Lake Erie College of Osteopathic Medicine
Problem-Based Learning
L-E-C-O-M
Bradenton
School of Dental Medicine
New Case
Andrew Kasem
Written by: Dewan S. Raja, MBBS, Julie Brown PhD, and Erik Terdal PhD
Case Contents by Page
CC:
Chief Complaint
Hx: Patient History
PE:
Physical Examination
CDs
Ds and TX:
Diagnosis and Treatment
Clinical Course .
Outcome
CHIEF COMPLAINT:
Mr. Kasem is a 69-year-old white man, brought in by his son, who states:
My father has become increasingly confused, irritable and reclusive over the last three years, believing that his family members are plotting to steal his money.
History of Present Illness
Mr. Kasens son states that his father has become increasingly confused and withdrawn over the last three years, believing that his family members are plotting to steal his savings and possessions. Mr. Kasem has progressive difficulty remembering new things, difficulty expressing himself and balancing the checkbook. Sometimes he is unable to recall the name of everyday objects Recently, Mr. Kasem has been alluded to speaking with relatives who died several years ago.
Mr. Kasem has a hard time to drive to familiar supermarkets. Sometimes he lost his way to return home. Mr. Kasem has five grown-up kids and very often he confuses with the name of his children, became apathetic and forbade them to visit. He has no history of seizure
Past Medical History
Mr. Kasem has hypertension for about 15 years. He is also a patient of type 2 diabetes since 2007. His diabetes and hypertension were controlled by diet and medication so far According to the son, the father has no known serious general medical conditions, alcohol abuse, or psychological instabilities. Mr. Kasem has no history of head trauma and stroke. Mr. Kasem is a retired high school teacher. He has no history of surgery and hospitalization. He was well-liked by his students and colleagues for his pleasant personality
Family History
The son of the patient told that his grandparents are all expired and died of natural causes during their seventies. The son could not provide any clues to the neurological or psychological diseases in his family members
Social History
Mr. Kasem is married for 38 years. His wife is a 65-year-old woman and is apparently healthy. She takes care of her husband. Mr. Kasem never smoked in his life.
Drug History
Mr. Kasem is taking quinapril 40 mg daily and Glucophage) Metformin 11 mg once daily. His wife helps him to take the prescribed medications regularly
Vital Signs:
Temperature99.4°F (Axilla)
Pulse116 bpm
Respiration24/min
B.P.146/85 mmHg (right arm)
Weight 78KgPulse
Height 5 ft. 11 inches
Oximetry 97%
General: Malnourished and dehydrated. Sad and weak looking with possible weight loss
Skin: No lesions or rashes
HEENT: Pupils are round and reactive. Tympanic membranes normal bilaterally. No thyromegaly or cervical lymphadenopathy. No neck rigidity
Lungs: Clear to auscultation bilaterally. No rale, wheezing, and crepitus
Heart: PMI not palpable; Regular rate and rhythm. Normal S1, S2. No murmurs, clicks, gallops, or rubs. No paroxysmal nocturnal tachycardia, sleeps on two thin pillows, normal S1 and S2, no tachycardia, no murmur, and no history of fainting
Abdomen: Normal bowel sounds, soft, nontender, nondistended, no scars, no masses or hepatosplenomegaly.
Urologic: Hesitancy and incontinence, uses a pullover at night to prevent bed soiling
Extremities: No clubbing, cyanosis, or edema. Restricted range of motion.
Neurological Examination
Mr. Kasem seems to be disoriented to time and place. He could not tell the date of today and the location where he is now. Mr. Kasem followed some of the commands although he was partly inattentive and drowsy. He could produce a few recognizable words. His language is lacking in detail and substance. He had difficulty to understanding the spoken language of the attending physician. He could repeat three words but could not recall after a small distraction. Mr. Kasem has hard time to recall the name of three of his children and he failed to recall the everyday objects like the pencil, eraser, and paper. Mr. Kasem was unable to calculate simple math like two plus three is what. Mr. Kasem was unable to draw a circle. Mr. Kasem has a slow and shuffling gait, short steps, and has difficult to initiate walking. There is no tremor or rigidity.
CDs
CD 1 CBC
CD 2 Serum Electrolyte
CD 3 Hemoglobin A1C, Glucose and BUN/creatinine
CD 4 Liver and thyroid function Tests
CD 5 Serum vitamin B12, Iron, and Folic Acid
CD6 Urine Analysis
CD 6 Syphilis serology (RPR)
CD 7 HIV screening
CD 8 Lumbar puncture and CSF findings
CD EKG
CD 9 EEG
CD 10 CT scan and MRI of the brain
CD 11 Mini-Mental Status Examination
CD12 Trail Making Test
Treatment
Patient safety, including risks associated with impaired driving
Home safety to prevent fall
Cholinesterase inhibitors
Donepezil (Aricept) 5 mg QD for 4-6 weeks
Cognex (Tacrine Hydrochloride) 10mg QID for four weeks
NMDA receptor antagonist: Memantine (Namenda)any contraindication? 5 mg QD
Antipsychotic drugs
Olanzapine(Zyprexa) 2.5 mg QD
Objectives
After completing this case the students should be able to
Define dementia, amnesia, aphasia, apraxia, acalculia
List the causes of confusion
Describe the pathogenesis of Alzheimers disease
Enumerate the differential diagnosis of Alzheimers disease
Enlist the common drugs used for the treatment of Alzheimers Disease, their mechanism of actions and adverse effects
Write the management plan for a patient with Alzheimers disease