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Kas 4-1E: Delirium
55-year old married mother of two. FH: her father had a stomach tumor, her son is currently
hospitalized at the metabolic intensive care unit because of ethylic liver dysfunction PH:
hypertension. Drug abuse: according to her family she drinks a lot of alcohol for many years,
but the patient denies it. PPI: first contact with psychiatry, she has been transferred from
internal medicine department where she has been hospitalized for 2 days because of severe
digestive problems. As she started to be restless the doctors decided for transfer to psychiatry
unit.
History of present illness: the patient is restless, talkative, she shouts very loudly that she is in
“steel industry”, she calls the doctor “Mr. Technician” , she does not understand the situation,
it is July (not really), Wednesday (not really), she does not know which year it is. Also, she
insists she is at the airport and she complains of spiders which crawling on her blanket and
she tries to remove them out. She is afraid of an electricity line because it is “a snake”. She
comes to tears easily without explanation.
Mental status examination: During the interview she remains in bed, immobile. There is no
quality contact, her medical history is from the records. The orientation is …….. The answers
are not in the cathegory, confabulations, disturbances of perception……….. No delusions.
Mood disturbances…… Restless, concentration difficulties.
Questions and tasks:
1. Fill in the Mental status examination.
2. What could you probably find during the somatic exam?
3. What kind of checkup you need to investigate her current somatic status?
4. What is the name of the diseases.
5. What is it Wernicke´s –Korsakoff´s syndrome?
6. Which symptom from this Case is typical for Wernicke´s –Korsakoff´s syndrome?
7. Which part of the brain is affected? What is the etiology?
8. Explain the mechanism of alcohol influence on different organs and their parts
9. Pathology: changes of organs in chronic alcohol abuse (liver, pancreas, brain)
Cas 4-2 E: Organic mental disorders
A 75-year-old, married, retired woman. According to the family history, her sister died of
stroke at the age of 70. Her medical history includes diabetes since age 66 and hypertension
since age 67. Abuse: one bottle of beer daily, no smoking. Psychiatric anamnesis: The first
contact with psychiatry was at the age of 73 after sudden loss of speech. According to the
husband she was also confused and she fully recovered after few hours. For now, she is
admitted for the first psychiatric hospitalization.
History of present illness: she says: „it’s called here“......“hospital“... “it is”... „may be
winter“, when she is asked to tell the actual date, she says: „May? March?“...she doesn’t
know why she is here... When she is asked to name the watch, she answers it is “it”. After that
she stops speaking and cries... „ "I know my memory is bad," she says.
Collateral history of present illness (husband): during the last three months her forgetfulness
had started to go worse, she doesn’t know, where she put her handbag, she forgets to turn off
the gas when cooking, she isn't able to button her clothes...when he wants to help her, she
wrathfully resists. She is no longer able to stay alone, she complains of frequent feelings of
vertigo.
Mental Status Examination: clouding, oriented......, poverty of content of speech, prolonged
word latency, Thought…….., perceptual disturbances…… Dysforia, emotional lability till
incontinence. Memory loss, behavioural disturbances.
Questions and tasks:
1. Fill in the Mental Status Examination
2. To which specialist was the patient referred after the assessment of transient mutism and
why?
3. The patient is not able to name her watches and she is not able to use buttons. What is the
name of this symptom?
4. Which cognitive test will you administer to estimate the severity of cognitive impairment
and why?
5. List syndromological and differential diagnosis.
6. What is probable etiopathogenesis of this disorder and what is the prognosis?
7. Patophysiology of memory disturbances
8. Pathology: which organic brain disorders are accompanied by dementia?
Cas 4-3 E: Dementia
68-year old lady with University degree, retired, widow. FH: Aunt was treated with
depressive disorder. PH: Short unconsciousness after ski fall. Drugs: ocassionaly wine or
bear. PPI: First psychiatric service for anxiety, indecisivenesss at 48 years. She was treated for
one year. She thought that she is healthy and she stoped taking drugs. She is guyded by her
daughter now.
History of prezent illness: My thinking is slow. I have hard time to find some thinks at home.
Last time I had problem to find …..that…, that think for vision. When I call my friends I need
phone book for their numbers now. I had this number in my head but it is gone now. Her
landlord spread gass into her home to force her out. He smells it.
Collateral history (by daughter): She was lost during shopping last week. She said that her
glasses was stolen by newsreader. She sleeps during day and she goes urinate frequently
during night. When she sleeps at my new home she can not find her bedroom. She wears skirt
upside down and she is not able to tight the lace. She is desinterested and she prefers to sit
down or to lay in bed whole day.
Mental State Examination: Vigilant, orientation…….., answer after latention, poor thinking.
Thinking……., abnormality in perception………. Mood…..apathy, poor will, apraxia.
Memory and judgement disturbancies.
Questions and tasks:
1. Fill in the Mental Status Examination
2. How do we call this symptom: “she is not able to dress her skirt correctly and si not able
to tie the laces”.
3. What important questions are missing in the assessment ?
4. What screening test for dementia you can use ? What kind of functions you evaluate using
this test ?
5. What is the syndromological diagnosis and differencial diagnosis?
6. What neurotransmiter is affected in this disorder ? What kind of neuropatology changes
you can find?
7. Disturbances of neurotransmittrer systéme that originate in the brain stem.
8. Pathology: Alzheimer´s disease
Case 4-4 E: Alcohol-related disorders
60-year old reitred university graduate female. FH: her fater suffered from Parkinson´s
disease. PH: appendectomy in 20. Drug abuse: she drings liquers heavily for 3 years, smokes
nicotin cigarets for 20 years 20-40 daily. PPI: First contact with psychiatry 2 years ago for
anxiety. Now she is admitted for the first time because of her daughter´s wish.
History of present illness: “He thinks her children are reckless, because they do not take care
of their kids and she has to babysit them. She is nervous out of it. She feels lonely after
retiring from her job. She is irritable, anxious. She wakes up early in the morning sometime.
She does not eat too much, but she does not care. She admits she drinks half bottle of
Becherovka liquer daily, but it is not that much, isn’t? She feels less anxious after it and
doctors say that small amounts of alcohol is good for health anyway. Her first drink is always
in the morning because if she does not drink she shakes and after her drink it stops. She does
not think she has memory problems, it is true that she does not concentrate very well. She
thinks this hospitalization is not necessary because she feels there is no problem, her daughter
exaggerates. She does not think about suicide, but sometimes has an idea that life is
purposeless.
Mental status examination: Conscious, oriented. She cooperates, talkative. No disturbances of
perception. No disturbances of thought. Mood……...Morning tremor, morning snacks,
alcohol abuse which she depreciates and rationalizes. Memory without any clinically
detectable disturbances. She is not suicidal. Foetor ex ore alcoholicus.
Questions and tasks:
1. Fill in the Mental status examination. What does it mean that she “depreciates and
rationalizes” in this context?
2. Suggest the probable diagnosis. Which important question the doctor did not ask?
3. What could you probably find during the somatic exam and what biochemical tests would
you perform?
4. Name syndromes connected with alcohol use. If untreated, which syndrome would you
expect in this particular patient two days after admission to hospital?
5. What is it Wernicke´s –Korsakoff´s syndrome? Where are neuropathological lesions in
this condition? What is the etiology?
6. Disturbances of cerebellum.
7. Pathology: What changes in the skull and brain you expect in alcoholics?
Case 4-5 E: Substance-related disorders
20-year old male single secondary school graduate. FH: his uncle is treated for bipolar
disorder. PH: two years ago he was treated for thyreopathy, for which he received Euthyrox,
during last two years he suffers from repeated viroses frequently. Drug abuse: nicotin
cigarettes 20 daily, illicit drugs since 14, started with marihuana, then LSD, ecstasy, heroin,
currently 5 times daily pervitin (metamfetamine). PPI: first contact with psychiatry
History of present illness: " he was walking round the city, to see the bridge, there were tags
on the houses with German names: this was an evidence that he and all of us are controlled by
somebody, he saw smoke and smelled unpleasant odour, near the river Botic he realized that
birds fly in a way to avoid the factory chimneys. It is a message for people. He touched the
bridge and felt his heart like beating, he picked small stones up. He was aware of everything,
he saw traffic lights glimpsing as a signal to him. He found a paper near the parking lot and he
wanted to find a manager to give it to him. He was thirsty, he did not feel like sleeping. Now
he does not see or hear any signals to him. He feels a little nervous and in a spoiled mood.
Mental status examination: Conscious, oriented, spontaneous, cooperates well, talkative. His
answers are coherent, a little loosening of association. Content of thought.......... ...Currently
no disturbances of perception, during acute phase he described…............... Mood dysphoric,
nervousness. A little tense, with sufficient impulse control.
Questions and tasks:
1. Complete Mental Status Examination.
2. Which important question the doctor did not ask?
3. Would you expect withdrawal symptoms after admission to the hospital and if so, describe
them.
4. What is it pervitin (metamfetamin), what are its effects and mechanism of action?
5. Which substance from the list (nicotin, marihuana, LSD, ecstasy, pervitin, heroin) does
not lead to dependence with repeated use?
6. CNS changes connected to dependence and abstinence
7. Pathology: AIDS and CNS disturbances
Cas 4-6 E: Schizophrenia
34- year old graduated male, single, childless, living with his parents. FH: sister and
grandmother were treated for schizophrenia. PH: Premature delivery, boreliosis diagnosed in
VIII/07. He has been treated for thyroid dysfunction and asthma during last three years.
Alcohol and other substances history: daily consumption of 20 cigarettes. PPI: First contact
with psychiatry on outpatient basis in 2004 due to anxiety. Hospitalized in 2007 because
„Something unusual was happening around me. My life has changed upside down. I poisoned
myself with drugs, cut my forearms”. Currently admitted to a second hospitalization due to
relapse of the illness.
History of present illness: „He has been feeling unsafe among other people during last six
months. Without parents he would not be able to arrive at the hospital. He is convinced that
people around him know more about him that he desires. He has feelings of persecution. It
can be well a revenge of taxi drivers since he competed with them when having voluntary job
as a riksha in Prague. He noticed that they were following him at the time. He does not use
mobile phone because it is monitored. He has peculiar thoughts not knowing whether they
belong to him or the other person. Thoughts are protecting him in principle, saying like “don’t
do it” etc. His sleep is unstable, he awakes sometimes. Stress often leads to overeating in him.
He has gained more than10 kilograms of weight since summer. He does feel some elementary
joy, like having good dinner or sleeping well, however bad thoughts are prevailing. He is
considering not being here as a more rationale solution, since he is not able to take care of
himself, he has feelings of permanent failure and limited capacity of thinking.
Mental Status Examination : Calm, fully oriented, appropriate behavior, cooperating, giving
congruent responses, without substantial latencies, mild intrapsychical tension. Coherent
thinking, content of thoughts.........Mood .......Poor concentration, albeit with preserved
capability to follow main theme. Feelings of inferiority. Sleep disturbances, weight gain,
decline in social activities, partial loss of insight. Suicidal thoughts.
Questions and tasks:
1. Complete Mental Status Examination
2. What did doctor forget to ask to make an accurate differential diagnosis? What is,
therefore, missing in Mental Status Examination?
3. What is the diagnosis? How prevalent is this illness within general population?
4. Is there any relationship between dopaminergic system and mental illnesses? If so, name
dopaminergic tracts and describe its role in patophysiology and therapy of mental
illnesses.
5. Pathology: which organic brain disorders influence dopamine production
Case 4-7 E: Psychotic disorders
25-year old female university student. FH: 0. PH: Healthy. Drug Abuse: wine, beer and
nicotin cigarets occasionally, she tried marijuana irregularly, once a week for one year. PPI:
first contact with psychiatry when she was 16 for feelings of worthlessness, she stopped going
to school, she remained away from people as she felt they sneer at her, the diagnosis was
social phobia and for the following year she has been treated as an outpatient. This is her
second hospitalization.
History of present illness: In spring she felt in love, it was platonic relationship, the guy did
not respond. Since June there was a feeling that they are connected together by telepathy, she
was convinced she was able to feel what he had in mind. Also, she is convinced that she can
read thoughts. She felt like feeling his touches on her body even if he had not been present.
Later his voice started to comment about her, she found out that some of his thoughts were
somehow inserted into her head. Two days before the admission to psychiatric hospital there
were also some other voices in her head. She does not trust anybody, including her mother,
she insists this is not illness and refuses hospitalization.
Mental status examination: Conscious, oriented. She is paranoid, the core symptom is
disturbance of content of thinking............ Disturbances of perception....... A little
tangentiality and loosening of association, concentration difficulties. Mood helpless.
Hyposomnia, loss of apetite. Insight……
Questions and tasks:
1. Complete Mental Status Examination
2. What did doctor forget to ask to make an accurate differential diagnosis? What is,
therefore, missing in Mental Status Examination?
3. What kind of specific disturbance in content of thought did you diagnose in this patient.
Name some more other examples of this specific disturbance.
4. What is the diagnosis and differential diagnosis? Is there any role of marijuana smoking in
this disease?
5. Is there any role for glutamate, dopamine and serotonine in patophysiology of this
disease? If so, explain.
6. Pathology of motivation and emotion.
7. Pathology: viral encephalitis
Cas 4-8 E: Depression
50- year old self-employed married, mother of two, confectionery owner. FH: 0. PH: legs
varicose veins operation 6 years ago. Alcohol and other substances history: wine - at social
occasions. PPI: She sought psychiatrist one year ago. She felt tired, sad and anxious. She did
mistakes at work.
She has been taken to the first hospitalization for worsening condition.
History of present illness: Until 49 year she was OK. Then she lost the feeling of wellbeing.
She gave up work because she had the feelings that she forgets and make mistakes at work.
But still she handles household quite well. Feelings of anxiety are worse tonight.. She has to
make a big effort to start her usual daily activities. She is not able to enjoy anything. She has
not had a change in her weight. She overeats sometimes. She does suffer from ideas of guilty,
she feels, that she is not good grandmother. She does not enjoy playing with grandchildren.
She lost interest in her hobbies. She does not think about the suicide. She suffers from back
pain and fatigue. She is coldblooded.
Mental Status Examination: Consciouss, oriented completely. She is cooperative and her
answers are appropriate. Her appearance is normal, no eccentricity. She is calm, without
psychomotor retardation. Speech is normal (without retardation or pressure). The mood
…….. Anxiety is free floating. No perceptual disturbances. Mild form of abulia and attention
difficulties is present. The diurnal variation is present, symptoms are worse p.m. The thought
is coherent, no delusions. Abstract thinking is normal. MMSE – 28 points. Personality
disorder was not detected. She denied the presence of suicidal tendencies. Insight of illness is
present.
Questions and tasks:
1. Fill in the Mental status examination
2. Which important clinical information is missing? Can it influence diagnosis?
3. What check-up is essential for exclusion of possible „somatic“ cause of depression?
4. What is MMSE? What is the reason for using it in this case?
5. The change of sleep pattern is early non-specific sign. In what mental disorders does it
typically occurs? Is insomnia frequent in somatic disease? If so, give some
examples.What is it sleep architecture and what is the method of investigation.
6. Sleep and its disturbances
7. Pathology: tumors of brain hemispheres
Cas 4-9 E: Bipolar affective disorder
62-year old female retired ballet dancer. FH: her father suffered from depression and heart
arrhytmia, her mother died after stroke. PH: allergy, asthma bronchiale, treated for ischemic
heart disease, mitral valve prolapse, thyroid hypofunction, she had aspiratory pneumonia after
suicidal attempt 4 years ago. Drug abuse: 0. PPI: first contact with psychiatry 30 years ago, 4
years ago severe suicidal attempt (antidepressant overdose) with coma followed by aspiratory
pneumonia. She had been hospitalized 4 times for phases of mood disturbances, out of those
twice for restlessness, hyperactivity, excessive shopping, spending money, euforia and
sleeplessness. During this year the phases of mood disturbance are more frequent, ale there is
a tremor of hands. Now her husband brought her to hospital for worsening of apathy, she
almost does not move and does not communicate.
History of present illness: “she feels terribly, she shakes, she doe not want to be like that,
there are ideas in her head that life is not worth living, she tries to remove them with
something nice –such as that she has nice husband and son, but it does not work. She has not
prepared her plans for suicide yet. Two weeks ago she felt very good, her mood was a little
high, but no hyperactivity. Now she is not able to dress, to go shopping, she forgets what is
she supposed to buy, she is tired, exhausted, not able to concentrate. She suffers from
remorses and black ideas, it is better not to live, she is afraid about her future. She does not
feel like eating, but until now she has not lost weight.
Mental status examination: Conscious, oriented. Psychomotor activity ………..Thinking is
coherent, except slowness no formal thought disorder. Noé disturbances of perception.
Mood………. Tension, anxiety. Apathy, abulia, tends to social isolation. Loss of appetite, no
weight loss. Suicidal ideas……
Questions and tasks:
1. Fill in the Mental status examination.
2. Which important question the doctor did not ask? Does this patient have delusions and if
not, could she have any in theory?
3. What is it suicidal development and how do you investigate it? What arrangements are
you going to suggest in this patient?
4. For which disease phases of mood disturbance are typical?
5. Research of this condition focuses also on hippocampus. What is the role of hippocampus
in general and why are we interested in it particularly in this condition?
6. Pathology: hydrocephalus
Cas 4-10 E: Postpartum mental disorders
25- year old nurse. FH: negative. PH: Appendectomy (APPE) at the age of 11, frequent
superficial venous phlebitis. AH: bee sting allergy PPI: Obssesive-compulsive symptoms
appear after APPE at the age of 11, in particular mysophobia and compulsive hand washing, it
vanished in several months, without any psychiatric treatment. First contact with psychiatry3
weeks after delivery of her daughter for anxiety and 1 week treatment she was admitted to
psychiatric hospital because of symptoms progression.
History of present illness: Her pregnancy was without complication, but she felt sometimes
alone. After childbirth the breast-feeding didn't go her as planned. She wept first night in the
maternal hospital. From that time she often burst into tears. About one week post partum fear
about her little daughter appeared. She has feared that she does not cope with a basic care. All
the time she worried about it. She slept a little and she also got up at the night because of her
baby. Two weeks after childbirth came to her mind a bad thoughts. The thoughts intruded into
her mind frequently. She thought she could swash hot tea on her daughter, throw her out of
the window, stab her with needle. She was helpless. She didn't know how to dress baby,
herself. The worst were feelings that she had no emotions about her baby, she felt no joy. She
was worry about the fact that she was bad mother (she cries). She feels nothing to her baby.. it
horrifies her.. nor to her husband, to anybody around. She feels like sometimes it could be
better not to live.
Collateral History of present illness (husband): she haven't managed to cook and clean at all,
she had been saying perhaps she is crazy - she began to have strange thoughts, that she could
possibly drop the baby, she could pour a hot tea on her. Last 14 days she closed into herself,
doesn't speak a much. Family began to have fear for her. First they contacted a reiki healer. At
the end they appear in the psychiatric ambulance and she was recommended for
hospitalization.
Mental status examination: Lucid, orientated. Answers are after latency, sometimes no
answer. Mood..... Anxious, helpless, lacrimated. Auto-accusations. Hypomimia. Thinking
slowed - down, catathymic, in content dominate............. No satisfaction from motherhood.
Suicidal ideations, without tendency towards realization.
Questions and tasks:
1. Complete Mental status examination
2. Carry out a differential-diagnostic consideration
3. Are there any psychotic symptoms in this woman?
4. What is it postpartum blues? How frequent is this condition?Puerperal period is a one of
the most risky time for mental disorders development. Give an example of the mental
disorders that often appear in this period. Would you suggest any possible neurobiological
mechanisms?
5. What are the hazards for the mother and child in the similar situations?
6. Lactation and its disturbances
7. Pathology: post-partum changes of hypophysis
Cas 4-11 E: Eating disorders
16-year-old excellent student of a secondary school, lives with her parents. FH: neg. PH: neg.
GH: menarche at 13 years, amenorhea during last 3 months. Alergies: pollen, ......... Abuse:
neg. Hobbies: basketball, hip-hop. PH: 1,5 months is treated by a pedopsychiatrist on
recommendation of her pediatrition, no medication. Hospitalized for the first time.
History of present illness: She is hospitalized because her parents and the doctor believe that
she is too thin. She herself does not feel sick or too bony. On the contrary, she is afraid to look
like her brother, who is fat. She thinks they have similar type of figure. That is why she strives
to eat only healthy food, mainly fruits and vegetables. Other food is too heavy for her
stomach. When her parents make her eat dinner – potatoes with meat and gravy – she has
remorse. She has to take medicine to defecate. She exercises a lot to be fit. Besides exercising
she likes to sit at the computer and take part in discussions on different chats about healthy
food, dieting and weight loss. She is sure that it is normal for girls of her age not to have
regular menses.
During the last 2 months she has had low mood because of frequent quarrels about eating with
her parents. She is also unhappy that she is not as successful at school as she used to be, she is
not able to study so hard, she does not remember so well any more. Sometimes she cries
before going to bed and she usually wakes up at around 3 – 4 o’clock at night and has
difficulties to fall asleep again. Nothing makes her happy, she knows that she is moody and
irritable but she cannot help it.
Collateral history of present illness (parents): Their daughter wants to be the best in all areas,
to be handy, nice, to help everybody, to be friends with all students. One year ago she started
to restrict her food. She trained basketball a lot, she came home late in the evening and missed
the dinner. She lost much weight. During the last 6 months she has been eating very little. She
wanted to have a heathy diet – yoghurts, fruits and vegetables. She refused to eat in the school
cafeteria. After her basketball training she exersized every day 20 minuts on exercise bike.
She did not want her parents to know her weight. When the doctor started to check her weight
regularly she managed to drink 1,5 l of water before the control. This month she has drunk
only water and nutridrinks and eaten just fruits and vegetables. She counts the calories all the
time. Her mother says that her daughter has been sad during the last two months. Sometimes
she cries and does not want to say why. She becomes easily angry even for little things. When
her father gets up at half past five she is often already awake.
Mental Status Examination: Alert, fully oriented, cooperating. Mood: ………. No
hallucinations, no disturbance of thinking. Prominent symptoms include: …………… No
suicidal thoughts. Insight: …..
Somatic examination: weight 36,6 kg, height 166 cm, BMI 13,2
Questions and tasks:
1. Complete Mental Status Examination
2. What did the doctor forget to ask to make an accurate differential diagnosis?
3. What does the abbreviation BMI mean? How can you calculate BMI value?
4. What is the diagnosis and differential diagnosis? What are physical complications of the
disorder?
5. Which somatic causes of weight loss in adolescent patients must be excluded?
6. Overview of eating disorders
7. Pathology: cachexy and its causes
Case 4-12 E: Anxiety disorders
35- year old male university graduate, business owner, married. FH: 0; PH: heart
cathetrization for suspicion of myocardial infarction. Drug Abuse: one beer once or twice a
week. PPI: first contact with psychiatrist when he was 34 for anxiety with autonomic
symptoms; he received alprazolam.
History of present illness: During past 2-3 years he suffers from almost constant feeling of
being completely constrained, he thought that this was a result of work overload as he is
responsible for his own company. He feels butterflies in stomach, his chest is constrained. 3
years ago he felt this occasionally, now he feels it all the time, even during pleasurable
activities such as physical exercise. Even minor stressfull events, such as being a little late for
a meeting triger attacks of anxiety. During these attacks of anxiety he thinks of having a
myocardial infarction or fars of dying. Sometime it disappears in 30 minutes, but there are
days when it lasts for the whole day. He has been hospitalized in the internal medical
department for suspicion of myocardial infarction 2 years ago but this was ruled out. Also,
once he had such an intensive fear of dying, he was suffocating and he called the ambulance.
They arrived, made some tests and sent him home. He is anxious because of anticipating
another attack unpredictably comming.
Mental status examination: No restlesness, oriented completely, he behaves properly in the
context of this situation, his answers are coherent without any pauses, his mood is normal,
currently no signs of anxiety or tension. The core symptom in clinical picture
is…..........Thinking is without formal thought disorder, no delusions. No disturbances of
perception.
Questions and tasks:
1. Fill in the Mental status examination
2. Which important question the doctor did not ask?
3. Suggest the probable diagnosis and differential diagnoses. .
4. What is the functional anatomy of panic anxiety disorder.
5. Stress
6. Pathology: etiology of ischaemic heart disease in young people