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MRI/CT and Psychotic episodes

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It will be interesting to know if anyone had patients presenting with psychotic features who had CT/ MRI findings.

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Euthymic,

I had a recurrent depressive episode patient...

First episode 10 years back...

Now presented with fatigue, lethargy, decreased appetite, weight loss, decreased interest in daily activities... No psychotic features though...

Seen by medics... referred to us, thinking its another episode of depression...

Fortunately I did a physical examination... and to my surprise, I thought there was a right sided upgoing plantar... nothing else...

Arranged a CT scan... showed a huge mass in the left frontoparietal region...

Similar patient presented few months later.... all sgns of depression... only odd feature, occasional urinary incontinence... which people thot was due to decreased psychomotor activity and the patient not motivated to go to the toilet... (again no psychotic features)

CT revealed same mass lesion... possibly impinging on the paracentral lobule and hence the incontinence...

I have seen a couple of patients in delirium, who present with psychotic features... following head injury etc, which showed CT/MRI findings...

I have to admit it... sadistically I was overjoyed by the finding on the CT scan... that I was able to diagnose an organic etiology for the presentation... But looking back at what the patient and his relatives felt... I still feel bad about my own feelings....

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Euthymic,

I had a recurrent depressive episode patient...

I have to admit it... sadistically I was overjoyed by the finding on the CT scan... that I was able to diagnose an organic etiology for the presentation... But looking back at what the patient and his relatives felt... I still feel bad about my own feelings....

Interesting finding. Wonder if it cd be written up a case report

It can be tricky sometimes when you get these results; you feel pleased that you detected/diagnosed as a Dr, yet feel sad as a person for the px and their family...

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I've had a few schizophrenic patients who've had enlarged ventricles and dominant temp lobe abnormalities.

There's a recent yellow/bulletin article on neuroimaging.

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My patient had an atypical manic presentation.

No previous history, but a history of minor head injury (playing rugby) in the past.

No neurological findings.

CT showed a pituitary macroadenoma.

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My patient had an atypical manic presentation.

No previous history, but a history of minor head injury (playing rugby) in the past.

No neurological findings.

CT showed a pituitary macroadenoma.  

interesting... I wonder how we cud explain the manic symptoms...

will read up pituitary tumors

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Euthymic,

I had a recurrent depressive episode patient...

I have to admit it... sadistically I was overjoyed by the finding on the CT scan... that I was able to diagnose an organic etiology for the presentation... But looking back at what the patient and his relatives felt... I still feel bad about my own feelings....

Interesting finding. Wonder if it cd be written up a case report

It can be tricky sometimes when you get these results; you feel pleased that you detected/diagnosed as a Dr, yet feel sad as a person for the px and their family...

Sure,

It's exactly how I felt.

Any ideas how to make a case report.

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Euthymic,

I had a recurrent depressive episode patient...

First episode 10 years back...

Now presented with fatigue, lethargy, decreased appetite, weight loss, decreased interest in daily activities... No psychotic features though...

Seen by medics... referred to us, thinking its another episode of depression...

Fortunately I did a physical examination... and to my surprise, I thought there was a right sided upgoing[highlight] plantar[/highlight]... nothing else...

Arranged a CT scan... showed a huge mass in the left frontoparietal region...

Similar patient presented few months later.... all sgns of depression... only odd feature, occasional urinary incontinence... which people thot was due to decreased psychomotor activity and the patient not motivated to go to the toilet... (again no psychotic features)

CT revealed same mass lesion... possibly impinging on the paracentral lobule and hence the incontinence...

I have seen a couple of patients in delirium, who present with psychotic features... following head injury etc, which showed CT/MRI findings...

I have to admit it... sadistically I was overjoyed by the finding on the CT scan... that I was able to diagnose an organic etiology for the presentation... But looking back at what the patient and his relatives felt... I still feel bad about my own feelings....

Thats the advantage of doing full physical examination following all steps.

Though its not common to pick up such rare abnormalities in routine physical examination,it is worth doing proper,step wise physicals.

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Thanks justme.

Waiting for the template.

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Box 1: Stages in writing a case report

• Finding a rare case

• Literature search

• Collecting information related to the case, including consent

• Summarising and writing

• Revising and editing

Box 2: Format for writing a case report

• Finding a rare case

• Literature search

• Collecting information related to the case, including consent

• Summarising and writing

• Revising and editing

• Introduction

• Case report

o the real story

o History

o Clinical features

o Investigations

o Treatment and outcome

o Progress

• &nbsp:lol:iscussion

o review of literature

o Arguments

o Message

o Recommendations, if any

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Wow!

Thanks.

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Consent is the most important... depending on what journal you want to send it to... the consent forms vary... so get a few consents signed... as you dont know which journal would accept them...

If unfortunately, the patient died, you shud get consent from the nearest relative.... which may be more difficult...

In any case, it is best to get consent from the relative as well... especially if the patient is manic.... and you dont think he has the capacity...

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MRI in the treatment resistant depression

Recent advice from the authors of STAR*D study have suggested doing an MRI brain scan when patient has not responded to 3 different treatment startegies in depression.

This is ofcourse after reviewing diagnosis and treating comorbidity. Hopefully by this time you would have done all the bloods and physicals etc.

Early MS/ Parkinson's disease etc should be excluded.

What do you think?

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Saw a nice case recently on call.

45 year old with a h/o past heavy alcohol use (currently) abstinent. Admitted to the genral hospital with a h/o of ?? seizures at work. He was found on the floor at work with bruises on the face.

Reason for psych referal - agitated and was found standing on his bed holding a lighter. ? risk of violence and fire setting.

The gentleman in question very calm during the assessment. No past h/o of psych issues other than the alcohol dependence.

During the assessment described clear auditory hallucinations (saying he could hear voices outside the room saying 'we'll get the b******d' ). He said that he stood on the bed to use his lighter near the fire alarm so that he could then escape through the hospital fire exit..

Asked medics for urgent CT which they said they were going to do anyway.

Revealed a nice intracranial h'ge in the left temporal lobe.

Wrote up some antipsychotic meds and benzo's.

Felt good about the whole thing after the assessment.

Not sure how others feel. But don't you feel good when you see an organic presentation in your work??

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Beautiful case, mad max!

I hope he's alright now though..?

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Unfortunately don't know wht happened to him. They transferred him to King's college Hospital in London as the district hospital i worked in didn't have the expertise to sort that out.

The surgical reg thought that the prognsis was poor.. said it was bcos the h'ge was intracerebral.

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Unfortunately don't know wht happened to him. They transferred him to King's college Hospital in London as the district hospital i worked in didn't have the expertise to sort that out.

The surgical reg thought that the prognsis was poor.. said it was bcos the h'ge was intracerebral.

True... Been there before...

Feels good when you diagnose...

but then feel bad for the patient because of the poor prognosis...

Atleast if it was a functional psychosis... we had something to offer...

although we almost always forget that mortality is still high in functional affective/ non affective psychosis...

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I work in a special hospital in England & we have had 2 patients who have had positive MRI/SPECT(single positron emission computerised tomography) where fronto temporald ementia has been diagnosed with little or no memory problems.

Both patients came in with ?psychotic episodes, but ward staff on admissions felt they were unusual presentations, with little/no memory problems and more sexual disinhibition and in one case impulsivity leading him to eat his own diapers,being doubly incontinent etc..

both patients are under 50. so get an MRI(CT is mainly for bony lesions like fractures etc... or abscesses etc...) which shows moderate cerebral atrophy.

We did SPECT and found fronto temporal deficits.

We call Psychogeriatricians for opinion & Alzheimer's & multi infarct dementia were ruled out.

still team not happy with answers but we keep pegging... to no avail.

So we refer to Prof Neary,Neurology professor in Hope hospital, Manchester( who is an expert on fronto temporal dementia)(beware of funding issues if you want to refer from your service commissioners). he came and examined patient thoroughly, read all the notes patiently,speaks to nurses,Consultant & looks at scan pictures himself & gets some psychometrics from his team of neuropsychologists & they diagnosed fronto temporal dementia. he suggested SSRI to deal with impulsivity & it has worked in one patient so far.

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Box 1: Stages in writing a case report

• Finding a rare case

• Literature search

• Collecting information related to the case, including consent

• Summarising and writing

• Revising and editing

Box 2: Format for writing a case report

• Finding a rare case

• Literature search

• Collecting information related to the case, including consent

• Summarising and writing

• Revising and editing

• Introduction

• Case report

o the real story

o History

o Clinical features

o Investigations

o Treatment and outcome

o Progress

• &nbsp:lol:iscussion

o review of literature

o Arguments

o Message

o Recommendations, if any

And then the real work begins :lol:

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