicholas D. Tsopelas, M.D.
Pt is a 72 yo BM with h/o HTN, NIDDM,
who lives independently admitted in the
hospital after a minor CVA
Patient appears confused, sleeping most
of the time and when aroused answers
few questions and goes back to sleep
On day 6 consult is called to assess
patient’s depression
Dx: Hypoactive Delirium
I.D: 69 yo Filipino Female, retired nurse PMH: HTN, NIDDM, headaches X1 /w for
years tx with Tylenol , thyroidectomy in 2004
PΨH: None up to 2012 FH: Mother and brother h/o mild to
moderate MDD, sister dx with Myasthenia Gravis at age 45 yo
SH: Born and raised in Philippines Immigrated to USA at age 24 yo
Around mid- 2012 pt started feeling “not
right”, anxious ( e.g. future, finances, what
to do) with poor sleep, fatigue, lack of
energy/motivation, withdrawal, not able to
do household routines.
Middle of 2012 pt visited PCP and was prescribed Remeron
Late 2012 pt visited psychiatrist who continued Remeron, added Xanax
Middle 2013 another psychiatrist switched Remeron to Celexa, continued Xanax 0.25 mg daily
9/ 2013 Celexa was tapered off and pt started tx with Wellbutrin up to 150mg and Xanax 0.25 mg
10/2013 pt was admitted to Virtua
Hospital with increased frequency of
urination, slurred speech - while under
observation she suffered GTC seizures
and was discharged on Trazodone
1/2014 pt went to Philippines and
psychiatrist prescribed Paxil 20 mg and
Abilify 5 mg
Mental sxs: Extreme fatigue, lack of energy, preserved appetite with no weight changes, DFA , no REM disturbances, feeling tired next day, worrying about having MG
Cognitive sxs: Forgetting dates/appointments, missing or misplacing things, confused with directions, stopped driving due to anxiety/depression s/p ED visit
No anomia /no recognition/no language problems Neurological sxs: Double vision, loss of balance, loss of
muscle strength Functional problems: No problems with ADLs or IADLs Corroboration: Husband reports few other episodes with
slurred speech, choking on food/liquids, recently c/o double vision, loss of balance and few mechanical falls
ROS: anxiety 5/10, depression 7/10, cognitive d/o Yes Neuro exam: 3/5 in RLE, 4/5 in RUE, unable to do
tandem, poor balance on toes/heels, mild PMR, MSE: friendly , talkative, reduced facial expression, no
abno movements, depressed mood, dysphoric/constricted affect, normal TP, no psychotic sxs , no SI, good I+J
COG exam: No orientation/attention/speech/praxis problems, decreased abstraction, good recall of verbal prose, normal episodic/semantic memory
MOCA 18/30- deducted 1/1trail B, 1/1 cube, 2/3 in
watch, 1/3 in naming, 3/3 in subtractions, 1/2 in similarities, 3/5 in delayed recall
MDD primary or reactive
Anxiety d/o
Neuro-cognitive disorder
Conversion disorder ( somatic sxs d/o)
MDD primary v reactive due to GMC۞
R/O dementia due to GMC
Past episodes of conversion d/o low
probability
۞GMC: neuromuscular d/o v degenerative CNS d/o
Increase Paxil to 30 mg
Continue Abilify 5 mg
Continue with Trazodone 50-100 mg
Bring labwork and brain MRI
Make appt with neuro-specialist
Progressive Supranuclear Palsy
Dx was given after visiting neuromuscular
specialist, movement disorder specialist
and neuro-ophtalmologist
ID: 66 yo MM, practicing lawyer, lives with
wife
PMH: Chronic pharyngitis, Asthma,
GERD, IBS, DVT, CAD, BPH
PΨH: one brief period of anxiety back in
1985 due to misdx of melanoma
FH : none
SH: Non contributory
CC: 60% lightheadedness and anxiety…I
am not depressed… I want to persevere
till I find my answers…
Sxs: anxiety with occasional PAs,
irritability, frustration, worrying about his
decline, fatigue, preserved appetite, good
sleep, minor difficulties with professional
tasks
5/28/2013 visited ER with gradual swelling of R. leg due to DVT, prescribed coumadin X month
5/28/2013 and afterwards episodes of PAs, was prescribed metoprolol but stopped it due to PMR, “fogginess”
In view of continuing PAs pt underwent stress test (-) and cardiac catheterization indicative of CAD
PAs continued and in view of burning sensation in the stomach upper GI endoscopy non contributory
Pt was dx with Panic disorder and was recommended t x with clonazepam. Pt refused to take it due to fear of addiction and expressed his wish “to fight through”
Brain MRI/MRA in 7/2013 unremarkable
6/2014 seen by neurologist for attention problems, PMR, fatigue , lightheadedness while wife reported executive problems at work, neuro cognitive exam wnl, MMSE 29/30, and dementia was ruled out-
PCP during summer prescribed sertraline 25 mg which pt took for two weeks and then stopped it and restarted two weeks prior to his visit at Ralston
Mental sxs: anxiety, irritability with wife, preserved appetite and sleep, no REM behaviors, good energy level/motivation, optimistic attitude
Cognitive sxs: Unable to concentrate at times, missing or misplacing things, easily confused with tasks, forgetting tasks, keeping notes in duplicates/triplicates with fear of losing them,
No anomia /no recognition/no language problems Neurological sxs: as above noted lightheadedness, reading
problems, write ups seem disorganized, printing is changing, when he attempts to read letters seem different, or not in the right position, losing track of the reading lines at times, at times lacking sense where the floor is
Functional problems: No problems with ADLs or IADLs as per pt Corroboration: Wife reports pt appears confused with driving and
directions and has stopped driving, wife took over finances two months PTV due to reported omissions in checks, got recently confused with strings of numbers and could not do taxes, frustrated when attempts to get dressed/undressed, difficulties to pick up with legal procedures e.g. picking up jury, omitting necessary steps in his line of work
ROS: anxiety 8/10, Cognitive d/o present
NEURO exam: unremarkable
MSE: overtly anxious with painfully legalistic
argumentation in the most straight medically
pertinent question, minimizes the extent of his
cognitive and functional deficits
COG exam: deferred due to anxiety, reluctance
Anxiety d/o NOS
Neuro-cognitive d/o
MDD
Anxiety d/o NOS
Neuro-cognitive d/o (R/O PCA V FTD)
R/O vision problems
Increase sertraline to target dose 100 mg
Clonazepam 0.25 mg-0.5 mg QHS
PET – FDG was ordered
F/u in three weeks
Pt responded 70% in 6 weeks
MOCA in 12/2014 20/30 deducted 4/5 in
the executive part, 1/5 subtractions, 5/5 in
delayed recall
Brain PET summary reads “Diffusely
decreased activity in R. frontal and parietal lobes as well
as bilateral temporal lobes, R>L”
Pt departs for w/u in another institution
Pt underwent : EEG- dysrythmia grade 3 with focal b/l
posterior quadrant spikes and sharp waves, spinal tap,
Repeat MRI, Spinal tap and CSF sent to r/o Autoimmune
encephalitis v CJD Pt in 2/2015 starts steroid tx with family
reporting improvement in speech, psychomotor speed, fluidity, ability to converse but no change in visuospatial but more relaxed
Pt appeared more relaxed, somewhat dismissive of
Penn’s wisdom including myself but willing to continue
with me for his anxiety, and steroid tx with continuing
w/u at other institution
I disagreed with family’s impression and unfounded
optimism since pt has been stable at best
Pt had at least five minor head injuries since 1/2015 due
to space-depth deficits , one when he hit his forehead
on the roof of his car with posterior headache , visit to
ED and negative head CT
Pt eventually developed psychotic sxs tx succesfully
with olanzapine but after rapid decline died in12/2015
65 yo MWF, retired X 6 years accountant, in good physical health, non contributory FH
PMH s/f HTN, hypothyroidism CC: My brain is not working… as well when I go to
church, when they are talking I cannot follow them… I have difficulty to understand what people are talking about even when I watch TV….
4-6 yo h/o anomia ( e.g grand children names, food items, places she visited), Word finding/ spelling/reading difficulties
Short term memory problems but no missing/misplacing
Mild executive dysfunction with cooking otherwise preserved ADLs and IADLs
MMSE 19 , FRS 7, Penn Battery below cut off in all domains but trail A and B
Language evaluation: 1. Speech is somewhat slow but fluent with no
dysarthria 2.Failed to repeat “asparagus”, “buckle” and when asked to repeat “grasshopper”… “Grass is
outside” 3. Asked to spell “mattress” she spelled “matrish” 4. Asked to name “stapler” she stated: “ I use it all
the time…Press… Stamp…”
72 yo MWF , 14 yo edu, retired secretary, lives with husband PMH s/f HLD, unclear CVA 2011, CC: “My short term memory is not good but I do remember things
from way- way back…” Two year h/o memory difficulties, speech problems, confusion
when attempts to do things ( e.g. spills liquids constantly, attempts to cut the bread with the wrong tool- or the wrong part of the tool or attempts to cut an apple with scissors)
Able to do ADLs, prepare meals or do laundry. Stopped driving and husband took over finances
Increasingly apathetic with no zest for life, isolative, irritable when frustrated but not abusive
Myoclonic jerks v tremor in tx with Sinemet x few months PPH: mild anxiety/depression not formally tx but h/o ETOH
dependence with rehab in 12/2009 , then rare use and in full remission x 2months
Neurological findings ( decreased mobility, PMR, postural instability, gait abnormalities- slightly dragging R. foot, no tandem gait, decreased muscle strength symmetrically, DTR brisk with no Babinski, (+) FNF due to apraxia, could not do finger tapping with R. hand, micrographia, dysphasia -speech is slow, fluent with anomic dysphasia, WFD, circumlocution
No tremor / no myoclonia / no rigidity, No dysarthria, dysphagia, no emotional incontinence No ataxia No hallucinations, no alien hand phenomenon MMSE 19, Penn Battery below 10th percentile in all
domains
ID: 83 yo WM, retired neurologist PMH: s/f HTN,HLD, CHF, syncope, depression FH: of unknown SDAT-mother Onset : 3 years Short term memory problems, anomia, WFD,
confusion with visitors in the house, stopped driving
Irritable, argumentative , paranoid about wife/daughter handling finances, VH
Good appetite, sleeps more, takes naps Able to do ADLs, and some IADLs, MMSE 15, Penn memory <4% in all domains
76 yo SWF, with h/o CAD, HTN, mild COPD, GERD, DJD, cataracts , who lives independently admitted to ED for chest pain
Next morning has angioplasty and in the early evening she becomes agitated, pulls IV line and tries to escape
Pt is evaluated , was put on 1 to 1, and prescribed haldol 0.5 mg QHS and 0.5 mg Q12 PRN
On day 4 patient is back to baseline