Abnormal Behavior

Question 1

Definition of mental status changes

Answer 1

An alteration in mental status refers to general changes in brain function, such as confusion, memory loss, change in alertness, loss of orientation to self, time and place, strange behavior, disruptions in perception and psychomotor skills.

Question 2

Terms used to refer to conditions hallmarked by mental status changes

Answer 2

Confusion, lethargy, dementia, encephalopathy and organic brain syndrome

Question 3

Mini Mental State Exam

Answer 3

Orientation to time- 5
Orientation to place- 5
Registration (repeated named prompts)- 3
Attention and Calculation (serial 7s, spelling "world" backwards)- 5
Recall (from registration words)- 3
Language (name a pencil and a watch)- 2
Repetition (speaking back a phrase)- 1
Complex commands (draw the figure shown)- 6
TOTAL= 30

• Any score equal or over 24- normal
• 19-23 is mild impairment
• 10-18 is moderate impairment
• less than 9 is severe impairment

Question 4

Best initial step to evaluate a patient presenting with global neurologic dysfunction?

Answer 4

CMP- comprehensive metabolic panel
-Metabolic causes (i.e., hyper/hyponatremia, hyper/hypoglycemia, hypercalcemia, hyper/hypothyroidism, hypoxia/hypercapnea, hepatic encephalopathy, uremic encephalopathy, drug intoxication/withdrawal, Wernicke encephalopathy)

Question 5

Other causes of global neurologic dysfunction

Answer 5

2. meningitis
3. encephalitis
4. seizures-postictal state
5. hypertensive encephalopathy
6. vasculitis

-As opposed to stroke, structural lesions, arrythmias which lead to focal, asymmetric neurologic changes rather than global, symmetric changes

Question 6

Possible cause of global neuro dysfunction is hypercalcemia, treatment for this is

Answer 6

• First step in the management of hypercalcemia is fluid resuscitation with intravenous isotonic saline.
• Calcitonin, peptide hormone, decreases bone resorption and increases renal calcium excretion. Can rapidly reduce total calcium within 4-6 hours and lose their benefit after 48 hours. So works quickly but does not sustain response well.
• Bisphosphonates block osteoclast-mediated bone resorption, thus inhibiting calcium release. Acts 2-4 days after administration and results are longer lasting. IV preparations are preferred over oral formulations.
• Glucocorticoids can be used to treat hypercalcemia by decreasing gastrointestinal absorption of calcium.

Question 7

What is the best initial test to evaluate the cause of the patient’s hypercalcemia?

Answer 7

Parathyroid hormone measurement (PTH)

Question 8

A recent increase in calcium with weight loss points towards

Answer 8

a malignant neoplasm

Question 9

Long-term, stable mild hypercalcemia without symptoms or weight loss is suggestive of

Answer 9

primary hyperparathyroidism

Question 10

Most common cause of hypercalcemia with low PTH level is

Answer 10

malignant disease

• Osteolytic process such as in Multiple myeloma.
• PTHrP secretion such as from squamous cell lung cancer.
• Tumors producing 1,25 dihyroxyVitamin D such as in lymphoma.
• Others: 25-OH vitamin D intoxication, granulomatous disorders, hyperthyroidism, immobilization and adrenal insufficiency.