I heard talking to yourself is a sign of intelligence not psychosis, that being said the person I heard that from was me
23 y/o, presenting with visual hallucinations, fine tremor and nausea x16 hours, hx of polysubstance abuse. No pupillary exam findings. Denies taking street drugs recently.
Alcohol Hallucinosis
Pearl: Visual but accusatory most common, 12-48 hours after last drink, DIFFERENT from hallucinations with DTs.
60 y/o with recent admission for post obstructive pneumonia in the setting of bronchiectasis, arriving from her SNIF febrile to 103, initial concern was change in mentation. Oxygen sat 88 on RA. Neutrophilic leukocytosis.
Septic Encephalopathy
Pearl: Always consider running the encephalopathy differential when some is labeled psychotic
19 y/o with no PMHx, no substance abuse arriving for subacute diarrhea, profuse/watery, with triage noting mild confusion and pressured speech. vitals revealing tachycardia, elevated blood pressure to 142/90, afebrile. Fhx of hashimoto's. Exam reveals fine tremor
Thyroiditis
Pearl: There is an MD calc for likelihood of thyroid storm, values that get the most weight are fever/lethargy.
5 y/o with no pmhx, arriving for confusion after x1 day of neck pain. Vitals reveal low grade fever, otherwise unremarkable. Child is agitated but responds to their name. LP performed, pertinent for 35 lymphs and 200 protein. Mom notes GI illness x1 week ago.
Aseptic Meningoencephalitis
Pearl: we have what is called a "ME" panel, that tests for the most common viral causes. The criteria for encephalitis requires 2/3: fever > 24 hours, encephalopathy, or findings on CSF.
3 y/o with <2 mm ulcers on the posterior oropharynx, low grade fever, goes to day camp. Other than pain with swallowing pt. seems unphased.
Herpangina/CXA
Pearl: HSV mucogingival dz usually has HIGH fever, malaise and ulcers are anterior buccal +/- lip involvement
45 y/o s/p STEMI complicated by mediastinitis treated appropriately with resolution of symptoms/fever, about to be downgraded, now having acute hallucinations and agitation. Vitals and labs unchanged.
ICU syndrome or psychosis/Delirium
Pearl: Delirium can affect any age, esp. with a prolonged ICU course. Hallucinations can be part of the presentation.
67 y/o with multiple back-to-back admissions for COPD exacerbation (3 within a month, also visited urgent care once) arriving from home for AMS, spouse noted they were confused and combative. Vitals unremarkable, afebrile. Labs unremarkable. Becomes better in a few days without intervention
CCS psychosis
Pearl: Tricky entity - unlike other CCS ADRs, less predictable. Has been documented to occur, after 1st dose of CCS, prolonged use, and after discontinuation.
75 y/o with chronic "dementia" times years, now complicated by visual hallucinations that pt. reports but is not bothered by as well as tremor. HDS afebrile.
Lewy Body Dementia
Pearl: Criteria includes progressive dementia + 2 of the following: fluctuating mentation, parkinsonism, visual hallucinations, delusions. Thought to account for a total of 20% dementia.
15 y/o without PMHx arriving home from a night out with friends found to have progressive confusion, agitation, hypertension, mydriasis. Labs pending.
Sympathomimetic Toxidrome
Pearl: Signs of acute catecholaminergic are most commonly drug side effects. PCP, "wet", cocaine, amphetamines are all examples.
62 y/o with known small cell lung cancer stage 3 in treatment, arriving to the office for evaluation for new weakness. Labs in house are at baseline, CPK is not elevated. Exam pertinent for new mild right sided ptosis, cancer is on the left. EMG pending. Afebrile and hemodynamically stable. No rashes.
Lambert-Eaton Syndrome
Pearl: Most commonly secondary to cancer (of which, SCC is the most common) or autoimmunity. Most notable hallmark is improved weakness after use, but other very common symptoms include dysautonomia, areflexia.
12 y/o pt. left home during the school day due to URI symptoms. When parents arrive home, pt. is confused, febrile, and agitated. Her URI symptoms were malaise and rhinorrhea, mom also had the illness without complication. Arrives febrile and tachycardiac. Exam pertinent for muscular rigidity and confusion. No drug paraphernalia found, no hx of substance use, parents do not have any of their medications at home.
Dextromorphan Toxicity
Pearl: Found in mucinex/robitussion, common OTCs. Cases often reveal that OD was not intentional, mis-reading label is common.
14 y/o arriving for abdominal discomfort, found to have large volume ascites, no pmhx. Initial lab work revealed: Coombs negative hemolytic anemia, AST predominant transaminitis 400/100, ALP of 6, mixed elevated bilirubinemia to 2.5, cr of 2.5. Exam notable for AAOx2 and dysarthria.
Wilson's Disease
Pearls: A few here - although low ceruloplasmin is the "hallmark" of wilson's, the sensitivity/spef are both <50. AST:ALT ratio of 2.2, ALP/total bilirubin <4 are both >90 for both sense/spef.
Serotonin Syndrome
Pearl: Similar to CCS, serotonin syndrome does not have a set threshold that causes symptoms. More likely in pt.'s on multiple serotonergics, but can happen on a single serotonergic, and does not necessarily correlate directly with initiation of the med or increase in dose.
Hunter's criteria: Helps make clinical diagnosis.