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


This is an online E log book to discuss our patient's de-identified health data shared after taking his/her/guardian's signed informed consent. 

Here we discuss our individual patient's problems through series of inputs from available global online community of experts with an aim to solve those patient's clinical problems with collective current best evidence based inputs. 

This E log book also reflects my patient-centered online learning portfolio and your valuable inputs on the comment box is welcome.
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


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