lausanne orendain m d january 30 2009 adolescent medicine
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15 y.o . male with “behavioral problems”

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Lausanne Orendain, M.D. January 30, 2009 Adolescent Medicine. 15 y.o . male with “behavioral problems”. HPI. Patient’s CC – “I don’t know” Mom’s CC: Behavioral problems

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Presentation Transcript
slide2
HPI
  • Patient’s CC – “I don’t know”
  • Mom’s CC: Behavioral problems
  • HPI: 15 year old Filipino male brought in by mom for behavioral problems that began with drug use on Halloween (3 mos PTP)
  • Problems consist of drug use, failing grades, running away, skipping school.
transitioning
Transitioning
  • Pt admits to having a hard time with transitioning to 9th grade at new school: Bishop Gorman
    • Friends
    • Peers
    • Drug tested twice: negative
    • Grades started to decrease
timeline
Timeline
  • Halloween: Patient drank unknown quantity and type of alcohol, ate pizza and then felt “weird.”
  • Denies knowingly taking drugs by ingesting, drinking, or smoking
  • At home, experienced visual and auditory hallucinations
  • He called his mom
timeline continued
Timeline… continued
  • Stayed home for next 2 days
  • Brought to U.C. on day 3 post-ingestion
    • UDS positive for marijuana
    • Was discharged from U.C.
  • November: Patient insisted on switching to public school
    • Lost relationships with friends and family
    • Began failing all classes
    • Ran away for 3 days
      • Stayed at friend’s house.
timeline1
Timeline
  • December: Patient was switched to public high school
    • Began skipping school
  • 1st week of January: Was found at home high on marijuana with friend
  • 2nd week of January: Continued to miss school for 13 days
    • Sent home after finals because teacher believed he was intoxicated with alcohol
intervention
Intervention
  • Mom grounded patient over Christmas break
  • Mom brought him to 4 sessions with a counselor
  • No meds were taken/given
past medical history
Past Medical History
  • BHx: FT, NSVD, + PNC
    • Mom denies drugs, alcohol, tobacco while pregnant
    • No complications
  • Broken left wrist, right forearm, right elbow from skateboarding & snowboarding
  • No surgeries
past medical history1
Past Medical History
  • Diagnosed with ADHD in 7th grade treated with Adderall
    • Stopped by mom because it made him feel “slow”
  • Meds: None
  • ALL: NKDA, no food allergies
  • Development: Doing well (grades As-Bs) until Fall 2008
  • FHx:
    • Mom has arthritis, migraine headaches
    • No substance abuse, depression, or other psychiatric diagnoses
social history
Social History
  • Home: Lives with mom. “Latch-key kid” since 11 years old.
  • Education: Currently failing 9th grade. Goal is to finish high school and become stunt double in movies.
  • Activity: Inolved in Lacrosse teams and has been showboarding x 4 years
social history1
Social History
  • Drugs:
    • First substance use on Halloween
    • Admitted to alcohol but denies knowing how he had marijuana in his system
    • Smoked marijuana knowingly for first time 1st week of January
    • Denies any other drug use
social history2
Social History
  • Suicide: Denies ever having suicide ideation/plans. Admits to feeling a little sad
  • Sex: First intercourse last summer. Has had 2 female partners total, vaginal sex only, condom use 100% of the time.
  • Safety: Feels safe at home and at school.
crafft
CRAFFT
  • C – Has not ridden in car with someone who was under the influence
  • R – Does not use to relax
  • A – Does not use when alone
  • F – Did forget events at Halloween
  • F – Family has told him to stop using
  • T – Has gotten into trouble while using

* Has > than 2 positive responses

physical exam
Physical exam
  • Vitals: T-98 P-65 RR-16 BP-104/66
  • Wt 64kg (75%) Ht 174.5cm (50-75%)
  • Gen: WN, WD, Alert, NAD
  • Rest of exam normal and non-contributory including HEENT and skin exam
slide15
Plan
  • Mom wanted “resources” for her son and drug testing.
  • Patient refused any further counseling.
  • Patient plans to attend school and get better grades this semester
    • Wants to get his driving license this summer.
  • Patient agreed to return to clinic in one month and submit to urine drug testing
substance abuse criteria
Substance Abuse Criteria
  • Substance abuse: maladaptive pattern of substance use leading to clinically significant impairment or distress as manisfested by 1 or more episodes in a 12 month period
  • Symptoms do not meet dependence criteria
substance abuse criteria1
Substance Abuse Criteria
  • Recurrent substance use resulting in failure to fulfill obligations at work, school, home
  • Recurrent use in situations where it is physically hazardous
  • Substance-related legal problems
  • Continued use despite social/personal problems
substance dependence criteria
Substance Dependence Criteria

Three or more occurring at any time in same 12 months:

  • Tolerance – need for increased amounts
  • Withdrawal symptoms
  • Taking substance over longer time period or increased amounts
  • Cut Down – persistent desire & efforts
  • Time spent in obtaining substance
  • Social, work, recreational activities are given up
  • Continues substance use despite knowing problems are likely caused by substance
hallucinogen
Hallucinogen
  • Derived from Latin term “Alucinari” which means “to wander in mind”
  • Hallucinogen causes distortion of perceived reality vs. a true hallucination when a person has experiences that do not happen
  • “Synethesias” = mixing of senses
    • Hearing colors or seeing smells
slide20
Percentage of High School Students Who Reported Lifetime Hallucinogenic Drug Use,* by Sex** and Race/Ethnicity,*** 2007

* Used hallucinogenic drugs (e.g., LSD, acid, PCP, angel dust, mescaline, or mushrooms) one or more times during their life.

** M > F

*** W, H > B

National Youth Risk Behavior Survey, 2007

percentage of high school students who reported lifetime hallucinogenic drug use 2001 2007
Percentage of High School Students Who Reported Lifetime Hallucinogenic Drug Use,* 2001 – 2007

* Used hallucinogenic drugs (e.g., LSD, acid, PCP, angel dust, mescaline, or mushrooms) one or more times during their life.

1 Decreased 2001-2007, p < .05

National Youth Risk Behavior Surveys, 2001 – 2007

slide23
LSD
  • d-lysergic acid diethylamide
  • Originally derived from ergot fungus that grew on rye & wheat
  • Street Names: acid, dragon, white lightning, sorcerer’s apprentice, dots, microdot, battery acid, lucy in the sky with diamonds
  • Mechanism : serotonin and dopamine receptors like a serotonin agonist – increased glutamate
slide24
LSD
  • Forms: snorted, smoked, liquid, eye drops, blotter sheets
  • Onset: few minutes
    • Flush, mydriasis, pilorection, chills, tachycardia
  • Peak: 30-90 minutes
    • Visual and auditory illusions, synesthesia, see themselves or others aging, feel competent
    • Paranoia, confusion, depression, panic, anxiety
  • Duration: 8-12 hours
slide25
LSD
  • Acute toxicity: Coma, respiratory arrest, hypertension, tachycardia, hyperthermia, seizures
  • Chronic reactions:
    • personality changes
    • psychosis
    • ~50-60% will present with spontaneous flashbacks
      • may occur weeks to 1 year after last use, triggered by stress, illness, exercise
slide26
LSD
  • Hallucinogen Persisting Perception Disorder (HPPD) – DSM IV diagnosis
  • After few months to 5 years after stopping LSD use, continue to have:
    • geometric hallucinations
    • false perceptions of movement in the peripheral visual fields,
    • flashes of colors, intensified colors
    • trails of images of moving objects, afterimages, halos around objects
slide27
LSD
  • Urine tox screen: Not included
    • Have to specifically screen for it
  • Tolerance: Yes
  • Produces tolerance of psilocybin and mescaline, but not PCP and marijuana
  • Dependence: possibly psychological
morning glory
Morning Glory
  • Lysergic acid amide
  • Forms: Eaten whole or ground to flour and mixed in drinks
psilocybin
Psilocybin
  • Psilocybin Cubensis
  • Mushrooms grown in northwest and southeast of US
  • Found in South America, Mexico
psilocybin1
Psilocybin
  • Street Names: “shrooms,” magic mushrooms, liberty cap
  • Mechanism : Serotonin agonist
  • Forms: eat raw, dried, stewed
    • Average “dose” = 2-6 mushrooms
    • 1/3 of mushrooms sold contain psilocybin, many are laced with LSD or PCP
  • Onset: 20-30 minutes
    • Mydriasis, Facial flushing, dysphoric, hyperreflexia, paresthesia, ataxic, nausea
psilocybin2
Psilocybin
  • Peak: 1.5 hours
    • visual hallucinations, inappropriate laughter, altered perception of time
    • Cannot tell fantasy from reality
    • Panic reactions and psychosis with larger doses
  • Duration: 6 hours
  • Acute toxicity: chills, myalgia, rarely hyperthermia or seizures or coma
psilocybin3
Psilocybin
  • Urine tox screen: No
    • Need to specifically screen
  • Tolerance: Yes
  • Dependence: None
mescaline
Mescaline
  • Peyote cactus found in Southwest US, North/Central Mexico
  • Disc shaped buttons at crown of cactus that are dried
  • Street names: Mescal buttons, Mexc, cactus
  • Mechanism: Serotonin agonist
mescaline1
Mescaline
  • Forms: Ingested by chewing or soaking in water to produce tea
    • Average “dose” = 6-12 peyote buttons
    • Ground into a powder and smoked.
  • Onset: 30 minutes
    • Nausea, vomiting, diaphoresis, dizzyness, ataxia
  • Peak: 4 hours
    • Mydriasis, visual and auditory hallucinations, euphoria, paranoia, sense of increased physical power
  • Duration: 8-12 hours
mescaline2
Mescaline
  • Acute toxicity: nausea, vomiting, muscle weakness
  • Urine tox screen: No
  • Tolerance: Yes
  • Dependence: None
slide41
PCP
  • Phencyclidine
  • Originally developed as an anesthetic
  • Street Names: angel dust, loveboat, peace weed, super grass, elephant tranquilizer, rocket fuel, hog
  • Mechanism : Inhibits norepinephrine and dopamine reuptake
    • Some cholinergic and anticholinergic effects
slide42
PCP
  • Forms: powder - smoked, mixed with liquid, IV
  • Onset: 2-5 minutes
    • Unpredictable symptoms: calm or wild, violent or disoriented.
  • Peak: 15 minutes
    • Bizarre and psychotic behaviors
    • Dissociative drug – feel minimal pain
    • Tachycardia, hypertension, miosis with a blank stare, nystagmus (rotary)
slide43
PCP
  • Duration: 16 hours  48 hours
    • Acute toxicity: Delusions, paranoia, anxiety, Muscle rigidity, myoclonus
  • Complications: severe agitation and muscle rigidity rhabdomyolysis and myoglobinuric renal failure. Violent behavior & decreased sense of pain  law problems
slide44
PCP
  • Long term: memory loss, difficulties with speech, thinking, depression can persist up to 1 year after stopping
  • Utox screen: Yes, 3-8 days after
  • Tolerance: Yes
  • Dependence: Yes, psychological. Repeated abuse leads to addiction and craving.
jimson weed
Jimson Weed
  • Originally derived from poisonous plant native to North America
  • Street Names: Jamestown weed, Angel’s trumpet, Loco weed
  • Mechanism : anticholinergic, has atropine
  • Forms: kidney shaped seed which can be ingested, smoked
jimson weed1
Jimson Weed
  • "red as a beet, dry as a bone, blind as a bat, mad as a hatter, and hot as a hare.“
  • Urine tox screen – no
    • Need to specifically screen for it
  • Symptoms: flushing, dry mouth, urinary retention, mydriasis and blurry vision, hyperthermia,
    • tachycardia, decreased GI motility, confused, hallucination, restless, irritable
slide49
MDMA
  • 3,4-methylenedioxymethamphetamine
  • Synthetically made by accident, initially recommended during marriage counseling
  • Street Names: ecstasy, XTC, Adam, E, X, clarity, Stacy, hug drug
  • Mechanism: massive serotonin release
  • Forms: tablet, powder, liquid
slide50
MDMA
  • Onset: 30 minutes
    • anxiety, tachycardia, mydriasis
  • Peak: 1-1.5 hours
    • Relaxation, empathy, euphoria, disinhibition, increased sensuality
    • See halos, sense of touch is enhanced, not really hallucinogenic, however may be mixed with other hallucinogenic drugs
  • Duration: 4-8 hours
slide51
MDMA
  • Acute toxicity: bruxism, hyperthermia, hypertension, v. fib
  • Complications: belief that water is antidote with SIADH-like effect  hyponatremic induced seizures, rhabdomyolysis  myoglobinuric renal failure
  • Long term: permanent mood disorders, degradation of serotonergic neurons
slide52
MDMA
  • Utox screen: Yes – up to 2 days after
  • Tolerance: Yes
    • “Suicide Tuesday” – lethargy, anorexia, dysphoria about 48 hours after ingestion
  • Dependence: Possibly psychological
teen resources
Teen Resources
  • www.justthinktwice.com - DEA
  • www.abovetheinfluence.com - National Youth Anti-Drug Media Campaign
  • www.freevibe.com - National Youth Anti-Drug Media Campaign
references
References
  • Barangan, Caroline and Elizabeth Alderman. Management of Substance Abuse. Pediatrics in Review, 2002;23:123-31.
  • Center for Disease Control and Prevention. Morbidity and Mortality Weekly Report. Youth Risk Behavior Surveillance — United States, 2007. June 6, 2008 / Vol. 57 / No. SS-4. http://www.cdc.gov/HealthyYouth/yrbs/pdf/yrbss07_mmwr.pdf
  • Department of Justice. www.usdoj.gov/dea.
  • Hahn, IH and D. Yew. Toxicity, MDMA. eMedicine Specialties Toxicology. http://emedicine.medscape.com/article/821572-overview
  • National Institute on Drug Abuse. High School and Youth Trends 2008. www.drugabuse.gov.
  • National Institute on Drug Abuse. NIDA InfoFacts: Hallucinogens - LSD, Peyote, Psilocybin, and PCP. http://www.nida.nih.gov/infofacts/hallucinogens.html
  • National Organization for Drug-Induced Disorders. HPPD DSM-IV Diagnostic Criteria. http://nodid.org/dynamic/index.php?option=com_content&task=view&id=51.
  • Richards, M. and Parish, B. Hallucinogens. eMedicine Specialties. http://emedicine.medscape.com/article/293752-overview.
  • Werner, Mark. Hallucinogens. Pediatrics in Review, 1993; 14:466-72.
  • Youth Risk Behavior Survey (YRBS) 2007. www.cdc.gov/HealthyYouth/yrbs/index.htm.
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