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