Case 32 - 65 yo F with forgetfulness and confusion

Question 1

Gathering history

Answer 1

ADLs (bathing, feeding, toileting, in and out of chairs and bed, cooking, paying bills, using telephone, cleaning house)

Question 2

Physical examination

Answer 2

Eye exam (inspected pupils, fundus)
Neck exam (carotid auscultation)
CV exam (auscultation and orthostatic vital signs)
Pulmonary exam (auscultation)
Abdominal exam (palpation)
Neurologic exam (MMSE, CNs, motor exam, DTRs, gait, Romberg's sign, sensory exam)

Question 3

Differential diagnosis

Answer 3

Alzheimer’s disease
Multi-infarct (vascular) dementia (h/o fall, HTN and MI, weakness)
Depression (loss of husband, poor appetite, feelings of sadness)

Question 4

Differential diagnosis

Answer 4

Alzheimer’s disease (steady cognitive decline, memory impairment, impaired executive functioning, decline in ADLs, failed three-item recall)
Multi-infarct (vascular) dementia (h/o fall, prior stroke, HTN and MI, decreased strength, DTRs 3+, positive Babinski’s sign, failed three-item recall)
Dementia syndrome of depression (dysphoria after loss of husband, poor appetite, feelings of sadness, failed three-item recall, memory impairment)

Question 5

Diagnostic work-up

Answer 5

CT - head or MRI - brain
EEG or SPECT (differentiate delirium from depression or dementia)
CBC (look for macrocytic anemia in vitamin B12 deficiency)
Serum B12, TSH, RPR
Electrolytes, calcium, glucose, BUN/Cr (medical conditions that can present with cognitive dysfunction - hypernatremia, hypercalcemia, hyperglycemia, uremia)

Question 6

What would be the neurologic exam for this patient?

Answer 6

Alert and oriented to person, place and time
Say list of three items (ball, tree and flag)
Spell WORLD forward and backward
Repeat list of three items (ball, tree and flag)
CNs
DTRs
Babinski sign
Cerebellar testing (Romberg, heel to shin, finger to nose)
Gait
Sensation (pinprick and soft touch)