A 54-year-old Latin woman which is in the emergency department, complains of persistent, extreme upper quadrant pain radiating to her right scapula, which lasted nearly six hours. two She vomited 2 times without pain relief. A few weeks earlier, she had two similar, but less intense, episodes of such pain, where she didn't seek for medical attention. She has no chronic condition. The test shows a fairly obese woman with a temperature of 100.4°F. Her sclerae are mildly icteric. She exhibits abdominal guarding, mild right upper quadrant tenderness on palpation, delay of inspiration during palpation, and regular intestinal sounds. The WBC count is 14,000 cells/mm³ and the alkaline phosphatase rate is increased to 200 IU/L. The overall rate of bilirubin is 4 mg/dL. Her serum aminotransferase values are good values.

What diagnosis for this individual? What kind of imaging study shall we do? How to manage her condition?

 

 

An 80-year-old white male is taken to the hospital by his wife because she is worried for his memory. The only medical problem for the patient is moderate hypertension, treated with hydrochlorothiazide (12.5 mg daily). During the initial clinical consultation, his wife admits that about two years earlier she started to note that he was getting more forgetful and irritable. A former primary school teacher, he's always been a little stubborn, but rising stubbornness is driving his wife's patience. A year earlier, the wife took up the challenge of paying bills after her husband fell behind in this obligation and started to collect late notices. Progressively, his participation and engagement in the hobbies he previously loved diminished. He began to sleep throughout the day and spent lot of time at night. Often she found him in the kitchen, cooking dinner at 4 o clock in the morning. She's been terrified to leave him at home alone. Half year before, he had been involved in a minor motor vehicle crash and had been charged with refusing to take the responsibility, and he refuses to stop driving even though there were a series of close accidents since then. Τhe patient is a tall, well-dressed man with a polite attitude, but with no spontaneity.

BP = 165/80 mmHg

Pulse = 75 beats/min

Respiration = 18 beats/min

Temp = 98.6F

Study results during the medical assessment, including a detailed neurological examination, was common except for bilateral capsule reflexes. He has trouble executing basic instructions. His Folstein MMSE score = 20/30, and he is oblivious of his mistakes. He gets 3/30 on the Geriatric Depression Scale indicating that he isn't depressed. When questioned how everything is at home, he pauses for a moment and replies, everything is okay. When asked about his relationship with his wife, all he mentions is that his wife is a lovely woman. His self-assessment is that he's doing fine for an elderly man. When questioned about his memory, he says it's fine, and he doesn't have trouble recalling pressing matters.

Lab analysis demonstrates good hematocrit and serum creatinine levels. The findings of the liver function test are good. B12 level = 480 pg/mL; folate = 10 ng/mL and TSH = 3 IU/mL. The rapid plasma reagent test (for syphilis) is non-reactive. CT scan of the head acquired at the time of his car crash six months ago, allegedly revealed age-consistent ocerebral atrophy.

 

What is the most important feature of this patient's appearance when constructing a differential diagnosis? What results are most typical of AD or other causes of dementia in the MRI or CT? What is the potentially treatable factor of loss of memory for this person to be screened? Could something be done to support his spouse handle her husband's behavior?

See below, thank you.

Step-by-step explanation

Case 1.

What diagnosis for this individual? 

The diagnosis is acute cholecystitis along with choledocholithiasis and gallstone obstruction of the bile duct. Prior indications of this woman, consistent with chronic bile pain, indicate gallstone disease. The more significant indications she has currently, consistent with leukocytosis, upper right quadrant abdominal tenderness, and inspiratory arrest with palpation in the upper right quadrant, indicate acute cholecystitis. Increased alkaline phosphatase and complete bilirubin levels are indicative of obstruction of the common bile duct. (Total bilirubin rarely increases above 3 mg/dL in cholecystitis on its own)

What kind of imaging study shall we do? 

Abdominal ultrasonography can be conducted on a regular basis in individuals with suspected of developing gallstone disease. In this individual, the traditional presentation, which points to acute cholecystitis and cholelithiasis, makes further imaging studies needless. If the ultrasound does not display stones, a hepatobiliary scintigram can help for diagnose.

How to manage her condition?

Initial treatment should be the IV administration of fluids and antibiotic coverage for gram-negative pathogens, along with nasogastric suction. Cholecystectomy should be done shortly after the patient's health has improved; delay in surgery is linked to higher morbidity rates. If open cholecystectomy is established, the exploration of the bile duct should be highly considered. If a laparoscopic procedure is preferred, a preoperative ERCP must be done to extract the stone from the bile duct. If the patient's health does not improve fast and also has obstructive jaundice, an immediate ERCP should be used to decompress the biliary system.

Case 2.

What is the most important feature of this patient's appearance when constructing a differential diagnosis? 

His appearance is an instant clue for his condition. His spouse made the appointment as she was worried for his memory, while the patient was less conscious of his deficits. This pattern is a hallmark feature of dementia. If the individual had actually made the appointment himself and had come alone worrying about his memory or trouble in concentrating, this behavior may have been more associated with depression. Once dementia is advanced, the diagnosis is clear. The individual may mask or rationalize his deficits, and his processing improvements may be so gradual that they are more noticeable at home than in the hospital. This is where the experiences of the family have been incredibly useful. In this scenario, the patient's spouse got a lot of clues to her husband's dementia. Ordinary physical assessment is common in patients with early AD. The first pathological alterations in AD arise mainly in the brain's temporal and parietal lobes, and the motor strip is spared. Thus, the first indications are often related to memory failure, slight personality changes (e.g. elevated irritability), aphasia, and apraxia. 

Bilateral grasp reflexes were the only important findings during this patient's neurological test, in comparison to his irregular mental state examination. This answer, the spontaneous grasping of the examiner's fingers as the physician strokes the patient's hand, is a basic reflex that may manifest with bilateral frontal lobe disorder, which may occur in both AD and other dementias.

What results are most typical of AD or other causes of dementia in the MRI or CT? 

MRI or CT can reveal signs of early AD temporal lobe atrophy. Nevertheless, neuroimaging evidence of cerebral atrophy is more associated with old age than with a deterioration in mental status. MRI or CT results for white matter pathology associated with multi-infarct dementia have been confirmed in patients with normal cognition. Contrarily, CT and MRI did not reveal irregularities in 20% of individuals who were clinically diagnosed with AD. It is also not shocking that the results of the individual's CT scan were common for his age. If the dementia has advanced for a span of two years or longer, if the mental status test reveals significant deterioration, even if the individual has no focal neurological findings or gait dysfunction, neuroimaging is highly unlikely to show findings that would change treatment.

What is the potentially treatable factor of loss of memory for this person to be screened? 

The aim of the assessment is to classify conditions that can be identified confidently or with which intervention can cure cognitive deficits. The physician should then regularly take a thorough history, complete a careful physical examination, and prescribe a basic lab assessment, including a complete blood count, magnesium, serum electrolytes, creatinine, TSH, and B12. Certain examinations, such as MRI or CT, should be prescribed by the physician based on the findings of the history and physical examination. For instance, if an individual had a history of a new or rapid onset of cognitive dysfunction after a head wound, the likelihood of a subdural hematoma would suggest the need for brain imaging. This is especially valid if a physical examination shows a gait disorder or focal neurological symptoms. A recent onset triad of dementia, gait disorder, and urinary incontinence can indicate a condition of normal hydrocephalus pressure, another possibly reversible cause of cognitive impairment. This condition is very uncommon, and while some individuals can report change in ventricular shunting, postoperative complications (e.g. subdural hematoma, inflammation, and shunt obstruction) are indeed common. These diagnosis possibilities would not be likely for the individual mentioned in the preceding text. 

Hypothyroidism and B12 deficiency necessary to impair neural activity typically induce concentration and perception deficits, and are detected and treated well before dementia occurs. Occasionally, however, individuals pause in seeking medical attention until dementia is evident, so all patients should be assessed for these conditions.

Neurophylis is no longer a typical cause of cognitive dysfunction. These people commonly have other neurological findings, such as dorsal column disorder manifested by loss of location and vibratory feeling, as well as diminished mental state.

Severely depressed individuals can appear disoriented and poorly developed in cognitive function evaluations. These deficits may be due to temporary changes that mirror irreversible changes in dementia. Since the diagnosis of depression can be complicated and is dependent on the subtle observations of an aging patient, techniques such as the Geriatric Depression Scale have been developed to help detect depression. Sadly, the individual identified here did not show any of these potentially treatable abnormalities.

Could something be done to support his spouse handle her husband's behavior?

Yes of course. There's many ways of helping the patient's spouse handle the behavior of her husband. Caring for a demented patient is mentally and emotionally draining. As advised, the physician must consider not only the patient, but also the caregiver. Allowing caregivers to vent feelings, remembering the challenge of their work, reminding them what to expect as the condition progresses, providing respite support, and directing them to support groups are some steps that will help them better deal with the patient and his needs.

Treatment of behavioral disorders is challenging, but it can be successful. Daily exercise and restricting the amount and length of late-afternoon or late-night naps can help to minimize the night insomnia that sometimes complicates the treatment of demented elderly patients. Many sedatives and hypnotic agents, especially long ones, should never be used since they can induce over-sedation or a paradoxical rise in anxiety and can only exacerbate cognitive and behavioral problems. 

Delusions are normal in dementia syndromes. In reality, about 50 percent of patients with AD or multi-infarct dementia experience delusions. These signs can be followed by agitation and combative behavior. Cautionary use of smaller concentrations of haloperidol or other antipsychotic medications can help to change these behaviors.