Question

M.H. is an 80-year-old Caucasian female who is married and lives with her spouse. She presents to your office today with her spouse, feeling “coocoo, I just don’t feel right.” Currently she is taking rosuvastatin prescribed by her cardiologist for hyperlipidemia and a daily 325 mg aspirin. She drinks 3-6 hard liquor drinks a day, 3-4 times a week in the evening, and has a 65-year smoking habit, currently smoking two packs per day (ppd). She has no known allergies. Past surgical history includes hysterectomy for a benign fibroid. Family history of breast cancer in three sisters, Type 2 diabetes and CVA in one sister, cancer of unknown origin in one brother. All siblings and parents are deceased.

Her husband reports that she is hard of hearing. He feels that it is due to cerumen build-up in her ears, which she refuses to have him remove. Her husband is also worried about her memory—states that she “just does not remember things like she used to. She keeps asking me the same questions over and over.” She does not eat very well; this is the way that she has been for years, but it does seem to be getting worse.

You notice on her chart that she was given lisinopril-hydrochlorothiazide 40/25 mg daily at her last office visit but she is not currently taking it. She states that she did take the medicine but she ran out. She reports that she does not have high blood pressure. She has fallen a few times in the past year but her husband states that he has fallen more, so he is not concerned.

Last mammogram was two months ago and was normal. She gets her influenza vaccine yearly. Last pneumonia vaccine was two years ago. She had a colonoscopy several years ago and it was normal.

Vitals signs: BP 172/96 right arm, 179/92 left arm; pulse regular 92; respirations 18; temp 97.4 F Weight 72 lbs. Height 4’11”

No chest pain, shortness of breath, edema, headache, change in vision, abdominal pain, vomiting, black tarry stools, blood in the stools, dysuria, urgency, frequency, nocturia, enuresis, sore throat, or recent fever. Positive cough, rhinorrhea, nausea, and slight dizziness.

Answer the following questions:

1. List three concerns about this patient and why you are concerned.
2. Do you want more information? If so, what?
3. Will you order tests? If so, what testing?
4. List at least four differential diagnoses.
5. What counseling and recommendations would you give to M.H.?

Answer 1

■.Some of the concerns about this patient are

• An abnormal elevated blood pressure can make the patient to end up in stroke by thus age
• Patient is under risk of getting cancer due to the habit of smoking and alcohol
• Patient has difficulty in memory may be due to old age ,medication
• There are high chances for the body to function normally when one smokes and drinks heavily by this age
• Patient seems to be addicted to the substance besides her medical condition and family history

■Some of the additional information to be collected which can aide in appropriate diagnosis are

• Her food habits
• Personal hygienic practices
• Any Cognitive changes,behaviour and mood changes,confusion, anger
• Since when she is forgetting things.

■Some basic tests like

• ECG to rule out cardiac functons
• The Mini-cog test to assess her memory status
• Blood test(vitamin B12 ,folate, LFT,RFT, Thyroid test)
• Brain scans to identify the cause of her occasional memory loss
• General Practitioners Assessment of Cognition Test is the most commonly used one

■Some of the differential diagnosis are

• Alzheimer's disease
• Dementia
• Dementia with Lewis body
• Parkinson's disease

■Some of the counselling and recommendations needed for this patient are

• To take antihypertensive medication as per order to prevent unnecessary shooting up of BP
• Definitely not to skip medication
• Instruct to reduce alcohol and smoking because this can aggravate cardiac conditions
• Encourage to have adequate lighting ,skid proof floor in the home to prevent floor
• Follow a healthy diet
• Can do simple memory training exercises