Case Index

CASE STUDIES IN NEUROLOGY
Case 5 March 1, 10:00 a.m.

HPI

Mr. X is a 70-year-old retired college professor who comes to your office accompanied by his wife. Mrs. X is concerned about her husband’s memory. When you question her about her precise concerns, she notes that he will frequently walk into a room and forget why he has gone there. In addition his ability to recall things that have happened to him recently is diminishing. For example, his son and daughter-in-law recently visited from the East coast, and a few days afterward he asked his wife when they were coming to visit. On one occasion he drove to the store to pick up a few grocery items and returned 3 hours later, without the groceries and unable to account for why he was gone so long. Mrs. X cannot precisely date the time she became concerned about her husband, but believes that the problems are getting worse. She thinks he may be depressed because he is less interested in spending time with friends and is losing interest in reading and going to the movies.

Mr. X himself feels his wife is overreacting. He says that he has no concerns about his memory, and that he feels fine. He is still able to manage the household finances, play golf, and work in his garden. He is able to manage all his activities of daily living. He denies feelings of sadness, and sleeps well and has a good appetite.

PMH

He had an appendectomy many years ago and has had mild untreated hypertension. He never smoked, and drinks about 2 or 3 drinks of hard liquor each evening. His wife is concerned that he drinks too much. He is taking no medications.

PE
  • General Exam: Exam is unremarkable.
  • VS: BP 145/90, pulse 76.
  • He appears in good health.
NEURO
  • MS: He is alert, and knows he is at the doctor’s office but did not recall the exact address or your name. He gives the date as Tuesday, January 25, 1999 when it is in fact Tuesday January 26, 2000. He knows that the current President is Bill Clinton, and can tell you that he was recently "almost impeached". He can recite the presidents in reverse order back to FDR. He cannot recall any of 4 words you have given him to remember after 5 minutes, and is not quite sure that you have even given him any to memorize. His spontaneous speech is fluent, with normal comprehension, and repetition. He has some difficulty naming unusual objects Ð although he named a watch and a pen well, he called the watch buckle a "thing for closing it" and was unable to generate the name for a shoelace. He is able to follow a three-step command. He draws simple geometric figures well.
  • Examination of the CN, Motor, and Sensory are normal. Although his deep tendon reflexes are generally normal, you cannot elicit ankle jerk reflexes. There is no Babinski sign. Cerebellar testing and gait are normal.


Study Questions:
  1. Summarize the key history and physical exam findings.
  2. Where is the lesion?
  3. What is the most likely diagnosis and differential diagnoses?
  4. What is the difference between delirium and dementia? Why is this important?
  5. What tests will you order?
  6. What will you tell him and his wife?