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If you have completed case M, this is a review. Completion of this case will not be counted toward your assignment.
This case scenario assumes you are in a multi-specialty group practice. Your office staff includes a nurse and a laboratory/radiology technician. Your office group has a diagnostic x-ray machine and laboratory equipment to perform the tests listed.
One of your patients, Mr. Rodriguez, called requesting you to see his 73 year-old wife who accidentally took her husband’s antihypertensive medications this morning. Although she is feeling fine, you ask them to come to your office.
When Mr. and Mrs. Rodriguez arrive later that day, you inquire more about what happened. You are told that Mrs. Rodriguez "got confused" which medications she was supposed to take, and mistakenly took her husband’s pills. She apparently took his metoprolol (Lopressor) 50 mg pill. Mrs. Rodriguez has no history of blood pressure problems, and she is normotensive and not bradycardic at this time.
Mrs. Rodriguez has been asymptomatic since taking her husband’s medication and her blood pressure and pulse are within normal limits. Since metoprolol has a half-life of 3 to 7 hours, you feel comfortable that she is not in any immediate danger from the medication. However, let us consider some important questions that are now running through your mind.
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Now let’s see Mrs.
Rodriguez. You were given the history that she accidentally took her
husband’s anti-hypertensive medication this morning. She experienced no
symptoms of dizziness or lightheadedness. She states that she feels fine.
PMH: COPD with an O2 requirement, hyperlipidemia Allergy: NKDA Medications: theophylline, guaifenesin, prednisone, atorvastatin, and potassium tablets Family history: Patient’s mother became "very confused" in the years prior to her death. Social history: Smoked one pack of cigarettes a day for 50 years until quitting 3 years ago, denies alcohol or drug use. Lives in the area with her husband. Patient has a 53 year-old son who is divorced and living in Florida, and a 49 year-old daughter who is married and living in Maryland; patient does not have any grandchildren. Review of Systems: Patient denies any fevers or unintended weight loss, denies recent head trauma or headaches, denies any cough, SOB, or increased DOE. Patient admits she does not always use her supplemental O2. No diarrhea, constipation, nausea, or vomiting. Patient also denies urinary frequency, urgency, or dysuria. HEENT: Normocephalic, atraumatic, pupils equal and reactive to light, extraocular motions intact. Canals are clear, and TMs are clear and intact bilaterally. Oral mucosa is moist and without lesions. Neck is supple, non-tender, no JVD. Trachea midline. No masses noted and no adenopathy. Chest is generally clear to auscultation, though a few scattered rales are noted. Reasonable air exchange. Cardiac regular rate and rhythm, no murmurs appreciated, no S-3 or S-4. Abdomen: Bowel sounds are present, soft, non-tender, non-distended, no masses, no CVA tenderness, no organomegaly appreciated. Extremities are without cyanosis, clubbing, or edema. Palpable dorsalus pedus pulse present bilaterally. Neuro: muscle strength 5/5 globally, DTRs 2+ and equal throughout, CN II-XII grossly intact, no focal deficits apparent. At this point, you decide to evaluate Mrs. Rodriguez’s mental status
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Mental Status Examination:
Appearance – Mrs. Rodriguez appears her stated age, and is in no acute distress. Posture – good, sitting upright on examination table. Facial expression – appropriate Attitude – cooperative and optimistic Affect – happy Mood – "very good" Speech – coherent, though somewhat slow Thought process/content – clear and logical Orientation – fair; Mrs. Rodriguez is oriented to person and place, but not to time Memory – remote memory intact, but some difficulty with recent memory Intelligence – estimated as average |
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Mrs. Rodriguez has some impairment in orientation, attention and calculation, and recall. She is unsure of both the day and date (minus 2 points), is unable to count backwards from 100, by 7’s, despite her high school education (minus 5 points), and only identifies one of the three items she learned previously (minus 2 points). Therefore, she scores a 21/30 on the Mini Mental Status Exam. Because any score less than 28 is not considered normal, you are concerned about Mrs. Rodriguez’s function and want to investigate possible etiologies of her cognitive impairment. |
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Mrs. Rodriguez has the blood tests drawn in
your office, and the UA results are available immediately:
UA: Cloudy, + leukocyte esterase, trace blood on dip stick; microscopic exam showed many bacteria, 3+ WBCs, 1+ RBCs, These findings of bacteria, WBCs, RBCs, and leukocyte esterase in the urine are consistent with a urinary tract infection. |
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You advise Mr. and Mrs. Rodriguez
of the results of her UA, and tell them that you believe she has a urinary
tract infection. Although you suspect that there may be some underlying
dementia, you realize that an accurate evaluation is difficult while she
has the urinary tract infection. You prescribe 7 days of TMP/SMX for Mrs.
Rodriguez and ask her to come back to your office in 10-14 days for
further evaluation. Because Mrs. Rodriguez has no evidence of a focal
neurological lesion and no history of trauma, you decide not to pursue a
CT or MRI at this stage.
When Mr. and Mrs. Rodriguez return to your office in two weeks, you inform them that all of the blood work was normal. Mrs. Rodriguez had no difficulty with the antibiotic you prescribed for her, and a repeat UA is now negative. You decide to talk to the two of them about Mrs. Rodriguez’s "forgetfulness." Upon questioning, Mr. Rodriguez admits that his wife has had difficulty remembering things for the past few years, and that it has been worsening for several months. She recently left the stove on for several hours before Mr. Rodriguez discovered it. Also, she stopped driving alone earlier this year after becoming lost several times while driving home from church, which is located just a few blocks from their home. You decide to repeat the Mini Mental Status Exam now that Mrs. Rodriguez’s urinary tract infection has apparently resolved. Her orientation has improved slightly, and she now scores a 23/30 on the exam. Because her score is still lower than what you would expect, you are concerned about other causes of mental status impairment. |
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| Mr. Rodriguez tells you that despite the fact that his wife does not like using the O2 supplementation, he has encouraged her to use it most of the time. She is followed very closely by her pulmonologist, who feels that she is doing quite well. |
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| Mrs. Rodriguez denies any of the signs/symptoms of depression, and states that she is "fortunate to have so much when others have so little." |
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The Alzheimer’s Association has developed a list of warning
signs that include common symptoms of Alzheimer’s disease:
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| Many patients are taking herbal products and alternative treatments such as Vitamin E, Ginkgo biloba, and Huperzine A that are being marketed for memory enhancement. Some of these products are relative safe, but others may have serious drug interaction and side effects. It is important to inquire about usage of these products in our patients. |
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