医学专业英语课件_2

CASEPRESENTATIONDr.LU,QINCHIDEPARTMENTOFNEUROLOGYRENJIHOSPITALSHANGHAIJIAOTONGUNIVERSITYSCHOOLOFMEDICINETel:[phone]Email:[e-mail]68-year-oldwomanhasbeennotedbyherdaughtertohavememorylossandconfusion.Thedaughterstatesthathermotherhasbeengoing“downhill”forthepastseveralmonths.Themotherhaslivedonherownformanyyears,butrecentlyshehasbeguntobecomeunabletotakecareofherself.HistoryThedaughterstatesthathermotherhasbecomewithdrawnandhaslostinterestinherusualactivities,suchasgardeningandreading.Hermother’smemoryispoor,andsheisoftenfatigued.Thepatientstatesthatshesleepswellatnightandthatherappetiteisgood,althoughshehaslost10lboverthepast6months.Shedeniesbowelandurinaryincontinence.HistoryThepatient’spastmedicalhistoryissignificantforhypertensionforwhichshehasbeentakinghydrochlorethiazide.Thepatientwaslasthospitalized35yearsagowhensheunderwentatotalabdominalhysterectomywithbilateralsalpingo-oophorectomy.Thepatienthasenjoyedoverallgoodhealth.Shedoesnotsmokeordrink.PhysicalExamOnexamination,herbloodpressureis116/56mmHg,herheartrateis78bpm,hertemperatureis37.5。C,andherrespiratoryrateis18breathsperminute.Sheweighs88kgandherheightis1.62m.Thepatientisawell-developedwhitewomenwithaflataffect.Sheisorientedtoperson,butsheisnotorientedtotimeandplace.Pyhsical&NeuroExamMiniMentalStatusExaminationgivesascoreof18outof30.Theheadandneckandcardiovascularexaminationareunremarkable.Abdomenisbenignwithouthepatosplenomegaly.Theextremitiesarewithoutedema,cyanosis,orclubbing.Theneurologicexaminationrevealsthatthecranialnervesareintact,andthemotorandsensoryexamsarewithinnormallimits.Cerebellumexaminationisunremarkableandthegaitisnormal.QuestionsWhatisthemostlikelydiagnosis?Whatarethenextdiagnosticsteps?Whatisthebesttreatmentforthiscondition?Summary:A68-year-oldwomanhasmemoryloss,confusion,andfatigue,andiswithdrawn.Shehadaflataffect.Sheisorientedtoperson,butsheisnotorientedtotimeandplace.Theremainderoftheexamination,includingneurologicalexamination,isnormalexceptforalowscoreontheMMSE.Mostlikelydiagnosis:Alzheimerdementia.Nextdiagnosticstep:Assessfordepressionandreversiblecausesofdementia.Probabletreatment:AcetylcholinesteraseinhibitorAnalysisObjectivesKnowsomeofthecommoncausesofdementiaUnderstandthepresentationanddiagnosisofAlzheimerdementiaKnowthetreatmentforAlzheimerdementiaisacetylcholinesteraseinhibitorConsiderationsThisisanelderlywomanwithoutanysignificantpastmedicalhistoryexceptforhypertensionwhowasbroughttoyourofficewithahistoryofprogressivefunctionaldeclineandmemoryloss.Thefirststepshouldbetoruleoutdepression.Depressionintheelderlymayhaveapresentationverysimilartothatofdementiawithwithdrawal,apathy,irritability,memoryimpairment,andconfusion.ConsiderationsThenextstepshouldbetoruleoutallthepossiblecausesofreversibleorarrestabledementia,suchasmulti-infarctdementia,hypothyroidism,drugs,B12deficiency,normalpressurehydrocephalus,alcoholism,HIV,andsyphilis.ConsiderationsLaboratorytestswillhelpyoutoeliminatesomeofthesecommoncausesofreversibledementia:completebloodcount(CBC),comprehensivemetabolicpanel,thyroid-stimulatinghormone(TSH),urinalysis,serologictestforsyphilis,andaheadCT(seetable49-1).Table49-1ABBREVIATEDWORKUPFORDEMENTIACompletebloodcountandconsidererythrocytesedimentationrate(ESR)ChemistrypanelThyroid-stimulatinghormonelevelVenerealDiseaseResearchLaboratory(VDRL)HIVassayUrinalysisSerumvitaminB12andfolatelevelsChestradiographElectrocardiogramCTorMRIimagingoftheheadConsiderationsThepossibilityofHIV-induceddementiaisnothighonthedifferentialinthiscasegiventhepatient’sage,butitwouldcertainlybeaconsiderationinyoungerpeople.PossibleinfectiouscausesofreversibledementiaincludenotonlyHIVbutalsoneurosyphilis.Therefore,aserologictestforsyphilisisindicated.ConsiderationsBecauseourpatientdoesnothaveahistoryofchronicalcoholism,wecanruleoutthiscondition.TheCBCandmeancellvolume(MCV)arenormal,asistheTSH,eliminatingthepossibilitiesofvitaminB12deficiencyandofhypothyroidism.Thepatientisonlytakinghydrochlorothiazide,whichisnotassociatedwiththedescribedmentalstatuschanges.ACTheadscancanassessforbrainlesions,multipleinfarcts,andhydrocephalus.ConsiderationsTherefore,inthiscaseweareleftwiththepossibilityofmulti-infarctdementiaandAlzheimerdisease.Multi-infarctdementiadevelopslaterinlifeandiscausedbydiffusecerebrovasculardisease.Mostofthepatientswillhaveahistoryoftransientischemicattacksandstrokes,andstepwiseprogressionofdementiawhichourpatientdoesnotreport.Inthisparticularcase,Alzheimerdementiabecomesthemostlikelydiagnosis.APPROACHTODEMENTIADefinitionsAlzheimerdisease:Theleadingcauseofdementia,accountingforhalfofthecasesinvolvingelderlyindividuals,correlatingtobrainatrophywithventricularenlargement.Dementia:Progressiveandgeneralizeddeclineofintellectualabilityfromapreviouslyattainedlevel,usuallywithoutalterationofconsciousness.DefinitionsMultiinfarctdementia:Numeroussmallcerebralvascularaccidents,mostcommonlycausedbyatheroscleroticdisease,leadingtodementia.Normalpressurehydrocephalus:Reversibleformofdementiawherethecerebral