A 58 year old man with unexplanied dementia, slurring of speech and urinary incontinence since 6 months and forgetfulness since 3 months

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Here is a case i have seen:

Case history

A 58 year old man,saree maker by occupation was brought to the hospital with h/o

Slurring of speech since 6 months , associated with drooling of saliva from left angle of mouth, food particles and water predominantly from left angle of mouth and smacking of lips

Urinary incontinence since 6 months, dribbling of urine while rushing to bathroom.

Forgetfulness since 3 months, able to remember his name and close relatives. Patient often forgets path to his own home, forgets wearing chappals, patient also wanders sometimes, self hygiene is maintained.

He has delayed response to commands.

Dysphagia to both solids and liquids since 10 days.

No h/o self talking, self smiling, hallucinations,tremors, giddiness, headache,trauma to head, involuntary movements.

Reference: Detailed history taken by dept of psychiatry: Dr.srinivas,Dr Tabitha, Dr.Hira, Dr.Raghu,Dr.Vinya

PAST HISTORY: 

No h/o Diabetes,Tb,seizures,Asthma,Epilepsy, ofCoronary artery disease.

PERSONAL HISTORY:

patient has mixed diet, sleeps adequately,has decreased appetite, normal bowel and bladder movements, used to drink alcohol occasionally since 20 years but has stopped drinking 3 years back ,not a smoker.

GENERAL EXAMINATION:

Patient is conscious, coherent and cooperative

Oriented to person, not to time and place

Appears to be malnourished

No signs of pallor,icterus,cyanosis, clubbing, lymphadenopathy,edema

VITALS: 

Patient is afebrile

BP-130/70mmhg

Pulse-95 bpm

RR-16 cpm

Grbs-146mg/dl

Spo2-98%

SYSTEMIC EXAMINATION:

RS   - BAE +,NVBS

CVS-S1 S2 heard, no murmurs heard

P/A -soft, non tender

CNS--

MMSE

Orientation   1/5

 Registration 1/5

Attention calculation 0/5

Recall  0/3

Language 2/2

3 stage command 3/3

Total score 9/30

HIGHER MENTAL FUNCTIONS

Speech is slurred 

Fluency is decreased

Comprehension- present

Repetition          -present

Naming    -intact

Writing   - patient is illiterate but Is able to write his name

Lobar function tests

Parietal lobe:Ideational apraxia-normal

           Right to left orientation-lost

          Finger agnosia-present

        Able to do Simple calculations.

        Visio spatial function -lost

Constructional apraxia -lost

Occipital lobe:

Prosopagnosia- absent..     patient is able to recognise known faces

Temporal lobe: 

Aphasia present

CRANIAL NERVES EXAMINATION

Sense of smell : not elicited

Visual Acuity: (+)

EOM Movements: (+)

Pupil Size: Normal

Direct and indirect Light Reflex +

Corneal Reflex:+, jaw jerk -normal

Ptosis: absent

Nystagmus-absent

Palatal movements - normal

Shrugging of shoulders-Present

No deviation of tongue

Motor System Examination 

Tone      Upper Limb             Lower Limb

Right          Normal               Normal 

Left             Normal              Normal 

Bulk         Right           Left

Arm             23 cms     23 cms   

Forearm      21 cms     21 cms

Thigh           36 cms     36 cms

Leg               26 cms     26 cms

Power  

Upper limbs-5/5

lower limbs-patient is able to get up from the ground, can climb stairs without any support

Hand grip 100% in both sides

Superficial Reflexes

                             Right     Left   

Corneal                  +            +

Conjunctival          +            + 

Abdominal             +            + 

Plantar                flexor     flexor

Deep Tendon Reflexes 

                                   Right      Left                                      Biceps                 3+           3+

       Triceps                 2+           2+

       Supinator             3+           3+

       Knee                     3+           3+

      Ankle                     2+           2+

    

Cerebellar Examination

Dysdiadokinesia: absent

Finger nose: no incoordination

Tandem walking: not elicitable

Sensory System Examination

Pain and temperature sensation-intact

Vibration sense-intact

Joint sense-could not be elicited

INVESTIGATIONS:

   

DIAGNOSIS 

-Neurodegenerative disease- Alzheimer's disease

TREATMENT:

  Inj: Optineuron 1 amp in 100 ml NS/iv/od 

Tab: donepezil 10mg od