Full Transcript Case Presentation and Initial Symptoms 0:08 Okay, so let's start. Imagine that you 0:08 Okay, so let's start. Imagine that you have a 74 year old brought in for an 0:11 have a 74 year old brought in for an 0:11 have a 74 year old brought in for an inability to talk and her husband is 0:14 inability to talk and her husband is 0:14 inability to talk and her husband is very concerned. Brought her into the 0:16 very concerned. Brought her into the 0:16 very concerned. Brought her into the emergency department. Her chief 0:19 emergency department. Her chief 0:19 emergency department. Her chief complaint is, "I want to talk, but I 0:21 complaint is, "I want to talk, but I 0:21 complaint is, "I want to talk, but I can't." So, right off the bat, there's a 0:23 can't." So, right off the bat, there's a 0:23 can't." So, right off the bat, there's a discrepancy here. She is talking and 0:26 discrepancy here. She is talking and 0:26 discrepancy here. She is talking and saying that she can't. uh and yet uh she 0:30 saying that she can't. uh and yet uh she 0:30 saying that she can't. uh and yet uh she really does experience that she's having 0:32 really does experience that she's having 0:32 really does experience that she's having difficulty with speech. 0:35 difficulty with speech. 0:35 difficulty with speech. The symptoms had started the day before. 0:37 The symptoms had started the day before. 0:37 The symptoms had started the day before. So that gives you a bit of a timeline as 0:39 So that gives you a bit of a timeline as 0:39 So that gives you a bit of a timeline as to how long these have been going on. 0:40 to how long these have been going on. 0:40 to how long these have been going on. This this would be considered acute.
History, Exam, and Early Differential 0:44 This this would be considered acute. 0:44 This this would be considered acute. So let's stop here. The point of 0:47 So let's stop here. The point of 0:47 So let's stop here. The point of reflection, what else do you want to 0:48 reflection, what else do you want to 0:48 reflection, what else do you want to know in terms of trying to figure this 0:51 know in terms of trying to figure this 0:51 know in terms of trying to figure this medical mystery out? What are the 0:54 medical mystery out? What are the 0:54 medical mystery out? What are the questions that are generated in your 0:55 questions that are generated in your 0:55 questions that are generated in your head? 0:57 head? 0:57 head? What else do you want to do in terms of 0:59 What else do you want to do in terms of 0:59 What else do you want to do in terms of evaluations, 1:01 evaluations, 1:01 evaluations, tests, laboratory analyses, physical 1:04 tests, laboratory analyses, physical 1:04 tests, laboratory analyses, physical exams, 1:06 exams, 1:06 exams, and where is your mind taking you if 1:08 and where is your mind taking you if 1:08 and where is your mind taking you if you're considering different diagnosis, 1:12 you're considering different diagnosis, 1:12 you're considering different diagnosis, different treatment options? Uh, is your 1:15 different treatment options? Uh, is your 1:16 different treatment options? Uh, is your mind already generating some options? 1:19 mind already generating some options? 1:19 mind already generating some options? That's just for the sake of reflection, 1:20 That's just for the sake of reflection, 1:20 That's just for the sake of reflection, but I'll continue with the story. In 1:23 but I'll continue with the story. In 1:23 but I'll continue with the story. In terms of the history of present illness, 1:25 terms of the history of present illness, 1:26 terms of the history of present illness, her core symptoms included the 1:27 her core symptoms included the 1:27 her core symptoms included the following. Uh, and by the way, most of 1:30 following. Uh, and by the way, most of 1:30 following. Uh, and by the way, most of the history was obtained from the 1:32 the history was obtained from the 1:32 the history was obtained from the husband who accompanied her. She 1:34 husband who accompanied her. She 1:34 husband who accompanied her. She appeared anxious and at times was unable 1:37 appeared anxious and at times was unable 1:37 appeared anxious and at times was unable to verbalize. She stated that she wanted 1:40 to verbalize. She stated that she wanted 1:40 to verbalize. She stated that she wanted to respond to questions, but her brain 1:42 to respond to questions, but her brain 1:42 to respond to questions, but her brain was in a quote whirl and she was unable 1:45 was in a quote whirl and she was unable 1:45 was in a quote whirl and she was unable to get the words out. During the 1:48 to get the words out. During the 1:48 to get the words out. During the interview, the patient was noted to be 1:50 interview, the patient was noted to be 1:50 interview, the patient was noted to be unable to verbalize at times and 1:52 unable to verbalize at times and 1:52 unable to verbalize at times and occasionally when distracted, the 1:54 occasionally when distracted, the 1:54 occasionally when distracted, the patient appeared to be able to respond. 1:57 patient appeared to be able to respond. 1:57 patient appeared to be able to respond. Her vital signs included a blood 1:59 Her vital signs included a blood 1:59 Her vital signs included a blood pressure of 181 over 98. So very high 2:02 pressure of 181 over 98. So very high 2:02 pressure of 181 over 98. So very high systolic, heart rate of 86, respiratory
Psychiatric History and Medications 2:07 systolic, heart rate of 86, respiratory 2:07 systolic, heart rate of 86, respiratory rate 18, temperature 37.1 or 98.8 2:11 rate 18, temperature 37.1 or 98.8 2:11 rate 18, temperature 37.1 or 98.8 Fahrenheit, and O2 saturation is 95% on 2:15 Fahrenheit, and O2 saturation is 95% on 2:15 Fahrenheit, and O2 saturation is 95% on room air. She was breathing okay 2:17 room air. She was breathing okay 2:17 room air. She was breathing okay although a bit taken and her blood 2:21 although a bit taken and her blood 2:21 although a bit taken and her blood pressure was elevated. 2:23 pressure was elevated. 2:24 pressure was elevated. Her mental status was interesting. It uh 2:27 Her mental status was interesting. It uh 2:27 Her mental status was interesting. It uh revealed in bold there in terms of 2:29 revealed in bold there in terms of 2:29 revealed in bold there in terms of appearance that she was very anxious, 2:31 appearance that she was very anxious, 2:31 appearance that she was very anxious, depressed and somewhat frazzled. She was 2:35 depressed and somewhat frazzled. She was 2:35 depressed and somewhat frazzled. She was propped up in a stretcher and groaning 2:37 propped up in a stretcher and groaning 2:37 propped up in a stretcher and groaning at times. Uh, skipping down to the 2:41 at times. Uh, skipping down to the 2:41 at times. Uh, skipping down to the psychiatric components of the mental 2:42 psychiatric components of the mental 2:42 psychiatric components of the mental status exam. She was alert and oriented 2:45 status exam. She was alert and oriented 2:45 status exam. She was alert and oriented times three. She was anxious, especially 2:48 times three. She was anxious, especially 2:48 times three. She was anxious, especially when unable to get out the words, 2:51 when unable to get out the words, 2:51 when unable to get out the words, cooperative, but a bit frustrated during 2:53 cooperative, but a bit frustrated during 2:53 cooperative, but a bit frustrated during these periods of what we call ephasia, 2:56 these periods of what we call ephasia, 2:56 these periods of what we call ephasia, lack of ability to speak. She was 2:59 lack of ability to speak. She was 2:59 lack of ability to speak. She was depressed appearing. Um neurologically 3:02 depressed appearing. Um neurologically 3:02 depressed appearing. Um neurologically she really had no focal findings. So no 3:04 she really had no focal findings. So no 3:04 she really had no focal findings. So no no major deficits and she was moving all 3:08 no major deficits and she was moving all 3:08 no major deficits and she was moving all extremities uh all four of them against 3:11 extremities uh all four of them against 3:11 extremities uh all four of them against gravity meaning moving them well. 3:14 gravity meaning moving them well. 3:14 gravity meaning moving them well. The husband revealed that patient also 3:17 The husband revealed that patient also 3:17 The husband revealed that patient also had some other symptoms. She had at 3:20 had some other symptoms. She had at 3:20 had some other symptoms. She had at times tried to go to the bathroom at 3:22 times tried to go to the bathroom at 3:22 times tried to go to the bathroom at night complaining of inability to 3:24 night complaining of inability to 3:24 night complaining of inability to urinate 3:25 urinate 3:26 urinate and sometimes the patient was walking 3:29 and sometimes the patient was walking 3:29 and sometimes the patient was walking with her with him protecting her, but 3:32 with her with him protecting her, but 3:32 with her with him protecting her, but she'll immediately stop thinking that 3:34 she'll immediately stop thinking that 3:34 she'll immediately stop thinking that she's about to fall over and never did 3:36 she's about to fall over and never did 3:36 she's about to fall over and never did fall. No report of other concerning 3:40 fall. No report of other concerning 3:40 fall. No report of other concerning findings like fever, chills, sweats, or 3:42 findings like fever, chills, sweats, or 3:42 findings like fever, chills, sweats, or what we call diapharesis, chest pain. 3:44 what we call diapharesis, chest pain. 3:44 what we call diapharesis, chest pain. She did report some palpitations or 3:46 She did report some palpitations or 3:46 She did report some palpitations or heart chest flutters. Did have some 3:49 heart chest flutters. Did have some 3:49 heart chest flutters. Did have some constipation and take some laxatives for 3:51 constipation and take some laxatives for 3:51 constipation and take some laxatives for that. Um, and had to take some emodium 3:54 that. Um, and had to take some emodium 3:54 that. Um, and had to take some emodium also or leeramide for that. uh compliant 3:59 also or leeramide for that. uh compliant 3:59 also or leeramide for that. uh compliant with her prescription medications. So, 4:01 with her prescription medications. So, 4:01 with her prescription medications. So, she was taking all of her usually 4:02 she was taking all of her usually 4:02 she was taking all of her usually prescribed medications. So, again, 4:05 prescribed medications. So, again, 4:05 prescribed medications. So, again, another stopping point to reflect. What 4:07 another stopping point to reflect. What 4:07 another stopping point to reflect. What else do you want to know? Right? What 4:09 else do you want to know? Right? What 4:09 else do you want to know? Right? What information would be helpful to figure 4:11 information would be helpful to figure 4:11 information would be helpful to figure this out? What else do you want to do? 4:15 this out? What else do you want to do? 4:15 this out? What else do you want to do? What tests, laboratory analyses, 4:17 What tests, laboratory analyses, 4:17 What tests, laboratory analyses, interview questions, physical exam 4:19 interview questions, physical exam 4:19 interview questions, physical exam questions do you have in your head? And 4:21 questions do you have in your head? And 4:21 questions do you have in your head? And where is your mind taking you at this 4:22 where is your mind taking you at this 4:22 where is your mind taking you at this point? Do you have any differential 4:24 point? Do you have any differential 4:24 point? Do you have any differential diagnostic categories, potential 4:26 diagnostic categories, potential 4:26 diagnostic categories, potential diagnoses, and potential therapy 4:29 diagnoses, and potential therapy 4:29 diagnoses, and potential therapy options? 4:30 options? 4:30 options? Moving on to reveal more of the story, 4:33 Moving on to reveal more of the story, 4:33 Moving on to reveal more of the story, patient commented that she is very 4:35 patient commented that she is very 4:35 patient commented that she is very anxious and depressed. She is herself 4:37 anxious and depressed. She is herself 4:37 anxious and depressed. She is herself subjectively feeling that husband states 4:39 subjectively feeling that husband states 4:39 subjectively feeling that husband states for the the past year or so, the patient 4:41 for the the past year or so, the patient 4:41 for the the past year or so, the patient has been very melancholic and cries over 4:44 has been very melancholic and cries over 4:44 has been very melancholic and cries over everything. 4:47 everything. 4:47 everything. also thinks that she has been impacted 4:50 also thinks that she has been impacted 4:50 also thinks that she has been impacted by the death of two of her close 4:52 by the death of two of her close 4:52 by the death of two of her close friends, his own open heart surgery and 4:55 friends, his own open heart surgery and 4:55 friends, his own open heart surgery and lung cancer diagnosis. So he's been 4:58 lung cancer diagnosis. So he's been 4:58 lung cancer diagnosis. So he's been through his own medical issues and also 5:00 through his own medical issues and also 5:00 through his own medical issues and also one of their son's illnesses. So a lot 5:03 one of their son's illnesses. So a lot 5:03 one of their son's illnesses. So a lot of stressors states that the patient 5:05 of stressors states that the patient 5:05 of stressors states that the patient thinks that she has multiple illnesses 5:07 thinks that she has multiple illnesses 5:07 thinks that she has multiple illnesses and has undergone different tests but 5:09 and has undergone different tests but 5:09 and has undergone different tests but some tests without any significant 5:11 some tests without any significant 5:11 some tests without any significant findings. So patient really has been 5:13 findings. So patient really has been 5:13 findings. So patient really has been worrying about her illness quite a bit. 5:15 worrying about her illness quite a bit. 5:15 worrying about her illness quite a bit. Sleeping has been a struggle. Although 5:17 Sleeping has been a struggle. Although 5:17 Sleeping has been a struggle. Although with ambient or Zulpadm she might sleep 5:20 with ambient or Zulpadm she might sleep 5:20 with ambient or Zulpadm she might sleep around six hours for the night according 5:22 around six hours for the night according 5:22 around six hours for the night according to the husband. 5:24 to the husband. 5:24 to the husband. A little more history in terms of past 5:26 A little more history in terms of past 5:26 A little more history in terms of past medical history. She does have 5:28 medical history. She does have 5:28 medical history. She does have gastroosophageal reflux disease or gird. 5:31 gastroosophageal reflux disease or gird. 5:31 gastroosophageal reflux disease or gird. She does have hypertension, hyper 5:33 She does have hypertension, hyper 5:33 She does have hypertension, hyper lipidmia or elevated lipids, anxiety, 5:37 lipidmia or elevated lipids, anxiety, 5:37 lipidmia or elevated lipids, anxiety, depression, psoriasis, seroriatic 5:39 depression, psoriasis, seroriatic 5:40 depression, psoriasis, seroriatic arthritis and osteoarthritis. All of 5:43 arthritis and osteoarthritis. All of 5:43 arthritis and osteoarthritis. All of these are chronic conditions that she's 5:45 these are chronic conditions that she's 5:45 these are chronic conditions that she's been managing for some time. Nothing 5:46 been managing for some time. Nothing 5:46 been managing for some time. Nothing new. Terms of past surgical history, she 5:50 new. Terms of past surgical history, she 5:50 new. Terms of past surgical history, she has bilateral total knee replacements 5:53 has bilateral total knee replacements 5:53 has bilateral total knee replacements and choicesctomy or gallbladder removal 5:56 and choicesctomy or gallbladder removal 5:56 and choicesctomy or gallbladder removal and a C-section way back when she had a 5:58 and a C-section way back when she had a 5:58 and a C-section way back when she had a kid. Past psychiatric history includes 6:01 kid. Past psychiatric history includes 6:01 kid. Past psychiatric history includes again this poorly stated depression, 6:04 again this poorly stated depression, 6:04 again this poorly stated depression, anxiety, no no DSM diagnoses that were 6:06 anxiety, no no DSM diagnoses that were 6:06 anxiety, no no DSM diagnoses that were offered times many years managed by a 6:09 offered times many years managed by a 6:09 offered times many years managed by a primary care physician, not a 6:11 primary care physician, not a 6:12 primary care physician, not a psychiatrist and has not really had 6:14 psychiatrist and has not really had 6:14 psychiatrist and has not really had significant psychiatric evaluations and 6:16 significant psychiatric evaluations and 6:16 significant psychiatric evaluations and certainly no inpatient psychiatric care, 6:19 certainly no inpatient psychiatric care, 6:19 certainly no inpatient psychiatric care, no suicide attempts, no substance use, 6:22 no suicide attempts, no substance use, 6:22 no suicide attempts, no substance use, although has been smoking half a pack a 6:25 although has been smoking half a pack a 6:25 although has been smoking half a pack a day of cigarettes uh since the age of 6:28 day of cigarettes uh since the age of 6:28 day of cigarettes uh since the age of 20. So, some nicotine use there for 6:30 20. So, some nicotine use there for 6:30 20. So, some nicotine use there for sure. Terms of family history, father 6:33 sure. Terms of family history, father 6:33 sure. Terms of family history, father had Alzheimer's disease and mother had 6:37 had Alzheimer's disease and mother had 6:37 had Alzheimer's disease and mother had essential tremor. Also has another 6:40 essential tremor. Also has another 6:40 essential tremor. Also has another sibling. Uh it's unclear if it was 6:42 sibling. Uh it's unclear if it was 6:42 sibling. Uh it's unclear if it was brother or sister with Alzheimer's. So 6:45 brother or sister with Alzheimer's. So 6:45 brother or sister with Alzheimer's. So as you take this into account, there's 6:47 as you take this into account, there's 6:47 as you take this into account, there's some genetic loading, some history here, 6:49 some genetic loading, some history here, 6:49 some genetic loading, some history here, some chronic conditions, and some uh 6:52 some chronic conditions, and some uh 6:52 some chronic conditions, and some uh note of psychiatric illness without uh 6:56 note of psychiatric illness without uh 6:56 note of psychiatric illness without uh clear u determination as to what the 6:59 clear u determination as to what the 6:59 clear u determination as to what the diagnosis is. Terms of her home 7:02 diagnosis is. Terms of her home 7:02 diagnosis is. Terms of her home medications, there are many. She had 7:05 medications, there are many. She had 7:05 medications, there are many. She had been taking at the time of arrival 7:07 been taking at the time of arrival 7:07 been taking at the time of arrival duloxitine also known as symbalta uh 60 7:11 duloxitine also known as symbalta uh 60 7:11 duloxitine also known as symbalta uh 60 milligrams twice a day. Oxycodone acetto 7:13 milligrams twice a day. Oxycodone acetto 7:13 milligrams twice a day. Oxycodone acetto medicine or percoet 10 mg/325 7:17 medicine or percoet 10 mg/325 7:17 medicine or percoet 10 mg/325 milligrams every 6 hours. Methotraate 7:21 milligrams every 6 hours. Methotraate 7:21 milligrams every 6 hours. Methotraate 2.5 milligrams 7:23 2.5 milligrams 7:23 2.5 milligrams once a week on Fridays. Zulpadm or 7:25 once a week on Fridays. Zulpadm or 7:25 once a week on Fridays. Zulpadm or ambient that I mentioned 10 milligrams 7:27 ambient that I mentioned 10 milligrams 7:27 ambient that I mentioned 10 milligrams at night. Enbril 50 milligrams 7:29 at night. Enbril 50 milligrams 7:29 at night. Enbril 50 milligrams subcutaneously once a week on 7:31 subcutaneously once a week on 7:31 subcutaneously once a week on Wednesdays. Folate or folic acid 7:33 Wednesdays. Folate or folic acid 7:33 Wednesdays. Folate or folic acid supplementation emloopenearten 7:36 supplementation emloopenearten 7:36 supplementation emloopenearten azor 7:38 azor 7:38 azor 5/20 milligrams daily for heart and and 7:42 5/20 milligrams daily for heart and and 7:42 5/20 milligrams daily for heart and and blood pressure. Propranol or indurol 7:45 blood pressure. Propranol or indurol 7:45 blood pressure. Propranol or indurol extended release 60 milligrams daily as 7:48 extended release 60 milligrams daily as 7:48 extended release 60 milligrams daily as needed for anxiety. Alprazilam or xanax 7:52 needed for anxiety. Alprazilam or xanax 7:52 needed for anxiety. Alprazilam or xanax 0.25 milligrams daily as needed for 7:54 0.25 milligrams daily as needed for 7:54 0.25 milligrams daily as needed for anxiety and clinazipam or clonopin.5 7:58 anxiety and clinazipam or clonopin.5 7:58 anxiety and clinazipam or clonopin.5 milligrams daily as needed for anxiety. 8:01 milligrams daily as needed for anxiety. 8:01 milligrams daily as needed for anxiety. So you can see a number of strategies 8:03 So you can see a number of strategies 8:03 So you can see a number of strategies here, pharmacologic strategies for 8:05 here, pharmacologic strategies for 8:05 here, pharmacologic strategies for anxiety that also have side effects and 8:09 anxiety that also have side effects and 8:09 anxiety that also have side effects and other other concerns. So quite a bit of 8:11 other other concerns. So quite a bit of 8:11 other other concerns. So quite a bit of medication here. So again, more 8:14 medication here. So again, more 8:14 medication here. So again, more information has been revealed at this 8:15 information has been revealed at this 8:15 information has been revealed at this point in terms of stopping and 8:17 point in terms of stopping and 8:17 point in terms of stopping and reflecting on the case. What else once
Workup and EEG Reveals Seizures 8:19 reflecting on the case. What else once 8:19 reflecting on the case. What else once again do you want to know? What other 8:21 again do you want to know? What other 8:21 again do you want to know? What other tests, labs, findings do you consider? 8:24 tests, labs, findings do you consider? 8:24 tests, labs, findings do you consider? Um how uh do you obtain those? So what 8:27 Um how uh do you obtain those? So what 8:27 Um how uh do you obtain those? So what else do you want to do? And finally, 8:30 else do you want to do? And finally, 8:30 else do you want to do? And finally, where is your mind taking you in terms 8:32 where is your mind taking you in terms 8:32 where is your mind taking you in terms of differential diagnoses and 8:34 of differential diagnoses and 8:34 of differential diagnoses and considerations? 8:35 considerations? 8:36 considerations? A little more information in terms of 8:38 A little more information in terms of 8:38 A little more information in terms of objective analyses. Her complete blood 8:42 objective analyses. Her complete blood 8:42 objective analyses. Her complete blood cells count and her electrolytes as well 8:45 cells count and her electrolytes as well 8:45 cells count and her electrolytes as well as her liver function tests were all 8:47 as her liver function tests were all 8:47 as her liver function tests were all within normal limits. So nothing too 8:49 within normal limits. So nothing too 8:49 within normal limits. So nothing too remarkable there. Her thyroid 8:51 remarkable there. Her thyroid 8:51 remarkable there. Her thyroid stimulating hormone TSH CK creating 8:54 stimulating hormone TSH CK creating 8:54 stimulating hormone TSH CK creating kynise, her ammonia, her folate, and her 8:57 kynise, her ammonia, her folate, and her 8:57 kynise, her ammonia, her folate, and her C reactive pro protein were all within 8:59 C reactive pro protein were all within 8:59 C reactive pro protein were all within normal limits as well. Her chest X-ray 9:03 normal limits as well. Her chest X-ray 9:03 normal limits as well. Her chest X-ray was also clean. Her EKG was within 9:05 was also clean. Her EKG was within 9:05 was also clean. Her EKG was within normal limits with a QTC of 434. Her CT 9:11 normal limits with a QTC of 434. Her CT 9:12 normal limits with a QTC of 434. Her CT of the brain which is visualized here 9:13 of the brain which is visualized here 9:13 of the brain which is visualized here was negative for any acute incraanial 9:15 was negative for any acute incraanial 9:15 was negative for any acute incraanial pathology 9:17 pathology 9:17 pathology although it showed some involutional 9:19 although it showed some involutional 9:19 although it showed some involutional changes with volume loss 9:22 changes with volume loss 9:22 changes with volume loss and as mentioned no CT evidence of any 9:25 and as mentioned no CT evidence of any 9:25 and as mentioned no CT evidence of any acute pathology. So some involutional 9:27 acute pathology. So some involutional 9:27 acute pathology. So some involutional changes or age related changes with a 9:29 changes or age related changes with a 9:29 changes or age related changes with a bit of atrophy or or reduction in the 9:32 bit of atrophy or or reduction in the 9:32 bit of atrophy or or reduction in the size of the cortical mass was noted but 9:35 size of the cortical mass was noted but 9:35 size of the cortical mass was noted but that happens very gradually and it's not 9:38 that happens very gradually and it's not 9:38 that happens very gradually and it's not typically the reason for somebody to 9:41 typically the reason for somebody to 9:41 typically the reason for somebody to have sudden findings like this patient 9:43 have sudden findings like this patient 9:43 have sudden findings like this patient did. 9:45 did. 9:45 did. The urine analysis also showed 9:47 The urine analysis also showed 9:47 The urine analysis also showed interestingly u some growth of klebsella 9:50 interestingly u some growth of klebsella 9:50 interestingly u some growth of klebsella bacteria and as you can see the findings 9:53 bacteria and as you can see the findings 9:53 bacteria and as you can see the findings there um might you know suggest an 9:57 there um might you know suggest an 9:57 there um might you know suggest an ideology or a cause for some of these 9:59 ideology or a cause for some of these 9:59 ideology or a cause for some of these new symptoms 10:04 when consultation leazison and 10:04 when consultation leazison and psychiatry was consulted or CL was 10:07 psychiatry was consulted or CL was 10:07 psychiatry was consulted or CL was consulted uh we conducted an intake and 10:10 consulted uh we conducted an intake and 10:10 consulted uh we conducted an intake and this is what we observed I'll read most 10:13 this is what we observed I'll read most 10:13 this is what we observed I'll read most of this um the patient was seen at 10:15 of this um the patient was seen at 10:15 of this um the patient was seen at bedside with a husband and interview was 10:18 bedside with a husband and interview was 10:18 bedside with a husband and interview was limited as at times patient was unable 10:21 limited as at times patient was unable 10:21 limited as at times patient was unable to verbalize and became silent through 10:23 to verbalize and became silent through 10:23 to verbalize and became silent through the conversation. Patient stated she has 10:26 the conversation. Patient stated she has 10:26 the conversation. Patient stated she has been feeling anxious for years now which 10:28 been feeling anxious for years now which 10:28 been feeling anxious for years now which she relates to numerous stressors 10:29 she relates to numerous stressors 10:30 she relates to numerous stressors including her husband's heart surgery, 10:32 including her husband's heart surgery, 10:32 including her husband's heart surgery, lung cancer diagnosis and a son's health 10:34 lung cancer diagnosis and a son's health 10:34 lung cancer diagnosis and a son's health as well as recent death of two of her 10:36 as well as recent death of two of her 10:36 as well as recent death of two of her very close friends. Patient stated that 10:39 very close friends. Patient stated that 10:39 very close friends. Patient stated that she's having a lot of free time and 10:41 she's having a lot of free time and 10:41 she's having a lot of free time and constantly worrying. She stated that her 10:43 constantly worrying. She stated that her 10:43 constantly worrying. She stated that her mood has been worsening in the last few 10:46 mood has been worsening in the last few 10:46 mood has been worsening in the last few months, stating feeling sad and that 10:48 months, stating feeling sad and that 10:48 months, stating feeling sad and that she's been crying every day. She stated 10:50 she's been crying every day. She stated 10:50 she's been crying every day. She stated sleep and appetite are quote horrible 10:53 sleep and appetite are quote horrible 10:53 sleep and appetite are quote horrible and always feeling tired. Patient also 10:55 and always feeling tired. Patient also 10:55 and always feeling tired. Patient also mentioned feeling hopeless but is not 10:57 mentioned feeling hopeless but is not 10:58 mentioned feeling hopeless but is not able to elaborate as she becomes silent 10:59 able to elaborate as she becomes silent 10:59 able to elaborate as she becomes silent on the conversation. patient is able to 11:02 on the conversation. patient is able to 11:02 on the conversation. patient is able to engage again with some redirection and 11:05 engage again with some redirection and 11:05 engage again with some redirection and support and she denied any self harm 11:08 support and she denied any self harm 11:08 support and she denied any self harm thoughts, passive or active suicidal or 11:11 thoughts, passive or active suicidal or 11:11 thoughts, passive or active suicidal or homicidal ideiation. She also denied any 11:14 homicidal ideiation. She also denied any 11:14 homicidal ideiation. She also denied any auditory hallucinations, visual 11:15 auditory hallucinations, visual 11:15 auditory hallucinations, visual hallucinations or paranoia. And the 11:18 hallucinations or paranoia. And the 11:18 hallucinations or paranoia. And the patients mentioned several times being 11:21 patients mentioned several times being 11:21 patients mentioned several times being concerned about different illnesses like 11:23 concerned about different illnesses like 11:23 concerned about different illnesses like Alzheimer's and being unable to walk. 11:27 Alzheimer's and being unable to walk. 11:27 Alzheimer's and being unable to walk. She also mentions that her father died 11:29 She also mentions that her father died 11:29 She also mentions that her father died from complications of Alzheimer's and 11:31 from complications of Alzheimer's and 11:31 from complications of Alzheimer's and she finally mentioned having essential 11:34 she finally mentioned having essential 11:34 she finally mentioned having essential tremors that run in her family. So you 11:37 tremors that run in her family. So you 11:37 tremors that run in her family. So you can see pretty quickly it was 11:40 can see pretty quickly it was 11:40 can see pretty quickly it was ascertained many biological, 11:41 ascertained many biological, 11:41 ascertained many biological, psychological and social variables that 11:43 psychological and social variables that 11:43 psychological and social variables that are affecting this individual at this 11:45 are affecting this individual at this 11:46 are affecting this individual at this time. 11:47 time. 11:47 time. So when it comes to the exercise of 11:50 So when it comes to the exercise of 11:50 So when it comes to the exercise of determining what is the diagnosis, it's 11:53 determining what is the diagnosis, it's 11:53 determining what is the diagnosis, it's important to have so-called differential 11:55 important to have so-called differential 11:55 important to have so-called differential diagnosis and consider many different 11:56 diagnosis and consider many different 11:56 diagnosis and consider many different options simultaneously, not exclude one 11:59 options simultaneously, not exclude one 11:59 options simultaneously, not exclude one or the other. 12:01 or the other. 12:01 or the other. At the top of the list, we have the 12:02 At the top of the list, we have the 12:02 At the top of the list, we have the possibility of an anxiety disorder that 12:04 possibility of an anxiety disorder that 12:04 possibility of an anxiety disorder that has never been properly diagnosed and is 12:07 has never been properly diagnosed and is 12:07 has never been properly diagnosed and is now manifesting in unusual ways with 12:09 now manifesting in unusual ways with 12:09 now manifesting in unusual ways with fear of walking, fear of talking, if you 12:13 fear of walking, fear of talking, if you 12:13 fear of walking, fear of talking, if you will, and relative periods of mutism. 12:16 will, and relative periods of mutism. 12:16 will, and relative periods of mutism. Another option is an adjustment disorder 12:18 Another option is an adjustment disorder 12:18 Another option is an adjustment disorder which is a timelimited reaction to 12:21 which is a timelimited reaction to 12:21 which is a timelimited reaction to recent stressors. If somebody's going 12:23 recent stressors. If somebody's going 12:23 recent stressors. If somebody's going through quote a hard time, losses, 12:27 through quote a hard time, losses, 12:27 through quote a hard time, losses, deaths, um challenges, they may have an 12:30 deaths, um challenges, they may have an 12:30 deaths, um challenges, they may have an adjustment disorder with anxiety and or 12:33 adjustment disorder with anxiety and or 12:33 adjustment disorder with anxiety and or depression. Another option here is a 12:36 depression. Another option here is a 12:36 depression. Another option here is a sematic symptom disorder in which 12:37 sematic symptom disorder in which 12:37 sematic symptom disorder in which somebody is very preoccupied with their 12:40 somebody is very preoccupied with their 12:40 somebody is very preoccupied with their physical health and diagnosis 12:44 physical health and diagnosis 12:44 physical health and diagnosis and are so preoccupied that they're 12:47 and are so preoccupied that they're 12:47 and are so preoccupied that they're they're experiencing functional 12:49 they're experiencing functional 12:49 they're experiencing functional impairments as a result of that. Chronic 12:51 impairments as a result of that. Chronic 12:51 impairments as a result of that. Chronic pain should be considered here as an 12:53 pain should be considered here as an 12:53 pain should be considered here as an important variable. This individual is 12:55 important variable. This individual is 12:56 important variable. This individual is taking percoet u every day presumably 12:59 taking percoet u every day presumably 12:59 taking percoet u every day presumably for her osteoarthritis and seroriatic 13:01 for her osteoarthritis and seroriatic 13:02 for her osteoarthritis and seroriatic arthritis. And it's important to 13:04 arthritis. And it's important to 13:04 arthritis. And it's important to understand that chronic pain comes with 13:06 understand that chronic pain comes with 13:06 understand that chronic pain comes with biocschosocial complexities. It's not 13:08 biocschosocial complexities. It's not 13:08 biocschosocial complexities. It's not typically just a condition about pain. 13:11 typically just a condition about pain. 13:11 typically just a condition about pain. Very often individuals have overlays of 13:13 Very often individuals have overlays of 13:13 Very often individuals have overlays of anxiety, depression, and all sorts of 13:15 anxiety, depression, and all sorts of 13:15 anxiety, depression, and all sorts of other challenges. 13:17 other challenges. 13:17 other challenges. Polyfarm pharmacy or the interaction of 13:19 Polyfarm pharmacy or the interaction of 13:19 Polyfarm pharmacy or the interaction of various medications is very important 13:21 various medications is very important 13:21 various medications is very important here. We saw a long list of medications 13:23 here. We saw a long list of medications 13:23 here. We saw a long list of medications and she is of advanced age. Perhaps 13:27 and she is of advanced age. Perhaps 13:27 and she is of advanced age. Perhaps these medications are having 13:28 these medications are having 13:28 these medications are having interactions causing all sorts of issues 13:31 interactions causing all sorts of issues 13:31 interactions causing all sorts of issues in terms of impaired ability to speak, 13:35 in terms of impaired ability to speak, 13:35 in terms of impaired ability to speak, maybe some confusion, maybe some 13:37 maybe some confusion, maybe some 13:38 maybe some confusion, maybe some difficulty with urination as described 13:40 difficulty with urination as described 13:40 difficulty with urination as described earlier, in terms of antiolinergic 13:42 earlier, in terms of antiolinergic 13:42 earlier, in terms of antiolinergic effects. There are many possibilities 13:44 effects. There are many possibilities 13:44 effects. There are many possibilities here and these medications in 13:46 here and these medications in 13:46 here and these medications in combination may be catching up with her 13:48 combination may be catching up with her 13:48 combination may be catching up with her if you if you will. There's also the 13:51 if you if you will. There's also the 13:51 if you if you will. There's also the possibility of neurologic disorder, 13:53 possibility of neurologic disorder, 13:53 possibility of neurologic disorder, meaning something that is brainbased, 13:54 meaning something that is brainbased, 13:54 meaning something that is brainbased, that hasn't been diagnosed, that is 13:56 that hasn't been diagnosed, that is 13:56 that hasn't been diagnosed, that is causing these freeze episodes, the 13:59 causing these freeze episodes, the 13:59 causing these freeze episodes, the mutism. 14:01 mutism. 14:01 mutism. Personality traits and disorders are 14:03 Personality traits and disorders are 14:03 Personality traits and disorders are always under consideration as possibly 14:06 always under consideration as possibly 14:06 always under consideration as possibly contributing to a picture. Is this 14:07 contributing to a picture. Is this 14:08 contributing to a picture. Is this individual particularly dependent? Is 14:11 individual particularly dependent? Is 14:11 individual particularly dependent? Is this somebody who's clingy, needy, if 14:13 this somebody who's clingy, needy, if 14:13 this somebody who's clingy, needy, if you will, at 14:16 you will, at 14:16 you will, at you know at baseline and depends 14:18 you know at baseline and depends 14:18 you know at baseline and depends excessively on others whether it's 14:20 excessively on others whether it's 14:20 excessively on others whether it's doctors, providers or husband etc. 14:23 doctors, providers or husband etc. 14:23 doctors, providers or husband etc. Delirium is an important consideration 14:25 Delirium is an important consideration 14:25 Delirium is an important consideration also known as encphylopathy. 14:27 also known as encphylopathy. 14:27 also known as encphylopathy. Confusion caused by a medical a medical 14:32 Confusion caused by a medical a medical 14:32 Confusion caused by a medical a medical cause. 14:33 cause. 14:33 cause. Catatonia is also to be considered. 14:36 Catatonia is also to be considered. 14:36 Catatonia is also to be considered. Catatonia is a condition in which 14:37 Catatonia is a condition in which 14:37 Catatonia is a condition in which individuals freeze up uh become rigid 14:40 individuals freeze up uh become rigid 14:40 individuals freeze up uh become rigid become mute become immobile and and are 14:43 become mute become immobile and and are 14:43 become mute become immobile and and are unable to to basically move and operate 14:47 unable to to basically move and operate 14:47 unable to to basically move and operate fluidly as they used to. So that is also 14:50 fluidly as they used to. So that is also 14:50 fluidly as they used to. So that is also a consideration here and still others. 14:53 a consideration here and still others. 14:53 a consideration here and still others. It's important to remain as as 14:55 It's important to remain as as 14:55 It's important to remain as as clinicians and providers open to the 14:58 clinicians and providers open to the 14:58 clinicians and providers open to the possibility of different explanations 14:59 possibility of different explanations 14:59 possibility of different explanations for this whether it's medical, physical, 15:03 for this whether it's medical, physical, 15:03 for this whether it's medical, physical, psychological, social, spiritual. 15:06 psychological, social, spiritual. 15:06 psychological, social, spiritual. So these were all of the considerations 15:08 So these were all of the considerations 15:08 So these were all of the considerations that were swirling through the minds of 15:10 that were swirling through the minds of 15:10 that were swirling through the minds of the providers. Neurology was consulted 15:13 the providers. Neurology was consulted 15:13 the providers. Neurology was consulted by the medical team because they felt 15:16 by the medical team because they felt 15:16 by the medical team because they felt that actually one of the other 15:17 that actually one of the other 15:18 that actually one of the other considerations was possible psychoggenic 15:20 considerations was possible psychoggenic 15:20 considerations was possible psychoggenic non-epileptic seizures. Now this refers 15:23 non-epileptic seizures. Now this refers 15:23 non-epileptic seizures. Now this refers to of course not epilepsy but 15:27 to of course not epilepsy but 15:27 to of course not epilepsy but seizure episodes or seizure- like 15:29 seizure episodes or seizure- like 15:29 seizure episodes or seizure- like episodes that are thought to be 15:31 episodes that are thought to be 15:31 episodes that are thought to be psychologically mediated. And so the 15:34 psychologically mediated. And so the 15:34 psychologically mediated. And so the medical team wanted to rule this out, 15:35 medical team wanted to rule this out, 15:36 medical team wanted to rule this out, wanted to exclude this possibility. And 15:38 wanted to exclude this possibility. And 15:38 wanted to exclude this possibility. And at face value, it seems like it's a bit 15:40 at face value, it seems like it's a bit 15:40 at face value, it seems like it's a bit premature to jump to that conclusion, 15:43 premature to jump to that conclusion, 15:43 premature to jump to that conclusion, but neurology was consulted anyway. 15:46 but neurology was consulted anyway. 15:46 but neurology was consulted anyway. They also consulted us psychiatry um 15:50 They also consulted us psychiatry um 15:50 They also consulted us psychiatry um sort of urgently for this anxiety and 15:52 sort of urgently for this anxiety and 15:52 sort of urgently for this anxiety and panic. So you can you can see the 15:55 panic. So you can you can see the 15:55 panic. So you can you can see the primary medical team already being sort 15:57 primary medical team already being sort 15:57 primary medical team already being sort of biased towards a psychiatric or 15:59 of biased towards a psychiatric or 15:59 of biased towards a psychiatric or psychological explanation for the 16:01 psychological explanation for the 16:01 psychological explanation for the condition based on everything that we 16:03 condition based on everything that we 16:03 condition based on everything that we just reviewed. her normal CAT scan of 16:06 just reviewed. her normal CAT scan of 16:06 just reviewed. her normal CAT scan of the brain, her relatively normal labs. 16:08 the brain, her relatively normal labs. 16:08 the brain, her relatively normal labs. The fact that she's able to talk at 16:10 The fact that she's able to talk at 16:10 The fact that she's able to talk at times but not at others, which makes it 16:13 times but not at others, which makes it 16:13 times but not at others, which makes it makes one think this is inconsistent and 16:15 makes one think this is inconsistent and 16:15 makes one think this is inconsistent and it's maybe even selective. The fact that 16:17 it's maybe even selective. The fact that 16:17 it's maybe even selective. The fact that she has a history of depression, 16:18 she has a history of depression, 16:18 she has a history of depression, anxiety, a number of medications in 16:21 anxiety, a number of medications in 16:21 anxiety, a number of medications in board, that she has stressors that maybe 16:24 board, that she has stressors that maybe 16:24 board, that she has stressors that maybe could be affecting her in a 16:25 could be affecting her in a 16:25 could be affecting her in a psychological way. All of this perhaps 16:28 psychological way. All of this perhaps 16:28 psychological way. All of this perhaps understandably influenced the medical 16:30 understandably influenced the medical 16:30 understandably influenced the medical team to think of a medical or excuse me 16:34 team to think of a medical or excuse me 16:34 team to think of a medical or excuse me psychiatric explanation. 16:37 psychiatric explanation. 16:38 psychiatric explanation. But labs and an electronogram were 16:41 But labs and an electronogram were 16:41 But labs and an electronogram were ordered by neurology and interestingly 16:45 ordered by neurology and interestingly 16:45 ordered by neurology and interestingly we found an abnormal electron or EEG in 16:48 we found an abnormal electron or EEG in 16:48 we found an abnormal electron or EEG in the awake and drowsy states. Something 16:50 the awake and drowsy states. Something 16:50 the awake and drowsy states. Something was off. four electroclinical focal 16:53 was off. four electroclinical focal 16:53 was off. four electroclinical focal onset seizures were recorded arising 16:55 onset seizures were recorded arising 16:55 onset seizures were recorded arising from the right frontal central region. 16:57 from the right frontal central region. 16:58 from the right frontal central region. In other words, actual epileptic events 17:01 In other words, actual epileptic events 17:01 In other words, actual epileptic events were captured and recorded by the EEG a 17:05 were captured and recorded by the EEG a 17:05 were captured and recorded by the EEG a brain wave test uh arising from the 17:08 brain wave test uh arising from the 17:08 brain wave test uh arising from the right front part of the brain. 17:11 right front part of the brain. 17:11 right front part of the brain. Neurology actually started some 17:12 Neurology actually started some 17:12 Neurology actually started some medications, antiepileptics known as 17:14 medications, antiepileptics known as 17:14 medications, antiepileptics known as Vimpat and Kera, loaded the individual
Treatment Response and Follow-Up 17:18 Vimpat and Kera, loaded the individual 17:18 Vimpat and Kera, loaded the individual with that and then changed over to a 17:20 with that and then changed over to a 17:20 with that and then changed over to a different one or vaporic acid and were 17:23 different one or vaporic acid and were 17:23 different one or vaporic acid and were able to stop the seizures. And in 17:26 able to stop the seizures. And in 17:26 able to stop the seizures. And in subsequent evaluations, she also 17:28 subsequent evaluations, she also 17:28 subsequent evaluations, she also received an MRI of the brain and found 17:32 received an MRI of the brain and found 17:32 received an MRI of the brain and found same thing parankal volume loss, some 17:35 same thing parankal volume loss, some 17:35 same thing parankal volume loss, some changes that came with age, but no major 17:39 changes that came with age, but no major 17:39 changes that came with age, but no major abnormal acute 17:41 abnormal acute 17:41 abnormal acute emergent findings. There's a lot of 17:43 emergent findings. There's a lot of 17:43 emergent findings. There's a lot of language on this slide, but I'll focus 17:45 language on this slide, but I'll focus 17:45 language on this slide, but I'll focus also on what's in bold. There was also 17:48 also on what's in bold. There was also 17:48 also on what's in bold. There was also this possibility of marrow infiltrative 17:50 this possibility of marrow infiltrative 17:50 this possibility of marrow infiltrative process such as metastasis which is of 17:53 process such as metastasis which is of 17:53 process such as metastasis which is of course what happens with cancer when it 17:55 course what happens with cancer when it 17:56 course what happens with cancer when it spreads and the radiologist reading this 17:58 spreads and the radiologist reading this 17:58 spreads and the radiologist reading this MRI said maybe multiple myyoma lymphoma 18:01 MRI said maybe multiple myyoma lymphoma 18:01 MRI said maybe multiple myyoma lymphoma or other possible cancer cannot be 18:04 or other possible cancer cannot be 18:04 or other possible cancer cannot be excluded and they recommended clinical 18:06 excluded and they recommended clinical 18:06 excluded and they recommended clinical correlation in other words follow this 18:08 correlation in other words follow this 18:08 correlation in other words follow this up do tests do labs and they did and 18:12 up do tests do labs and they did and 18:12 up do tests do labs and they did and basically found u nothing nothing else 18:16 basically found u nothing nothing else 18:16 basically found u nothing nothing else on other tests this is the rest of the 18:18 on other tests this is the rest of the 18:18 on other tests this is the rest of the workup. They did a CAT scan of the 18:20 workup. They did a CAT scan of the 18:20 workup. They did a CAT scan of the abdomen and the chest. There was no 18:21 abdomen and the chest. There was no 18:21 abdomen and the chest. There was no evidence of cancer thankfully and also 18:24 evidence of cancer thankfully and also 18:24 evidence of cancer thankfully and also her hemat hematologic or cell lines were 18:28 her hemat hematologic or cell lines were 18:28 her hemat hematologic or cell lines were okay. They consulted hematology for 18:30 okay. They consulted hematology for 18:30 okay. They consulted hematology for that. So we did not think the cancer was 18:32 that. So we did not think the cancer was 18:32 that. So we did not think the cancer was really um at play here and in fact she 18:36 really um at play here and in fact she 18:36 really um at play here and in fact she improved dramatically. No further 18:38 improved dramatically. No further 18:38 improved dramatically. No further symptoms on the depico 250 milligrams 18:41 symptoms on the depico 250 milligrams 18:41 symptoms on the depico 250 milligrams every 6 hours. She was tolerating it 18:43 every 6 hours. She was tolerating it 18:43 every 6 hours. She was tolerating it well too. and she connected with 18:45 well too. and she connected with 18:45 well too. and she connected with neurology as an outpatient once she was 18:47 neurology as an outpatient once she was 18:47 neurology as an outpatient once she was discharged and she kept taking the 18:49 discharged and she kept taking the 18:49 discharged and she kept taking the depico or vaporic acid. She did complain 18:52 depico or vaporic acid. She did complain 18:52 depico or vaporic acid. She did complain of some side effects and asking to come 18:53 of some side effects and asking to come 18:53 of some side effects and asking to come off of it but that's a whole other 18:55 off of it but that's a whole other 18:55 off of it but that's a whole other matter. She did respond well to this and
Aphasia, Aphemia, and Speech Arrest 18:57 matter. She did respond well to this and 18:57 matter. She did respond well to this and didn't have any further episodes of the 18:59 didn't have any further episodes of the 18:59 didn't have any further episodes of the talking freezes. 19:01 talking freezes. 19:01 talking freezes. So it was an important reminder of 19:06 So it was an important reminder of 19:06 So it was an important reminder of the 19:08 the 19:08 the differential diagnosis that cause speech 19:11 differential diagnosis that cause speech 19:11 differential diagnosis that cause speech arrest. This image here is a reminder of 19:13 arrest. This image here is a reminder of 19:14 arrest. This image here is a reminder of the different types of aphasia. Aphasia 19:15 the different types of aphasia. Aphasia 19:16 the different types of aphasia. Aphasia is a cessation of speech or an 19:18 is a cessation of speech or an 19:18 is a cessation of speech or an interruption of speech, abnormal speech 19:20 interruption of speech, abnormal speech 19:20 interruption of speech, abnormal speech due to a neurologic or other medical 19:22 due to a neurologic or other medical 19:22 due to a neurologic or other medical process. And you can see that the way us 19:26 process. And you can see that the way us 19:26 process. And you can see that the way us you know doctors are meant to organize 19:28 you know doctors are meant to organize 19:28 you know doctors are meant to organize these is to think of uh what's called 19:30 these is to think of uh what's called 19:30 these is to think of uh what's called fluent aphasia, meaning is the is the 19:33 fluent aphasia, meaning is the is the 19:33 fluent aphasia, meaning is the is the speech itself being communicated clearly 19:36 speech itself being communicated clearly 19:36 speech itself being communicated clearly or expressive aphasia. you know, is the 19:39 or expressive aphasia. you know, is the 19:39 or expressive aphasia. you know, is the person not not even understanding or 19:41 person not not even understanding or 19:41 person not not even understanding or receiving the information, right? Um, 19:44 receiving the information, right? Um, 19:44 receiving the information, right? Um, and can they repeat it back? And so, you 19:46 and can they repeat it back? And so, you 19:46 and can they repeat it back? And so, you see all of these questions that we ask 19:49 see all of these questions that we ask 19:49 see all of these questions that we ask ourselves to then go down the algorithm 19:51 ourselves to then go down the algorithm 19:52 ourselves to then go down the algorithm or the tree to see which one of these 19:54 or the tree to see which one of these 19:54 or the tree to see which one of these might be the aphasia at play. Now, in 19:57 might be the aphasia at play. Now, in 19:57 might be the aphasia at play. Now, in this case, she actually wasn't diagnosed 20:00 this case, she actually wasn't diagnosed 20:00 this case, she actually wasn't diagnosed with a conventional aphasia because it 20:02 with a conventional aphasia because it 20:02 with a conventional aphasia because it was temporary and it was reversed with 20:05 was temporary and it was reversed with 20:05 was temporary and it was reversed with treatment. Instead, what we thought 20:08 treatment. Instead, what we thought 20:08 treatment. Instead, what we thought about with this case is what's called 20:11 about with this case is what's called 20:11 about with this case is what's called aphemia. Now, aphemia is a different 20:14 aphemia. Now, aphemia is a different 20:14 aphemia. Now, aphemia is a different slightly different phenomenon than 20:16 slightly different phenomenon than 20:16 slightly different phenomenon than aphasia. And Broca, who's pictured here, 20:19 aphasia. And Broca, who's pictured here, 20:19 aphasia. And Broca, who's pictured here, is a very famous uh physician who 20:22 is a very famous uh physician who 20:22 is a very famous uh physician who described aphasas, but also described 20:25 described aphasas, but also described 20:25 described aphasas, but also described aphemia. Aphemia is something that most 20:28 aphemia. Aphemia is something that most 20:28 aphemia. Aphemia is something that most physicians actually don't think enough 20:29 physicians actually don't think enough 20:29 physicians actually don't think enough about. Most physicians do learn about 20:32 about. Most physicians do learn about 20:32 about. Most physicians do learn about aphasia and broca and what part of the 20:35 aphasia and broca and what part of the 20:35 aphasia and broca and what part of the brain this is termed broca's cortex brok 20:39 brain this is termed broca's cortex brok 20:39 brain this is termed broca's cortex brok or broca's area what part of the brain 20:41 or broca's area what part of the brain 20:41 or broca's area what part of the brain is influenced or impact in impacted in 20:46 is influenced or impact in impacted in 20:46 is influenced or impact in impacted in aphasas but apheme is a different matter 20:49 aphasas but apheme is a different matter 20:49 aphasas but apheme is a different matter and I'll just quote what broker wrote a 20:51 and I'll just quote what broker wrote a 20:51 and I'll just quote what broker wrote a long time ago 20:53 long time ago 20:53 long time ago basically he described that there are 20:54 basically he described that there are 20:54 basically he described that there are cases where the general language faculty 20:56 cases where the general language faculty 20:56 cases where the general language faculty persists unaltered where the auditory 20:59 persists unaltered where the auditory 20:59 persists unaltered where the auditory apparatus is intact act where all the 21:01 apparatus is intact act where all the 21:01 apparatus is intact act where all the muscles not even accepting those of the 21:02 muscles not even accepting those of the 21:02 muscles not even accepting those of the voice and those of articulation obey the 21:05 voice and those of articulation obey the 21:05 voice and those of articulation obey the will and yet where a cerebral lesion 21:08 will and yet where a cerebral lesion 21:08 will and yet where a cerebral lesion abolishes articulated language. So 21:10 abolishes articulated language. So 21:10 abolishes articulated language. So that's a lot of speech to say everything 21:13 that's a lot of speech to say everything 21:13 that's a lot of speech to say everything seems intact and yet the person's unable 21:15 seems intact and yet the person's unable 21:15 seems intact and yet the person's unable to talk. This abolition of speech 21:17 to talk. This abolition of speech 21:17 to talk. This abolition of speech constitutes a symptom so singular that 21:19 constitutes a symptom so singular that 21:19 constitutes a symptom so singular that it seems to be useful to designate it 21:20 it seems to be useful to designate it 21:20 it seems to be useful to designate it with a special name a 21:24 with a special name a 21:24 with a special name a deprivation of speech a speech. It is 21:28 deprivation of speech a speech. It is 21:28 deprivation of speech a speech. It is only the faculty of articulating words 21:31 only the faculty of articulating words 21:31 only the faculty of articulating words that these patients lack. Right? So 21:32 that these patients lack. Right? So 21:32 that these patients lack. Right? So they're thinking of the words and 21:33 they're thinking of the words and 21:33 they're thinking of the words and they're unable to sort of articulate it. 21:35 they're unable to sort of articulate it. 21:35 they're unable to sort of articulate it. They hear and comprehend all that one 21:37 They hear and comprehend all that one 21:37 They hear and comprehend all that one says to them. They all have their 21:39 says to them. They all have their 21:39 says to them. They all have their intelligence. They emit vocal sounds 21:41 intelligence. They emit vocal sounds 21:41 intelligence. They emit vocal sounds with ease. They execute with their 21:43 with ease. They execute with their 21:43 with ease. They execute with their tongue and their lip movements much more 21:45 tongue and their lip movements much more 21:45 tongue and their lip movements much more extensive and energetic than those 21:47 extensive and energetic than those 21:47 extensive and energetic than those required for the articulation of sounds. 21:49 required for the articulation of sounds. 21:49 required for the articulation of sounds. And yet the perfectly sensible response 21:51 And yet the perfectly sensible response 21:51 And yet the perfectly sensible response that they would want to make is reduced 21:53 that they would want to make is reduced 21:53 that they would want to make is reduced to a very small number of articulated 21:55 to a very small number of articulated 21:55 to a very small number of articulated sounds. So, this is a long way of saying 21:58 sounds. So, this is a long way of saying 21:58 sounds. So, this is a long way of saying that the individual is really trying 22:01 that the individual is really trying 22:01 that the individual is really trying hard to communicate what is in their 22:02 hard to communicate what is in their 22:02 hard to communicate what is in their mind. They know what to say and they 22:05 mind. They know what to say and they 22:05 mind. They know what to say and they just can't get it out. And it's kind of 22:08 just can't get it out. And it's kind of 22:08 just can't get it out. And it's kind of like having words at the tip of your 22:10 like having words at the tip of your 22:10 like having words at the tip of your tongue, but instead when you you're 22:13 tongue, but instead when you you're 22:13 tongue, but instead when you you're struggling and you have words in the tip 22:14 struggling and you have words in the tip 22:14 struggling and you have words in the tip of your tongue, you can't quite imagine 22:16 of your tongue, you can't quite imagine 22:16 of your tongue, you can't quite imagine the word. In somebody with aphia, they 22:19 the word. In somebody with aphia, they 22:19 the word. In somebody with aphia, they do imagine the word. They know what 22:21 do imagine the word. They know what 22:21 do imagine the word. They know what they're trying to say and they just 22:22 they're trying to say and they just 22:22 they're trying to say and they just can't get it out. 22:25 can't get it out. 22:25 can't get it out. So this creates a lot of clinical 22:27 So this creates a lot of clinical 22:27 So this creates a lot of clinical confusion for physicians, doesn't it? If 22:29 confusion for physicians, doesn't it? If 22:29 confusion for physicians, doesn't it? If somebody comes in and can't speak and 22:32 somebody comes in and can't speak and 22:32 somebody comes in and can't speak and frankly there have been reports like the 22:34 frankly there have been reports like the 22:34 frankly there have been reports like the ones I'm showing here of individuals who 22:37 ones I'm showing here of individuals who 22:37 ones I'm showing here of individuals who have had a 22:39 have had a 22:39 have had a which is arguably rare and it being 22:41 which is arguably rare and it being 22:41 which is arguably rare and it being confused for other things. For instance, 22:44 confused for other things. For instance, 22:44 confused for other things. For instance, this was a case that was published of 22:47 this was a case that was published of 22:47 this was a case that was published of somebody who had once again frontal lobe 22:50 somebody who had once again frontal lobe 22:50 somebody who had once again frontal lobe epilepsy, what's called non-convulsive, 22:53 epilepsy, what's called non-convulsive, 22:53 epilepsy, what's called non-convulsive, so not shaking status epilepticus 22:57 so not shaking status epilepticus 22:57 so not shaking status epilepticus uh or uncontrolled epilepsy. 23:00 uh or uncontrolled epilepsy. 23:00 uh or uncontrolled epilepsy. And the person had stuttering, had a 23:03 And the person had stuttering, had a 23:03 And the person had stuttering, had a semi aphasia. So it was mixed and it was 23:06 semi aphasia. So it was mixed and it was 23:06 semi aphasia. So it was mixed and it was not a sign of what we also call 23:08 not a sign of what we also call 23:08 not a sign of what we also call psychoggenic non-epileptic seizures in 23:10 psychoggenic non-epileptic seizures in 23:10 psychoggenic non-epileptic seizures in other spaces. Remember, the patient was 23:12 other spaces. Remember, the patient was 23:12 other spaces. Remember, the patient was called for that. 23:15 called for that. 23:15 called for that. And in this case, I'm not going to 23:17 And in this case, I'm not going to 23:17 And in this case, I'm not going to review all of this. They described an 23:19 review all of this. They described an 23:19 review all of this. They described an elderly man who experienced personality 23:21 elderly man who experienced personality 23:21 elderly man who experienced personality changes and bouts of stuttering followed 23:23 changes and bouts of stuttering followed 23:23 changes and bouts of stuttering followed by an arthria with preserved writing and 23:26 by an arthria with preserved writing and 23:26 by an arthria with preserved writing and then aphasia and then some confusion. 23:29 then aphasia and then some confusion. 23:29 then aphasia and then some confusion. And the EEG there showed non-convulsive 23:32 And the EEG there showed non-convulsive 23:32 And the EEG there showed non-convulsive status epilepticus. Again, this is not 23:35 status epilepticus. Again, this is not 23:35 status epilepticus. Again, this is not not physically shaking, so you can't see 23:37 not physically shaking, so you can't see 23:37 not physically shaking, so you can't see it. uh uncontrolled epilepsy with 23:40 it. uh uncontrolled epilepsy with 23:40 it. uh uncontrolled epilepsy with focality in other words focused in the 23:43 focality in other words focused in the 23:43 focality in other words focused in the left frontal region of the brain. Um so 23:47 left frontal region of the brain. Um so 23:47 left frontal region of the brain. Um so it was very interesting another case of 23:50 it was very interesting another case of 23:50 it was very interesting another case of sort of focal or localized seizure 23:53 sort of focal or localized seizure 23:53 sort of focal or localized seizure activity that you wouldn't really 23:56 activity that you wouldn't really 23:56 activity that you wouldn't really understand or pick up unless you did the 23:58 understand or pick up unless you did the 23:58 understand or pick up unless you did the EEG. 24:00 EEG. 24:00 EEG. This is actually a normal EEG 24:03 This is actually a normal EEG 24:03 This is actually a normal EEG showing the brain waves at different 24:06 showing the brain waves at different 24:06 showing the brain waves at different spots 24:08 spots 24:08 spots emanating in the cortex. These are all 24:10 emanating in the cortex. These are all 24:10 emanating in the cortex. These are all different markers for where the 24:12 different markers for where the 24:12 different markers for where the electrodes or the wires go on the scalp. 24:15 electrodes or the wires go on the scalp. 24:15 electrodes or the wires go on the scalp. Wires are placed with a, you know, a 24:17 Wires are placed with a, you know, a 24:17 Wires are placed with a, you know, a little gel on the scalp and it measures 24:19 little gel on the scalp and it measures 24:19 little gel on the scalp and it measures electrical activity below the scalp and 24:21 electrical activity below the scalp and 24:21 electrical activity below the scalp and skull. And you can see all of these 24:23 skull. And you can see all of these 24:23 skull. And you can see all of these different placements in the brain. This 24:25 different placements in the brain. This 24:25 different placements in the brain. This is a EKG down here, electroc cardiogram 24:27 is a EKG down here, electroc cardiogram 24:27 is a EKG down here, electroc cardiogram that's done at the same time just to 24:29 that's done at the same time just to 24:29 that's done at the same time just to correlate activity just to match it. And 24:32 correlate activity just to match it. And 24:32 correlate activity just to match it. And this is a normal EEG. 24:35 this is a normal EEG. 24:35 this is a normal EEG. This is from the article that we were 24:36 This is from the article that we were 24:36 This is from the article that we were just reviewing. When the individual 24:38 just reviewing. When the individual 24:38 just reviewing. When the individual could not get his words out, he had 24:42 could not get his words out, he had 24:42 could not get his words out, he had findings in the localized left frontal 24:45 findings in the localized left frontal 24:46 findings in the localized left frontal electrode. It says right here, cannot 24:48 electrode. It says right here, cannot 24:48 electrode. It says right here, cannot get words out. 24:50 get words out. 24:50 get words out. Later he also couldn't name write but 24:54 Later he also couldn't name write but 24:54 Later he also couldn't name write but did follow commands. So he's able to 24:55 did follow commands. So he's able to 24:55 did follow commands. So he's able to receive commands and yet wasn't able to 24:59 receive commands and yet wasn't able to 24:59 receive commands and yet wasn't able to name right
Broader Differential and Seizure Mimics 25:01 name right 25:01 name right during that time and then he became 25:04 during that time and then he became 25:04 during that time and then he became somewhat unresponsive mute confused. 25:06 somewhat unresponsive mute confused. 25:06 somewhat unresponsive mute confused. This is where electrical activity as you 25:08 This is where electrical activity as you 25:08 This is where electrical activity as you can see gets quite abnormal in multiple 25:10 can see gets quite abnormal in multiple 25:10 can see gets quite abnormal in multiple spaces. There's spreading of that 25:13 spaces. There's spreading of that 25:13 spaces. There's spreading of that phenomenon from just one or two 25:15 phenomenon from just one or two 25:15 phenomenon from just one or two electrodes to more. 25:19 electrodes to more. 25:19 electrodes to more. It just goes to show the progression of 25:21 It just goes to show the progression of 25:21 It just goes to show the progression of electrical changes in an individual. So 25:24 electrical changes in an individual. So 25:24 electrical changes in an individual. So that was from that case report. Another 25:26 that was from that case report. Another 25:26 that was from that case report. Another case report spoke about how 25:30 case report spoke about how 25:30 case report spoke about how later in life you can have some denovo 25:33 later in life you can have some denovo 25:33 later in life you can have some denovo or new aphasic status epilepticus. So 25:38 or new aphasic status epilepticus. So 25:38 or new aphasic status epilepticus. So seizure activity that is causing 25:40 seizure activity that is causing 25:40 seizure activity that is causing essentially speech problems. This is a 25:43 essentially speech problems. This is a 25:43 essentially speech problems. This is a report from 2022 in which they described 25:46 report from 2022 in which they described 25:46 report from 2022 in which they described this. Um I actually looked back at 25:48 this. Um I actually looked back at 25:48 this. Um I actually looked back at patients and over about eight years of 25:51 patients and over about eight years of 25:51 patients and over about eight years of practice in this group only 19 patients 25:53 practice in this group only 19 patients 25:53 practice in this group only 19 patients um with this aphasia aphasic status 25:57 um with this aphasia aphasic status 25:57 um with this aphasia aphasic status epilepticus had um no lesions in their 26:00 epilepticus had um no lesions in their 26:00 epilepticus had um no lesions in their brain when they had full imaging done. 26:02 brain when they had full imaging done. 26:02 brain when they had full imaging done. Most of them were women 71% and most of 26:05 Most of them were women 71% and most of 26:05 Most of them were women 71% and most of them were of of advanced age 66 in terms 26:08 them were of of advanced age 66 in terms 26:08 them were of of advanced age 66 in terms of mean age. Six died actually during 26:11 of mean age. Six died actually during 26:11 of mean age. Six died actually during these events. So this is a very serious 26:13 these events. So this is a very serious 26:13 these events. So this is a very serious condition. Um like all seizure disorders 26:15 condition. Um like all seizure disorders 26:15 condition. Um like all seizure disorders or epilepsy conditions needs to be taken 26:17 or epilepsy conditions needs to be taken 26:17 or epilepsy conditions needs to be taken seriously. It's an emergency and you 26:20 seriously. It's an emergency and you 26:20 seriously. It's an emergency and you need to abort the seizure activity. Give 26:21 need to abort the seizure activity. Give 26:21 need to abort the seizure activity. Give a bzzoazipene or an anti-epileptic drug 26:25 a bzzoazipene or an anti-epileptic drug 26:25 a bzzoazipene or an anti-epileptic drug right away if you identify that. 26:28 right away if you identify that. 26:28 right away if you identify that. It's interesting persistent aphasia that 26:30 It's interesting persistent aphasia that 26:30 It's interesting persistent aphasia that that sort of lasts longer than 65 hours 26:33 that sort of lasts longer than 65 hours 26:33 that sort of lasts longer than 65 hours according to this analysis and and other 26:35 according to this analysis and and other 26:35 according to this analysis and and other experts. If somebody's really having 26:37 experts. If somebody's really having 26:37 experts. If somebody's really having that difficulty of speaking longer than 26:39 that difficulty of speaking longer than 26:39 that difficulty of speaking longer than than 65 hours, it's likely um that they 26:43 than 65 hours, it's likely um that they 26:43 than 65 hours, it's likely um that they could have this this condition. It is 26:45 could have this this condition. It is 26:45 could have this this condition. It is rare, but it's a rare emergency. You 26:47 rare, but it's a rare emergency. You 26:47 rare, but it's a rare emergency. You wouldn't want to miss it. Terms of uh 26:51 wouldn't want to miss it. Terms of uh 26:51 wouldn't want to miss it. Terms of uh what a female looks like over time. 26:54 what a female looks like over time. 26:54 what a female looks like over time. There's a hint here that maybe it is 26:57 There's a hint here that maybe it is 26:57 There's a hint here that maybe it is correlated with some neurodeeneration. 26:59 correlated with some neurodeeneration. 26:59 correlated with some neurodeeneration. All right? So, changes in the brain. 27:02 All right? So, changes in the brain. 27:02 All right? So, changes in the brain. brain is um you know involuting, 27:05 brain is um you know involuting, 27:05 brain is um you know involuting, degenerating over time, atrophying, 27:07 degenerating over time, atrophying, 27:07 degenerating over time, atrophying, losing mass, which is why you see it in 27:09 losing mass, which is why you see it in 27:09 losing mass, which is why you see it in older populations. This is a case report 27:12 older populations. This is a case report 27:12 older populations. This is a case report from 2011 where they actually followed 27:15 from 2011 where they actually followed 27:15 from 2011 where they actually followed an individual over time for many years, 27:17 an individual over time for many years, 27:18 an individual over time for many years, a 70-year-old male who initially 27:19 a 70-year-old male who initially 27:19 a 70-year-old male who initially presented with difficulty pronouncing 27:21 presented with difficulty pronouncing 27:21 presented with difficulty pronouncing and producing words. 's first problem 27:23 and producing words. 's first problem 27:23 and producing words. 's first problem was with speech and over time there was 27:27 was with speech and over time there was 27:27 was with speech and over time there was an associated uh degeneration of brain 27:30 an associated uh degeneration of brain 27:30 an associated uh degeneration of brain matter. In other words, dementia of some 27:33 matter. In other words, dementia of some 27:33 matter. In other words, dementia of some sort. As you can see, this brain uh 27:36 sort. As you can see, this brain uh 27:36 sort. As you can see, this brain uh really does have a lot of atrophy or 27:39 really does have a lot of atrophy or 27:39 really does have a lot of atrophy or black space in there where the cortex 27:41 black space in there where the cortex 27:41 black space in there where the cortex used to reside. Um in younger times, 27:44 used to reside. Um in younger times, 27:44 used to reside. Um in younger times, this would have been all nice and full 27:46 this would have been all nice and full 27:46 this would have been all nice and full and gray, but you see all of these black 27:48 and gray, but you see all of these black 27:48 and gray, but you see all of these black interdigitations. 27:50 interdigitations. 27:50 interdigitations. Um and that's because of the atrophy of 27:53 Um and that's because of the atrophy of 27:53 Um and that's because of the atrophy of the of the brain. 27:56 the of the brain. 27:56 the of the brain. And uh this was thought in this case to 27:58 And uh this was thought in this case to 27:58 And uh this was thought in this case to be a precursor to what's called a 28:00 be a precursor to what's called a 28:00 be a precursor to what's called a praxia. A praxia is a a failure to to do 28:04 praxia. A praxia is a a failure to to do 28:04 praxia. A praxia is a a failure to to do various uh you know tasks, walking, 28:08 various uh you know tasks, walking, 28:08 various uh you know tasks, walking, talking, uh bathing themselves, eating 28:11 talking, uh bathing themselves, eating 28:11 talking, uh bathing themselves, eating motor tasks that is is seen in advanced 28:14 motor tasks that is is seen in advanced 28:14 motor tasks that is is seen in advanced dementia. So sometimes the earliest hint 28:16 dementia. So sometimes the earliest hint 28:16 dementia. So sometimes the earliest hint might be speech problems and that's why 28:18 might be speech problems and that's why 28:18 might be speech problems and that's why it's important to attend to this. Not 28:19 it's important to attend to this. Not 28:19 it's important to attend to this. Not not only because speech problems can be 28:22 not only because speech problems can be 28:22 not only because speech problems can be part of a seizure disorder as we're 28:24 part of a seizure disorder as we're 28:24 part of a seizure disorder as we're talking about but also can be the first 28:27 talking about but also can be the first 28:27 talking about but also can be the first hint the canary in the coalmine if you 28:28 hint the canary in the coalmine if you 28:28 hint the canary in the coalmine if you will towards uh other signs of dementia. 28:32 will towards uh other signs of dementia. 28:32 will towards uh other signs of dementia. And these are images showing changes 28:35 And these are images showing changes 28:35 And these are images showing changes over time. U the patient was imaged um 28:39 over time. U the patient was imaged um 28:39 over time. U the patient was imaged um at age um uh 75 and then was uh had 28:46 at age um uh 75 and then was uh had 28:46 at age um uh 75 and then was uh had another image five years later. that's 28:49 another image five years later. that's 28:49 another image five years later. that's in in B. And then one year later, so one 28:53 in in B. And then one year later, so one 28:53 in in B. And then one year later, so one year after that, that's C. And so you 28:55 year after that, that's C. And so you 28:55 year after that, that's C. And so you can see the reduction in these 28:57 can see the reduction in these 28:58 can see the reduction in these highlighted areas. That's brain activity 29:00 highlighted areas. That's brain activity 29:00 highlighted areas. That's brain activity from what's called a functional MRI. You 29:02 from what's called a functional MRI. You 29:02 from what's called a functional MRI. You can see the reduction over time. Sadly, 29:05 can see the reduction over time. Sadly, 29:05 can see the reduction over time. Sadly, just as age marches on, the brain loses 29:09 just as age marches on, the brain loses 29:09 just as age marches on, the brain loses its spark, if you will. You can see a 29:13 its spark, if you will. You can see a 29:13 its spark, if you will. You can see a petering out, if you will, in terms of 29:14 petering out, if you will, in terms of 29:14 petering out, if you will, in terms of that brain activity. means it's no 29:16 that brain activity. means it's no 29:16 that brain activity. means it's no wonder of course that there would be 29:18 wonder of course that there would be 29:18 wonder of course that there would be changes in speech or in um other 29:22 changes in speech or in um other 29:22 changes in speech or in um other activities. 29:25 activities. 29:25 activities. The case that I just described, I 29:28 The case that I just described, I 29:28 The case that I just described, I actually uh published in an academic 29:31 actually uh published in an academic 29:32 actually uh published in an academic journal, the journal of the academy of 29:33 journal, the journal of the academy of 29:33 journal, the journal of the academy of consultation, less and psychiatry 29:35 consultation, less and psychiatry 29:36 consultation, less and psychiatry um as a brief report to raise awareness 29:38 um as a brief report to raise awareness 29:38 um as a brief report to raise awareness about this finding aphia and to suggest 29:42 about this finding aphia and to suggest 29:42 about this finding aphia and to suggest that we should not jump to conclusions 29:45 that we should not jump to conclusions 29:45 that we should not jump to conclusions and say this is psychological or this is 29:47 and say this is psychological or this is 29:47 and say this is psychological or this is psychoggenic. 29:49 psychoggenic. 29:49 psychoggenic. It's important to rule out all other you 29:51 It's important to rule out all other you 29:52 It's important to rule out all other you know conditions. In this case, the EEG 29:53 know conditions. In this case, the EEG 29:53 know conditions. In this case, the EEG was very helpful, of course, in 29:55 was very helpful, of course, in 29:55 was very helpful, of course, in identifying frontal seizures that were 29:58 identifying frontal seizures that were 29:58 identifying frontal seizures that were causing mutism. And so we we published 30:02 causing mutism. And so we we published 30:02 causing mutism. And so we we published it with some of my colleagues that are 30:03 it with some of my colleagues that are 30:03 it with some of my colleagues that are listed there in order to increase that 30:06 listed there in order to increase that 30:06 listed there in order to increase that kind of awareness. And you're welcome 30:07 kind of awareness. And you're welcome 30:08 kind of awareness. And you're welcome to, of course, review the article on 30:10 to, of course, review the article on 30:10 to, of course, review the article on your own. This is an important task 30:12 your own. This is an important task 30:12 your own. This is an important task actually for consultationally as a 30:14 actually for consultationally as a 30:14 actually for consultationally as a psychiatrist. People might think that 30:16 psychiatrist. People might think that 30:16 psychiatrist. People might think that psychiatrists are really just there to 30:18 psychiatrists are really just there to 30:18 psychiatrists are really just there to quote shrink heads and label everyone 30:20 quote shrink heads and label everyone 30:20 quote shrink heads and label everyone with depression and anxiety, but 30:22 with depression and anxiety, but 30:22 with depression and anxiety, but actually we advocate for thorough 30:24 actually we advocate for thorough 30:24 actually we advocate for thorough medical evaluations. We advocate that, 30:28 medical evaluations. We advocate that, 30:28 medical evaluations. We advocate that, you know, no stone goes unturned, if you 30:30 you know, no stone goes unturned, if you 30:30 you know, no stone goes unturned, if you will, and that we exclude all of the 30:34 will, and that we exclude all of the 30:34 will, and that we exclude all of the other possibilities before jumping to 30:35 other possibilities before jumping to 30:36 other possibilities before jumping to conclusions. And in that way, 30:37 conclusions. And in that way, 30:37 conclusions. And in that way, paradoxically, we're actually more like 30:40 paradoxically, we're actually more like 30:40 paradoxically, we're actually more like medical sleuths, if you will, or 30:42 medical sleuths, if you will, or 30:42 medical sleuths, if you will, or investigators than than traditional 30:45 investigators than than traditional 30:45 investigators than than traditional psychiatrists. So, psychiatrists in the 30:46 psychiatrists. So, psychiatrists in the 30:46 psychiatrists. So, psychiatrists in the medical setting or consultation leads 30:48 medical setting or consultation leads 30:48 medical setting or consultation leads and psychiatrists really do something a 30:49 and psychiatrists really do something a 30:50 and psychiatrists really do something a little different in that respect. So, in 30:52 little different in that respect. So, in 30:52 little different in that respect. So, in summary, 30:54 summary, 30:54 summary, speech changes can have many, many 30:56 speech changes can have many, many 30:56 speech changes can have many, many causes. If you remember that list of 30:58 causes. If you remember that list of 30:58 causes. If you remember that list of possible diagnoses and presentations, 31:01 possible diagnoses and presentations, 31:01 possible diagnoses and presentations, speech in fact is a very complex 31:05 speech in fact is a very complex 31:05 speech in fact is a very complex neurobiological phenomena. We didn't 31:08 neurobiological phenomena. We didn't 31:08 neurobiological phenomena. We didn't even talk about volume and tone and rate 31:11 even talk about volume and tone and rate 31:11 even talk about volume and tone and rate and and accent and all of these other 31:14 and and accent and all of these other 31:14 and and accent and all of these other components of speech. But when speech 31:18 components of speech. But when speech 31:18 components of speech. But when speech goes ary, many different things can 31:20 goes ary, many different things can 31:20 goes ary, many different things can cause that. It's important to expand the 31:23 cause that. It's important to expand the 31:23 cause that. It's important to expand the differential diagnosis when we do that, 31:25 differential diagnosis when we do that, 31:25 differential diagnosis when we do that, of course. And that organic or what we 31:27 of course. And that organic or what we 31:27 of course. And that organic or what we call medical workup, not just 31:28 call medical workup, not just 31:28 call medical workup, not just psychiatric considerations, but organic 31:30 psychiatric considerations, but organic 31:30 psychiatric considerations, but organic workup is essential. Of course, we 31:33 workup is essential. Of course, we 31:33 workup is essential. Of course, we should trust our own awareness of what 31:35 should trust our own awareness of what 31:35 should trust our own awareness of what epileptic seizures are and what they 31:37 epileptic seizures are and what they 31:37 epileptic seizures are and what they aren't. Right? So, epileptic seizures 31:40 aren't. Right? So, epileptic seizures 31:40 aren't. Right? So, epileptic seizures are not just seizures involving people 31:43 are not just seizures involving people 31:43 are not just seizures involving people flapping around dramatically 31:46 flapping around dramatically 31:46 flapping around dramatically uh with their whole body shaking or what 31:48 uh with their whole body shaking or what 31:48 uh with their whole body shaking or what we might see in the movies. Uh that is 31:51 we might see in the movies. Uh that is 31:51 we might see in the movies. Uh that is part of seizures, right? Those are 31:52 part of seizures, right? Those are 31:52 part of seizures, right? Those are called grand mild seizures or tonoclonic 31:55 called grand mild seizures or tonoclonic 31:55 called grand mild seizures or tonoclonic seizures. But there are other types of 31:57 seizures. But there are other types of 31:57 seizures. But there are other types of seizures that are smaller in nature that 31:59 seizures that are smaller in nature that 31:59 seizures that are smaller in nature that only impact speech or other areas of 32:03 only impact speech or other areas of 32:03 only impact speech or other areas of functioning. And it's very important to 32:05 functioning. And it's very important to 32:05 functioning. And it's very important to not forget those seizures that we 32:08 not forget those seizures that we 32:08 not forget those seizures that we sometimes call focal or partial 32:09 sometimes call focal or partial 32:09 sometimes call focal or partial seizures. 32:12 seizures. 32:12 seizures. [Music]
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