Identification and Management of Common Medical Problems in the Psychiatric Setting: Cases for Your

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Identification and Management of Common Medical
Problems in the Psychiatric SettingCases for
Your Consideration

• Donald B. Middleton, MD
• September 15, 2006

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Areas of Concern

• Neurologic Huntingtons chorea, multiple
  sclerosis, dementia
• Endocrine diabetes mellitus, thyroid disease
• Metabolic hepatic disease, hypertension
• Toxic alcohol, medications, toxins
• Nutritional B12 deficiency, iron deficiency
• Infections HIV, postinfectious diseases
• Autoimmune systemic lupus erythematous
• Neoplastic primary, metastatic
• Anatomic obstructive sleep apnea

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The Perils of Poisons I

• A 63 year-old man, who works repairing
  generators, has a long standing history of
  hypertension. Six months ago he was found to be
  in hypertension-induced atrial fibrillation.
  Medications are 1) HCTZ, 25 mg, daily 2)
  atenolol, 25 mg, daily 3) lisinopril, 10 mg ,
  daily and 4) amiodarone, 200 mg, daily.
• At his next check-up, his wife, who is with
  him, says he is short of breath, seems hot all
  the time, lacks energy to get to work, and isnt
  sleeping. He never talks to her. Their marriage
  is struggling. He cant even seem to keep his
  face clean. He has a course tremor and a pulse
  rate of 110. He seems jittery and nervous.
• What would you do?

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Perils of Poisons II
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Evaluation of Cognitive/Mood Disorders

• Family history
• Medication review including
• OTC drugs
• PE with neurologic exam
• ( a note to the doctor?)
• Mental status exam
• Neuropsychiatric testing
• Laboratory
• Special tests

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Laboratory Tests for Cognitive/Mood Disorders

• Blood and urine screens for alcohol, drugs, and
  heavy metals (Hg, Pb)
• BMP/CMP, CBC, Mg, U/A
• Thyroid TSH, freeT4
• B12, folate, Fe/TIBC or ferritin
• HIV, RPR, steroid levels, ANA, ESR
• Radiographs CXR, CT, MRI
• Other EKG and Holter, EEG, LP, SPECT

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Alzheimer Disease MRI

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SPECT of Alzheimer Disease

• NORMAL ALZHEIMERS

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Perils of Poisons III

• CMP normal except liver tests are mildly
  elevated (AST 95 ALT 78)
• CBC nl
• TSH 0.01 (nl gt 0.4)
• CXR, EKG both unremarkable
• Now what would you do?

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Perils of Poisons IV

• Amiodarone toxicity
• 5 to 15 pulmonary scars, cough
• 2 to 20 abnormal thyroid function, gt 2
  hyperthyroid
• 25 to 75 abnormal skin color
• 3 to 30 neurologic complaints tremor, sleep
  disturbance, impaired memory
• 15 to 50 abnormal liver tests
• 10 to 30 GI upset

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A Family Affair I

• A formerly healthy 53 year old man, married
  with 3 children, is in for a wife-prompted
  routine physical. She reports that his memory is
  deteriorating he forgets where he is going,
  cant remember names of friends and seems overly
  irritable. FH is that his mother developed
  depression and committed suicide at age 58. His
  mgf had mental deterioration at age 80. He has 9
  siblings, 2 of whom have uncontrollable abnormal
  movements and 1 of whom has bankrupt his family
  through wild spending.

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A Family Affair II

• On exam he seems to be smacking his lips and
  twitching facial muscles constantly. Answers to
  questions are terse. On several occasions he
  fiddles with his shirt buttons. He seems
  distracted during the exam, once almost falling
  while getting off the table. Otherwise, the exam
  is normal. Lab evaluation (CBC, CMP, TSH) is
  normal.

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Common Memory Disorders

• Benign forgetfulness
• Age-related memory decline usually not
  progressive
• Mild cognitive impairment often
  progressive12/year may develop Alzheimers
• Amnesia
• Delirium
• Dementia multiple types
• Attention deficit/hyperactivity disorder
• Mental retardation borderline intellectual
  function

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Cognitive Disturbance Algorithm

• Complaint of impaired memory, attention,
  disorientation, consciousness, etc.
• Consider general medical disorders
• Acute onset of reduced ability to focus,
  sustain, or
• shift attention consider delirium
• Memory impairment and other cognitive
  impairment consider dementia
• Memory impairment in the absence of other
  cognitive impairment consider amnesia
• Prior intellectual impairment consider mental
  retardation
• Age related consider normal cognitive decline

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A Family Affair III

• What tests are indicated?
• What is the most likely diagnosis?
• What treatment is indicated?
• What should the children do to avoid similar
  problems?

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Huntingtons Chorea
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Huntingtons Chorea

• Genetic disorder autosomal dominant
• Onset after child bearing age
• Abnormal protein deposition in specific neurons
• Treatment is unsatisfactory SSRIs, minocycline,
  CoQ10, mirtazapine, haloperidol

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A Heavy Heart I

• Mr. JT is a 55 year-old, overweight, married,
  father of two, who has recently suffered a
  myocardial infarction. His weight at the time of
  the heart attack was 320 lbs. Following his
  recovery from the heart attack, he underwent a
  gastric bypass procedure that was initially
  highly successful. In fact, he lost 123 lbs.,
  felt much improved and was the subject of a great
  deal of praise from his physicians and his
  family. Unfortunately, over the next year he
  preceded to put back on most of the weight he had
  lost. He is once again having some shortness of
  breath and chest pain when he climbs the stairs
  in his home. His wife says he doesnt overeat.
• In the office today, he weighs 310 lbs.
• What behavioral problems enter into the
  differential diagnosis for this patient?

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Night Eating Syndrome

• Obesity up to 30
• 2000-3000 calories at night
• 30-50 of total daily
• calories at night
• 4) Often awaken from
• sleep to eat

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Unknown
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Addisons Disease

• Los of cortisol production
• Skin and mucous membrane pigmentation due to ACTH
  excess trying to cause cortisol production (find
  old pictures and compare to current look)
• Causes mental slowness, abnormal thought
  patterns, depression, and psychomotor
  retardation low blood pressure
• Replace cortisol

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What you can do!

• Consider getting blood pressure and pulse
• Communicate with the primary care doctor