Diagnosis of Cocaine abuse
Cocaine abuse Diagnosis: Book Excerpts
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HALLUCINATIONS:
Ask the Following Questions:
(Algorithmic Diagnosis of Symptoms and Signs)
- Is there a history of drug or alcohol ingestion? Hallucinations are common during alcohol withdrawal but also may be noted in cocaine addiction, marijuana addiction, LSD intoxication, and PCP intoxication.
- Are the hallucinations primarily visual in nature? This would suggest an organic cause such as organic brain syndrome, epilepsy, brain tumor, etc.
- Are the hallucinations episodic? If the hallucinations occur in episodes with normal behavior in between, one should consider epilepsy or narcolepsy.
- Are the hallucinations associated with early stages of falling asleep or awakening? These types of hallucinations are called hypnogogic and are common in narcolepsy but may also be seen in normal people.
- Are the hallucinations primarily auditory in nature? This is the type of hallucination most commonly associated with schizophrenia.
DIAGNOSTIC WORKUP
A blood alcohol level and urine drug screen are essential at the outset. Most physicians will want to refer the patient to a psychiatrist if these studies are negative. However, the interested physician may proceed further with a wake-and-sleep EEG to identify psychomotor epilepsy, or a CT scan and MRI to identify brain tumors and other causes of organic brain syndrome. Remember, the MRI costs twice as much as a CT scan. A spinal tap will be helpful in diagnosing central nervous system lues. A sleep study will help diagnose narcolepsy. Psychometric testing will help identify schizophrenia and other psychiatric disorders.
» READ BOOK EXCERPT ONLINE »
Source: Algorithmic Diagnosis of Symptoms and Signs, 2003
Hallucinations:
Differential Diagnosis
(In a Page: Signs and Symptoms)
- Delirium
–Develops over hours to days
–Fluctuates throughout the day
–Causes include dehydration, drug-induced, electrolyte imbalance, UTI, URI, hypoglycemia, and alcohol or drug withdrawal
–Occurs in 10–30% of hospital patients
–Drug-induced delirium (e.g., cocaine, β-blockers, alcohol, corticosteroids, pseudoephedrine, dopaminergic drugs)
- Alcohol withdrawal (delirium tremens)
–Often presents in hospitalized patients about 3 days after admission
–Commonly presents with tactile hallucinations (e.g., formication—the sense of insects crawling over body)
–May be accompanied by seizure activity
- Hallucinogenic syndromes (e.g., LSD, marijuana, mescaline, phencyclidine, mushrooms, amphetamines)
- Schizophrenia
–Auditory hallucinations are most frequent; visual hallucinations occur in about 50% of patients, tactile in 20%, olfactory in 6%
–Progresses to positive psychotic symptoms (e.g., hallucinations, delusions, thought disorder) and/or negative symptoms (e.g., anhedonia, poor concentration, flattened affect, poor social/personal function)
–1% incidence in the general population, males >females
-
Schizophreniform disorder
-
Schizoaffective disorder
-
Post-traumatic stress disorder
-
Dementia
-
Systemic lupus erythematosus
–Auditory hallucinations caused by corticosteroids; visual and tactile by lupus psychosis
-
Bipolar disorder
-
Psychotic depression
-
Postpartum major depression
-
Mass lesions
-
CNS infections/encephalitis
-
Seizures
-
Occipital lobe injury
-
Heavy metal ingestion
-
Lewy body dementia
Workup and Diagnosis
- History and physical examination
–In caring for patients with major psychiatric illness, follow three important principles: Know the patient's drug regimen, work with psychiatrist if changes are needed, and remember that chronic psychiatric patients have difficulty communicating medical history and needs
–Diagnosis of schizophrenia requires two positive or negative symptoms present for 1 month and signs continuing for at least 6 months (DSM-IV criteria)
–Assess for suicidal/homicidal ideations
–Note timing of hallucinations (e.g., following alcohol or drug use, at random, under stress)
-
Initial labs may include electrolytes, glucose, calcium, BUN/creatinine, albumin, liver function tests, alkaline phosphatase, magnesium, phosphate, CBC, ECG, pulse oximetry, urinalysis, toxicology screen, and drug levels
-
Chest X-ray may be indicated for infectious etiologies of delirium; lumbar puncture may be indicated
-
Further tests, if delirium is suspected, include vitamin B12 and folate levels, ANA, ammonia, and heavy metal screen
-
EEG may reveal slowing activity in delirium, low-voltage fast activity in alcohol withdrawal
-
Psychiatric consult after medical causes of psychosis are ruled out
» READ BOOK EXCERPT ONLINE »
Source: In a Page: Signs and Symptoms, 2004
Hallucinations:
Differential Diagnosis
(In A Page: Pediatric Signs and Symptoms)
-
Hallucinogenic drugs
–LSD, “mushrooms,” mescaline, and PCP are primarily hallucinogens
–Amphetamines, cocaine, inhalants, and marijuana may also produce hallucinations
-
CNS acute events
–Trauma
–CNS infection
–Hypoxic events
- Psychosis
–Defined as a mental state with significant impairment in cognition, interpersonal relations, and reality testing
–Hallucinations may be a major or minor component
–Psychosis may be psychiatric or organic (secondary to CNS insult)
- Schizophrenia
–A disorder of impaired perception, cognition, interpersonal relations, and behavior with illogical and disordered thought content
–Hallucinations (most often auditory) and
delusions are common findings
–Onset is frequently in adolescence
–Frequently a positive family history
-
Seizure disorders
–Prominent auras may manifest as perceptual disturbances; visual and olfactory are the most common; tactile may also occur
-
Narcolepsy
–Hypnagogic hallucinations are hallucinations that occur while falling asleep; they may be visual or auditory
-
Medications
–Antipsychotics, anticholinergics, and
corticosteroids can rarely cause
hallucinations
Workup and Diagnosis
- History
–History of mental illness
–Recent behavioral patterns including relationships,
self-care, and school performance
–Medication and illicit drug use
–Trauma, CNS infection, hypoxic episodes
–Family history of mental illness
- Physical exam
–Vital signs: Hallucinogens, amphetamines, and cocaine may cause tachycardia, hypertension, and hyperthermia
–Hallucinogens, amphetamines, and cocaine may also cause pupillary changes, tremor, ataxia, arrhythmia, and hyperreflexia
-
Mental status exam
–Orientation and general appearance
–Long- and short-term memory
–Affect and behavior
–Thought processing and content
–Speech and language
-
Labs
–Urine and serum toxicologic screen
-
Studies
–Cranial imaging is most useful when there is a history
of head trauma
–EEG for patients in whom a seizure is suspected
» READ BOOK EXCERPT ONLINE »
Source: In A Page: Pediatric Signs and Symptoms, 2007
HALLUCINATIONS:
Approach to Diagnosis
(Differential Diagnosis in Primary Care)
In the workup of hallucinations, it is essential to get a drug history from a relative or friend if not from the patient. Ask about a family history of epilepsy or head trauma. A drug screen should be ordered. If there is no mental deterioration, referral to a psychiatrist may be done but an EEG may still be indicated. With mental deterioration, a neurologist should be consulted. When there is doubt about mental deterioration, psychologic testing may be done. CT scans, EEGs, skull x-ray films, and arteriograms may be necessary in selected cases.
» READ BOOK EXCERPT ONLINE »
Source: Differential Diagnosis in Primary Care, 2007
Substance abuse and induced disorders:
Diagnosis
(Professional Guide to Diseases (Eighth Edition))
For characteristic findings in patients with this condition, see Diagnosing substance dependence and related disorders, page 430. Various tests can confirm drug use, determine the amount and type of drug taken, and reveal complications. For example, a serum or urine drug screen can detect recently ingested substances.
Characteristic findings in other tests include elevated serum globulin levels, hypoglycemia, leukocytosis, liver function abnormalities, positive Venereal Disease Research Laboratory test results, positive rapid plasma reagin test results due to elevated protein fractions, an elevated mean corpuscular hemoglobin level, elevated uric acid levels, and reduced blood urea nitrogen levels.
» READ BOOK EXCERPT ONLINE »
Source: Professional Guide to Diseases (Eighth Edition), 2005
Alcohol-related disorder:
Diagnosis
(Professional Guide to Diseases (Eighth Edition))
For characteristic findings in patients with alcoholism, see Diagnosing substance dependence and related disorders, page 430.
Clinical findings may help support the diagnosis of alcohol-related disorder. For example, laboratory tests can confirm alcohol use and complications and document recent alcohol ingestion. A blood alcohol level ranging from 0.08% to 0.10% weight/volume (200 mg/dl) is accepted as the level of intoxication, depending on the state or country. The blood alcohol level in a physically dependent and tolerant drinker may exceed levels that would cause severe dysfunction or death in a nontolerant drinker. For example, a tolerant drinker might have a blood alcohol level of more than 0.5 mg (the usual lethal level) and still be alive, talking, and moving.
In severe hepatic disease, the blood urea nitrogen level is increased, and the serum glucose level is decreased. Further testing may reveal increased serum ammonia and amylase levels. Urine toxicology studies may help determine if the patient with alcohol withdrawal delirium or another acute complication abuses other drugs as well.
Liver function studies revealing increased levels of serum cholesterol, lactate dehydrogenase, alanine aminotransferase, aspartate aminotransferase, and creatine phosphokinase may point to liver damage, and elevated serum amylase and lipase levels point to acute pancreatitis. A hematologic workup can identify anemia, thrombocytopenia, increased prothrombin time, and increased partial thromboplastin time.
» READ BOOK EXCERPT ONLINE »
Source: Professional Guide to Diseases (Eighth Edition), 2005
Delirium/Hallucinations:
Differential Overview
(Field Guide to Bedside Diagnosis)
Systemic
❑ Drugs/toxins
❑ Sepsis
❑ Hypoglycemia
❑ Hypercalcemia
❑ Hyponatremia
❑ Shock
❑ Delirium tremens
❑ Vitamin B12 deficiency
❑ Hypoxia
❑ Hypercapnia
❑ Thyrotoxicosis
❑ Uremia
❑ Hepatic encephalopathy
❑ Thiamine deficiency
❑ Heat stroke
❑ Hypothermia
❑ Lead intoxication
❑ Carbon monoxide poisoning
Neurologic
❑ Concussion
❑ Hypertensive encephalopathy
❑ Subdural hematoma
❑ Postictal
❑ Transient global amnesia
❑ Meningitis
❑ Right parietal stroke
❑ Encephalitis
❑ Vasculitis
❑ Carcinomatous meningitis
Hallucinations
❑ Drugs
❑ Schizophrenia
❑ Temporal lobe epilepsy
Diagnostic Approach
Delirium is characterized by gross disorientation in the presence of alertness and vigilance, disorders of perception with vivid illusions, and psychomotor and autonomic hyperactivity. It usually develops over a short time and is associated
with fluctuating mental status, decreased attention, disorganized thinking as indicated by rambling, irrelevant, or incoherent speech, and a decreased level of consciousness. The most sensitive findings are variability in level of arousal, impaired short-term memory (e.g., digit span), and disorientation to time. Relatives or friends are helpful sources of information about the tempo and degree of impairment.
Fever, tachycardia, or hypertension should prompt a careful evaluation for a medical cause. Infection is a common cause in the elderly, especially pneumonia or urinary tract infection. Visual hallucinations are organic in origin, due to factors such as drugs, rather than due to schizophrenia.
Confusion Assessment1) Change in mental state (from baseline) that is acute and fluctuates. 2) Difficulty focusing attention or trouble keeping track of what is said. 3) Disorganized thinking (rambling or irrelevant conversation, unpredictable switching between subjects, illogical flow of ideas). 4) Altered level of consciousness (lethargy, stupor, or hyperalert). A positive test requires 1 and 2 positive, and either 3 or 4.
» READ BOOK EXCERPT ONLINE »
Source: Field Guide to Bedside Diagnosis, 2007
Alcoholism:
Diagnosis
(Handbook of Diseases)
For characteristic findings in patients with alcoholism, see Diagnosing substance dependence and related disorders, page 286.
Laboratory values may help support the diagnosis of alcoholism — for example, they can confirm alcohol use and complications and indicate recent alcohol ingestion:
Blood alcohol level of 0.10% weight/volume (200 mg/dl) is accepted as the level of intoxication.
Blood urea nitrogen level rises in severe hepatic disease.
Blood glucose level is decreased.
Serum ammonia and amylase levels are increased.
Urine toxicology studies may help detect other types of drug abuse in patients with alcohol withdrawal delirium or another acute complication.
Liver function studies reveal increased levels of serum cholesterol, lactate dehydrogenase, alanine aminotransferase, aspartate aminotransferase, and creatine kinase (which indicate liver damage) and elevated serum amylase and lipase levels (which indicate acute pancreatitis).
Blood studies may identify anemia, thrombocytopenia, increased prothrombin time, and increased partial thromboplastin time.
» READ BOOK EXCERPT ONLINE »
Source: Handbook of Diseases, 2003
HALLUCINATIONS:
Approach to the Diagnosis
(Differential Diagnosis in Primary Care)
In the workup of hallucinations, it is essential to get a drug history
from a relative or friend if not from the patient. Ask about a family
history of epilepsy or head trauma. A drug screen should be ordered. If
there is no mental deterioration, referral to a psychiatrist may be done but
an electroencephalogram (EEG) may
still be indicated. With mental deterioration, a neurologist should be
consulted. When there is doubt about mental deterioration, psychologic
testing may be done. Computed tomography (CT) scans, EEGs, skull x-ray
films, and arteriograms may be necessary in selected cases.
» READ BOOK EXCERPT ONLINE »
Source: Differential Diagnosis in Primary Care, 2007
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