First Aid for the USMLE Step 2 CS

Section 4. Practice Cases

Case 32. 65-Year-Old Woman with Forgetfulness and Confusion

DOORWAY INFORMATION

Opening Scenario

Virginia Black, a 65-year-old female, comes to the clinic complaining of forgetfulness and confusion.

Vital Signs

BP: 135/85 mm Hg Temp: 98.0°F (36.7°C)

RR: 16/minute HR: 76/minute, regular

Examinee Tasks

1. Take a focused history.

2. Perform a focused physical exam (do not perform rectal, genitourinary, or female breast exam).

3. Explain your clinical impression and workup plan to the patient.

4. Write the patient note after leaving the room.

Checklist/SP Sheet

Patient Description

Patient is a 65 yo F, widowed with 1 daughter.

Notes for the SP

 The examinee will name 3 objects for you and ask you to recall them after a few minutes. Pretend that you are unable to do so.

 If asked, give the examinee a list of your current medications (a piece of paper with “nitroglycerin patch, hydrochlorothiazide, and aspirin” written on it).

 Pretend that you have some weakness in your left arm.

 Show an increase in DTRs of the left arm and leg.

Challenging Questions to Ask

“Do you think I have Alzheimer’s disease?”

Sample Examinee Response

“At this time I don’t know; we still need to run some tests. What makes you concerned about having Alzheimer’s?”

Examinee Checklist

Building the Doctor-Patient Relationship Entrance

 Examinee knocked on the door before entering.

 Examinee introduced self by name.

 Examinee identified his/her role or position.

 Examinee correctly used patient’s name.

 Examinee made eye contact with the SP.

Reflective Listening

 Examinee asked an open-ended question and actively listened to the response.

 Examinee asked the SP to list his/her concerns and listened to the response without interrupting.

 Examinee summarized the SP’s concerns, often using the SP’s own words.

Information Gathering

 Examinee elicited data efficiently and accurately.

Connecting with the Patient

 Examinee recognized the SP’s emotions and responded with PEARLS.

Physical Examination

 Examinee washed his/her hands.

 Examinee asked permission to start the exam.

 Examinee used respectful draping.

 Examinee did not repeat painful maneuvers.

Closure

 Examinee discussed initial diagnostic impressions.

 Examinee discussed initial management plans:

 Follow-up tests.

 Need to obtain history directly from other family members.

 Need to evaluate home safety and supervision.

 Need to obtain community resources to help the patient at home.

 Examinee offered support throughout the illness.

 Examinee asked if the SP had any other questions or concerns.

Sample Closure

Mrs. Black, your symptoms may be due to a number of disorders that can affect the brain, many of which are treatable. We need to run some tests to identify the cause of your problem. I would also like to ask your permission to speak with your daughter. She can help me with your diagnosis, and I can answer any questions she might have about what is happening to you and how she can help. I would also like you and your family to meet with the social worker to assess at-home supervision and safety measures. The social worker will inform you of resources that are available in the community to help you. If you would like, I can remain in close contact with you and your family to provide additional help and support. Do you have any questions for me?

History

HPI: 65 yo F c/o difficulty remembering x 1 year, after death of husband.

 Progressively worsening memory.

 Affects daily activities (bathing, feeding, toileting, dressing, transferring into and out of chairs and bed, shopping, cooking, managing money, using the telephone, cleaning the house).

 Transient orthostatic lightheadedness with frequent falls, 1 head injury without medical attention.

 Upset due to memory difficulty.

 Weight loss, no appetite.

 No headache, visual changes, gait problems, difficulty sleeping, or urinary incontinence.

ROS: Residual weakness in left arm after a stroke.

Allergies: NKDA.

Medications: HCTZ, aspirin, transdermal nitroglycerin.

PMH: Hypertension, stroke, MI. The patient cannot remember exactly when she had them.

PSH: Partial bowel resection due to obstruction many years ago. Patient does not remember how long ago this occurred.

SH: No smoking, no EtOH, no illicit drugs. She is a widow (husband died 1 year ago), is retired, lives with her daughter, and has a good support system (family, friends).

FH: Noncontributory.

Physical Examination

Patient is in no acute distress.

VS: WNL, no orthostatic changes.

HEENT: Normocephalic, atraumatic, PERRLA, no funduscopic abnormalities.

Neck: Supple, no carotid bruits.

Chest: Clear breath sounds bilaterally.

Heart: RRR; normal S1/S2; no murmurs, rubs, or gallops.

Abdomen: Soft, nondistended, nontender, no hepatosplenomegaly

Neuro: Mental status: Alert and oriented x 3, spells backward but can't recall 3 items. Cranial nerves: 2-12 intact. Motor: Strength 5/5 in all muscle groups except 3/5 in left arm. DTRs: Asymmetric 3+ in left upper and lower extremities, 1+ in the right,Babinski bilaterally. Cerebellar:Romberg. Gait: Normal. Sensation: Intact to pinprick and soft touch.

Differential Diagnosis

CASE DISCUSSION

Dementia is an acquired, progressive impairment in cognitive function that includes amnesia accompanied by some degree of aphasia, apraxia, agnosia, and/or impaired executive function. Additional historical information must be sought from other family members to establish an accurate time course of cognitive decline. The dementia syndromes are primarily clinical diagnoses, and therefore the initial diagnostic workup should be directed toward the exclusion of partially reversible causes of dementia. Moreover, the top three diagnoses for this patient encounter may coexist, further complicating treatment.

Patient Note Differential Diagnoses

 Alzheimer's disease: This patient presents with a steady decline in cognitive function that is most consistent with Alzheimer’s disease, the most common cause of dementia. Alzheimer’s disease usually has an insidious onset characterized by a steady, progressive decline in cognitive function over a period of years. The earliest findings are impairment in memory and visuospatial abilities. Alzheimer’s disease is a clinical diagnosis.

 Vascular ("multi-infarct") dementia: Vascular dementia often coexists with Alzheimer’s disease, and given the patient’s history of atherosclerotic vascular disease (eg, stroke, MI), it could certainly be contributing in this case. In vascular dementia, there is classically more of a fluctuating, stepwise cognitive deterioration that is temporally related to a recent stroke. This patient’s stroke is not recent, and the pattern of her cognitive decline is more consistent with that of Alzheimer’s disease. In addition, vascular dementia may be characterized by an earlier loss of executive function and personality changes.

 Dementia syndrome of depression (DSD): The time course of cognitive decline following the death of the patient’s husband may indicate depression. In the elderly, depression can present atypically with symptoms of neurocognitive decline (vs. young patients, in whom dysphoria predominates). These symptoms may mimic or, more commonly, coexist with dementia. In contrast to Alzheimer’s disease, DSD presents primarily as a dysexecutive syndrome and is a reversible cause of dementia. A thorough screening for depression should be conducted. However, it is more likely that this patient’s cognitive decline has been progressive for several years but became more noticeable to her children after her husband died.

Additional Differential Diagnoses

 Subdural hematoma: This should be ruled out given the patient’s history of falls and head trauma. Although her cognitive decline spans at least a year, it is possible that a comorbid chronic subdural hematoma could have exacerbated her mental status changes in recent weeks or months.

 Vitamin B12 deficiency: A prior bowel resection (eg, resection of the terminal ileum) may put the patient at risk for this deficiency. It can cause depression, irritability, paranoia, confusion, and dementia but is usually associated with other neurologic symptoms, such as paresthesias and leg weakness. On occasion, dementia may precede the characteristic megaloblastic anemia.

 Hypothyroidism: This can cause neuropsychiatric symptoms (often a late finding) and must be ruled out in patients with dementia. However, there are no classic signs or symptoms to suggest hypothyroidism in this case.

Diagnostic Workup

The goal of the diagnostic workup for cognitive decline is to rule out potentially reversible causes of dementia and search for causes such as electrolyte disturbances, neoplasms, or infarcts.

 CT—head: Used to look for a crescent-shaped, hyperdense extra-axial mass in subdural hematoma, intracerebral masses, strokes, or dilated ventricles (as in normal pressure hydrocephalus).

 MRI—brain: The most sensitive exam with which to look for focal CNS lesions or atrophy.

 EEG or SPECT: Used in rare cases to help differentiate delirium from depression or dementia.

 CBC: Used to look for macrocytic anemia in vitamin B12 deficiency.

 Serum B12, TSH, RPR: To screen for partially reversible causes of dementia (RPR can be restricted to patients who manifest signs of neurosyphilis).

 Electrolytes, calcium, glucose, BUN/Cr: To screen for medical conditions that can present with cognitive dysfunction (eg, hypernatremia, hypercalcemia, hyperglycemia, uremia).



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