Neurologic
A 70 year old with parkinsonism is now having visual hallucinations of small animals. What neurologic diagnosis is on your differential?
Lewy Body Dementia
A middle aged woman develops delusions, hallucinations, and disorganized thinking. She also has tachycardia, anxiety, heat intolerance, unexplained weight loss. Her T4 comes back severely elevated. What do we expect her TSH to be?
Extremely low.
Lyme Disease
A vegan patient has persecutory delusions and hallucinations, found to have ataxia and cogwheel rigidity on exam. What lab do you want to check?
B12
You're on call. A patient is on day 4 of his hospital stay for depression, when he develops confusion, fever, hypertension, tachycardia, and hallucinations. You talk with him and find out that he had been drinking alcohol heavily up until admission. What life-threatening condition are you worried about?
Delirium Tremens.
A 70 year old patient with a history of Alzheimers is in the ICU following a painful procedure. They suddenly become combative, disoriented, paranoid, and have visual hallucinations. Name 3 commonly used classes of medications to consider reducing?
Benzodiazepines, opioids, anticholinergics
New onset psychosis in 50 year old woman found to have abdominal swelling, RUQ pain, tremor and jaundice on exam. Her eyes have a golden ring on the outside of the iris. What lab test should we order, and what disease are we screening for?
Serum ceruloplasmin; Wilson disease
You're consulted on a patient with a history of HIV and Chlamydia for new cognitive deficits and visual disturbances vs hallucinations. They also have abnormal gait, headache, a stiff neck, and incontinence. What are you worried about?
Neurosyphilis
An older patient with a history of severe alcohol use disorder presents with new paranoia, short term memory loss and confabulates most of their history. What severe nutritional deficiency could they have?
Thiamine deficiency
A patient presents for confusion, disorientation, visual hallucinations, and paranoia. They are flushed, febrile, have dilated pupils, and have not urinated for >24 hours. Which class of medications do you want to hold on admission?
Anticholinergics
A patient with a history of seizures is experiencing intermittent deja vu, dissociations, and visual hallucinations. What single test could confirm the neurologic diagnosis?
EEG - Epilepsy
A patient presents for a kidney stone and is found to also be struggling with depression, fatigue, confusion, hallucinations. Labs are notable for abnormal calcium. Issues with what gland could cause all of these signs and symptoms?
Parathyroid disease
A patient with a history of untreated HIV presents for headache, seizures, focal neurologic deficits, delusions, and hallucinations. You see multiple ring enhancing lesions on MRI. What are you concerned about?
CNS toxoplasmosis
A patient with multiple substance use disorders presents for auditory hallucinations, paranoia, sensorimotor polyneuropathy, and ataxia. Labs are notable for low vitamin B12, elevated homocysteine and elevated methylmalonic acid. What substance could she have been using?
Nitrous oxide
A patient with presents for hematemesis due to esophageal varicies. You are consulted for insomnia, depression, confusion, and delusions. On exam, you observe jaundice, ascites, and asterixis. In addition to basic labs, what specific level should you check?
Ammonia
A patient with a history of lung cancer develops gradually worsening headache, seizures, focal neuro deficits, and visual hallucinations. What test do you order and what are you ruling out?
MRI; rule out brain tumor
An 18 year old female was recently diagnosed with schizophrenia. Since then, she's developed seziures, memory deficits, hypersomnia, choreoathetoid movements, and autonomic instability. What three tests do you want to get to rule out anti-NMDA encephalitis? (Hint: 1 lab, 1 imaging, 1 other)
MRI, EEG, and CSF IgG
A 15 year old presents in August after spending the summer at camp in the woods for a fever, headache, photophobia, confusion, and visual hallucinations. On exam, you observe flaccid paralysis. You get a lumbar puncture to look for what?
West Nile IgM in CSF sample
A 15 year old presents to the ED with their parents, who brought them in for severe agitation. The teenager is euphoric, hallucinating, and tachycardic. They mention something about taking something from their parents' medicine cabinet. What might they have taken?
Dextromethorphan (cough medicine)
35 year old woman has had years of pelvic pain and unexplained infertility. She now presents for weeks-months of cognitive deficits, altered consciousness, seizures, and psychosis. You place an oncology consult out of concern for what rare oncologic condition?
Ovarian teratoma