Final practical examination- long case

CBBLE UDHC SIMILAR CASES 

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Informant - Daughter in law 

A 85 year old man from Narketpally, who used to work as a merchant in a local market, came with chief complaints of uprolling of eyes, frothing from mouth,and clenching of both fists at 3:30 pm on Saturday.

History of presenting illness 

Patient was apparently asymptomatic on Saturday morning, had his lunch in the afternoon , sat on his bed, when he suddenly fell on the bed and developed clenching of his hands, uprolling of eyes and moving head to right side associated with frothing from mouth,  lasting for about 3 - 4 minutes.

No history of involuntary micturition or defecation, deviation of mouth, no history of  headache, nausea,vomitings prior to the event.

History of post ictal confusion present, patient was in drowsy state when brought to the hospital by the attenders.

Past history 

Patient was apparently asymptomatic 10 years back, he is a chronic alcoholic and chronic smoker , drinks around 90-180 ml of whisky and around 500ml of toddy daily and smokes about 3 -4 packets of beedis per day.

 He used to  work as a merchant at a local market, but stopped going to work due to regular alcohol consumption, which interfered with his work, as he used to drink during daytime and used to fall on roads in intoxication,  which made the family members to make him quit his work and stay at home. Since then, he stays at home , goes outside to drink alcohol ,chats with his friends and returns home.

Since the past 5-6 yrs, the attenders observed that he is forgetting things or events. He used to smoke beedis at home regularly which he personally keeps them at a particular place but forgets about it and asks family members  sometimes. Forgets events like whether he had lunch or not sometimes.

Fails to identify his family members and close relatives who visit their house on and off.

The attenders attributed all these symptoms to his chronic alcoholism and were used to taking care of his daily activities,  like guiding him to the bathroom, giving him clothes to dress.

He was once a well known person around his locality, settling any disputes or quarrels in his area, actively participating in local events. He gradually became less interested in those activities and usually stays at his home or goes to his daughter's house nearby.

3 years back , he attended a local wedding ceremony at night, had history of vomiting and involuntary defecation and micturition in the morning in his bed associated with uprolling of eyes and blinking, frothing from mouth and clenching of both fists,  which lasted for around 10 -15 minutes, with post ictal confusion. Patient brought to hospital, necessary clinical examination and investigations were done. MRI brain showed

Left occipital old insult with glinting changes, age relate cerebral and cerebellum atrophy, small vessel ischemic changes and periventricular leukaraiosis.

He got discharged the next day with ? Tab.phenytoin 100mg once daily( attender not sure of name of the drug,said it was in a bottle with 100 tablets) and used to take once in the morning. 

He was forced to quit alcohol by the attenders  since then, but still drinks around 250 ml of toddy once a week and smokes atleast one packet of beedis per day.

He limited going out of his house( regularly goes to shop in front of his home to buy beedis) , or goes to his daughter's house which is few streets away. He used to have irritable behavior and used to get angry and raise his his hands on his family members. 

Since the past 4-5 months, stopped taking antiepileptics ( due to cost issues and as he is seizure free for around 2 years).

He is not a known case of diabetes, hypertension, bronchial asthma,tuberculosis, coronary artery disease or thyroid disorders. 

Personal history 

He wakes up around 5 am ,goes to bathroom, roams around in the home,completes his bath, has to smoke his beedis, has his breakfast , again smokes, takes a nap for few hours. Has his lunch, sometimes goes outside to chat with his friends,sleeps for few hours, has his smoke, returns home, sleeps at around 9 pm after dinner. Easily wakes up during sleep on slight sounds at night.he stays with his wife, son, daughter in law and his grandkids.

Drug history

? Tab .Phenytoin 100mg od for 2 years

Family history 

No history of similar complaints in the family. 

Vitals

Temperature- afebrile

Pulse rate -82   bpm , regular 

Blood Pressure  -110/90  mmhg , right upper limb

Respiratory rate  - 18  cpm

Spo2 - 99 %

GRBS - 116 mg/ dl

General examination 

Patient is thin built and moderately nourished.

No Pallor,icterus ,cyanosis, clubbing, generalized lymphadenopathy 

Central nervous system examination 

Right handed person

Education - illiterate 

Higher mental function examination 

Consciousness- he is conscious, irritable 

Orientation- not oriented to person, place or time.

Memory- 

Immediate, recent and remote- pt not oriented and not co operative 

Behavioral observation :

Physical appearance-  thin built, moderately nourished 

Emotional status- irritated on asking questions 

Level of consciousness- conscious and irritable 

Level of cooperation- not cooperative

Attention:

Ill sustained

Language:

-Spontaneous speech - absent

-Comprehension - 

.Pointing commands --

.Yes or no response +

.Complex command --

-Repetition- absent

-Naming and word finding - not cooperative

-Reading and writing- illeterate.

Frontal lobe functions :

Attention ,working memory ,digit span- absent

Trail making test - couldn't be elicited

Sequencing test - couldn't be elicited

Verbal similarities and fluency test - couldn't be elicited 

Conflicting instructions- couldn't be elicited

Judgement and insight - absent 

Temporal lobe functions:

Memory

Recent memory,remote memory and historical facts, visual memory- not oriented

Parietal lobe functions:

Neglect

Inattention +

Decreased motivation +

Apraxia - couldn't be elicited 

Constructional ability- couldn't be elicited 

Calculation - absent

Right and left Orientation +

Finger agnosia and cortical sensations - couldn't be elicited. 

Occipital lobe functions:

Prosopagnosia +

Unable to recognize familiar faces.

His MMSE SCORE  is 3/30

Orientation 0

Registration  1

Attention and Calculation 0

Recall 0

Language  2

Cranial nerve examination:

1-olfactory:couldn't be elicited 
2-visual acuity:couldn't be elicited 
visual field:confrontation method
colour vision:couldn't be elicited 

3,4,6
eyelids
position of eyeball at rest - central
extraocular movements - normal
pupil :normal in size,shape , 

direct and indirect light reflex- couldn't be elicited 

5:sensory:touch
                        pain
                        temperature
motor: side to side jaw movement
reflexes: corneal
                    jaw jerk

Couldn't be elicited 

7th-
motor-raise eyebrows
                shuts eye. 
                orbicularis oculus - normal
                 orbicularis oris-  
sensory: taste:couldn't be elicited 

8th: rinnie's
          Weber's -couldn't be elicited 

9th,10th-
position of uvula: central
gag reflex present

11th- scm-
            trapezius -couldn't be elicited 

12th-
           tongue: normal size,symmetry, 

no deviation,tremor/fasiculation

motor:

Attitude of limbs:ul.         ll:
bulk : not co operative for taking measurements. On inspection ,no wasting 
tone:                                 Right.                     left
           upperlimb            normal               normal
           lowerlimb            normal                normal

power:couldn't be elicited as pt is not obeying commands 
1)Neck:.  flexors:
                     extension:
2) shoulder:abduction:
                            adduction:
                            flexion:
                            extension:
3)elbow: flexion:
                     extension:
4) wrist : flexion:
                    extension:
5) Trunk: elevation of head
                     beevor's
                      abduction: gluteus
                      adduction:
6)knee: flexion: hamstrings
                   extrnsion: quadriceps
7) ankle: plantar flexion:
                     dorsiflexion:
Reflexes:
superficial
corneal
abdominal
plantar:

deep:

jaw jerk
biceps
supinator
triceps
knee jerk
ankle jerk

Sensory:.

fine touch
joint position
vibration
crude touch
pain - flexing his limbs to pain
temperature

Romberg's test:couldn't be elicited 
cerebellum:couldn't be elicited 
finger nose
finger finger
knee heal
rebound phenomenon
tandem walking

Gait:

slow /rapid: slow
falling to sides: no
hand swing: present
turn: normal

autonomic nervous system: -
meningeal signs: -

Cardiovascular system :

S1 and s2 heard

No murmurs

Respiratory system :

Normal vesicular breath sounds heard 

Abdomen:

Shape of abdomen  -scaphoid

No palpable mass or tenderness on palpation

Provisional diagnosis 

Tonic seizures 

With dementia ?Vascular etiology  /Alzheimer's disease

Smoker since 70 yrs

Alcoholic since 70 yrs

Investigations 

Hemogram

Hb  12.2

Tlc   8,200

Platelets  1.7 lakhs

Serum electrolytes 

Na+ 146

K+ 3.7

Cl- 99

Serum Urea  31 mg/dl

Serum creatinine 1.0 mg/dl

LFT

total bilirubin  0.6 mg/dl

Direct  0.2 mg/dl

AST  13 Iu/l

ALT   18 Iu/l

ALP  146 Iu/l 

total protein   6.5 g/dl

Albumin 4 g/dl

Previous MRI brain 3 yrs back with perventricular leukaraiosis 

Left occipital old insult with gliotic changes

Review of literature:

Algorithm for diagnosis of dementia 

Differences between alzheimers disease and Vascular dementia 

Based on above features points in favor of Alzheimer's disease in this patient are :

Gradual onset

Episodic memory loss

No focal neurological deficits 

Points in favor of vascular dementia are :

Slow decline

Early appearance of executive dysfunction 

White matter lesions in MRI - leukaraiosis 

And small vessel ischemic changes

Seizures

Vascular risk factors - ?TIA, smoking, alcohol

 

Clinical appraisal :

Efficacy of donepezil in Early stage Alzheimers disease 

https://jamanetwork.com/journals/jamaneurology/fullarticle/787258#related-tab

Multicenter, randomized, double blinded, 24 week, placebo controlled study of patients with early stage alzheimers disease.

Objective 

To evaluate the efficacy of donepezil in patients with early stage alzheimers disease 

P - 153 patients with early stage alzheimers disease

I -  96 patients  were given donepezil 5mg for first 6 weeks, with escalation to 10 mg

     57 patients given placebo

C - primary efficacy measure was Alzheimer disease assessment scale- cognitive subspace.

     Secondary efficacy measure was MMSE, Computerized memory battery test, patient global assessment scale and apathy scale.

These were compared between two groups at weeks 12 and 24 and at end point.

O - donepezil group showed more improvement than the placebo group.

Conclusion 

Data shows significant treatment benefits of donepezil  in early stage alzheimers disease,  supporting the initiation of therapy to improve daily cognitive functioning.