Clinical Case: Is this just ‘old age’?
Student Surgery: You’re a medical student conducting a surgery list under supervision from your GP trainer. Your next patient is a retired GP who has been booked in by his wife for concerns about his memory.
A 74 year old retired GP, Dr Wallis comes to see you.His wife reports that his memory is not ‘as it was’ however the retired GP dismisses this as ‘nonsense’ and proceeds to tell you about his early research on the use of anti tuberculous medications. His wife is concerned that he may have a brain tumour. The concern about this is that she has read brain tumours can cause memory problems.
Dr Wallis is frustrated by his wife’s concerns about his memory and mentions she is always meddling in his affairs. In his history his wife tells you he has put on a stone in weight, and fractured an ankle when being run over by a car 12 months ago.
PMHx
Previous history of skin psoriasis, treated with topical preparations only.
Drug history
Vitamin D tablets ordered over the internet (patient unsure of strength, wife believes it to be 1000 international units a day)
Examination
You proceed to examine Dr Wallis to evaluate him for any neurological problems. The examination is as follows.
Observations normal. Normal Cardiovascular, Respiratory and Gastrointestinal Examination
Neurology:
| Upper Limbs | Lower Limbs | ||||
| Right | Left | Right | Left | ||
| Tone | N | N | N | N | |
| Power
|
5/5 | 5/5 | 5/5 | 5/5 | |
| Coordination | N | N | N | N | |
| Sensation
Fine touch Proprioception |
N
N |
N
N |
N
N |
N
N |
|
| Reflexes
Biceps triceps supinator
|
+
+ - |
+
+ + |
Knee
Ankle Plantar |
+
- ? |
+
+ ? |
Cranial Nerve Exam
Normal. Fundoscopy normal.
Mental Test Score:
| Question | Mark (x/10) |
| Age | Correct |
| DOB |
Correct |
| Time (nearest Hr) |
Correct |
| Person |
Correct |
| Place (house number/ name of hospital) |
Incorrect |
| Recall Address |
Correct |
| WWII |
Incorrect |
| Year |
Correct |
| Queen |
Correct |
| 20-1 |
Correct |
Adapted from Hodkinson HM. “Evaluation of a mental test score for assessment of mental impairment in the elderly.” Age and Ageing 1972;1:233-8
Recent blood tests
| Test | Result | Normal Range |
| Hb | 12.9 | (12-15g/dl) |
| WCC | 5.4 | (4-10 x109/l) |
| Plt | 152 | (150-300 x109/l) |
| MCV | 88 | (80-99 fL) |
| INR | 0.9 | (0.9-1.3) |
| Na | 137 | (135-145 mmol/l) |
| K | 4.8 | (3.5-5.1mmol/l) |
| U | 4.1 | (4-9mmol/l) |
| Creatinine | 88 | (60-100 micromols/l) |
| Albumin | 39 | (35-45g/l) |
| Alk Phos | 53 | (<110iu/l) |
| ALT | 45 | (<40 iu/l) |
| Bilirubin | 19 | (<20 micromols/l) |
| CRP | 9 | <5 |
| TSH | 5.6 | (0.5-5) |
| Fasting Blood sugar | 6.2 | (<7mmol/l) |
What is the most likely diagnosis is this just ‘old age’, and does the patient require any other investigations? You can pick a maximum of 5 answers.
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We have confusion and no real medical symptoms, with subjective evidence of persisting memory loss which would point to alzheimers?
Needs a ct or an MRI brain I think .
All dementia diagnoses need to be supported by a scan, of so we have been taught. Difficult Reading the neurology on an iPhone!
Vit D levels, MRI can be done at stage 2, Calcium should be in the list above, rpt TSH. Weight gain – may need a bit of clarification, for e.g. – is this abdominal size increase/ ovarian path related etc, CXR is a must for such patients, especially if they are smokers, not clear in the history.
Well done bateman.
The trick here is the information which is not relevant. This is a presentation of dementia: its not standard practice to MRI all dementia patients so that’s out. HIV can cause a dementia type picture, but with the absence of any other symptoms and signs that is out. Syphilis is a cause of reversible dementia but this seems quite unlikely, so you could check this serology but I think a history would be first. B12 and folate deficiency are causes of reversible dementia but again this is rare clinically, so they need to be checked.
VEP’s are used to look for demyelinatoin, there’s nothing to suggest this here, so they’re out.
A lumbar puncture doesn’t sound like its indicated in the presence of a non-acute problem (if it was acute it would be useful to rule out other things like an encephalitis but that would usually be associated with a decreased conscious level I think).
So… B12 Folate and a CT brain would be my 3.
nice job
The best answer would be for such a complex scenario would be exclude reversible causes
CT: Normal pressure hydrocephalus/ space occupying lesion/ subdural/ abscess as the main ones
Haem &Biochem: B12/ Fol/ TSH/ Syphilis serology/ serum calcium
The clinical examination does not suggest any other progressive neuro-degenerative condition, so these would be the start of a baseline investigations.