History of Present Illness
Mr. X is a 53-year-old male who presents to you with memory loss and blackouts. His wife thinks he has Alzheimer’s disease. She states that over the last year, Mr. X has become more and more forgetful. He used to take care of the family finances and run his own business out of his home until his memory loss forced him to turn the finances over to his wife and quit his business. Mrs. X also states that he forgets appointments and phone calls, sometimes just after he hangs up the phone.
His wife states that last week he blacked out while driving home from the grocery store, ran a stop sign and hit a parked car. No one was injured, but the episode scared them both.
Mrs. X states that over the last year, her husband has had problems walking. Although he was never very active prior to this, he has become more sedentary and prefers to sit in his recliner all day. Over the last 6 months, he has used a walker to get around the house.
He also reports urinary incontinence over the last 6 months. Mr. X describes it as “not being able to control it.”
Past Medical History
Unremarkable except for the report of a prior head injury with no loss of consciousness occurring last year.
He reports a 60 pack year smoking history, starting when he was 23. His alcohol consumption consists of about a case of beer a week.
Mr. X’s father died at the age of 49 from a heart attack. His mother is still alive and is in a nursing home. She moved there after having a stroke 3 years ago. His brother and sister are in good health.
Height: 5’11″ Weight 293
HEENT: Within normal limits
Biceps: 5/5 bilaterally
Triceps: 5/5 bilaterally
Quadriceps: 3/5 bilaterally
Hamstrings: 3/5 bilaterally
Pin-prick and temperature sensation and simple touch are intact. Vibration is normal in upper extremities, but diminished in lower extremities bilaterally.
Biceps: 2+ bilaterally
Brachioradial: 2+ bilaterally
Patellar: 3+ bilaterally
Ankle: 4+ bilaterally
Plantar Response: Extensor bilaterally
Proprioception and Cerebellar Function:
Finger to finger: normal
Heel to shin: normal
Rapid alternating movements: normal
Joint position: normal
Mr. X’s gait is abnormal, walking in a shuffling manner. He is mildly ataxic.
II-XII are intact.
Patient seems confused. He is oriented to person, but not place or time. He exhibits dyscalculia. Remote memory is intact, yet immediate recall is impaired. When asked to act out combing his hair or shaving, the patient could not do so. Complex commands were difficult for the patient to follow. Judgment was impaired as was the ability to describe simple analogies.
What is your Differential Diagnosis?
Reflect on the information you have gathered thus far.
* Chief complaint: memory loss and black outs
* Other major symptoms: urinary incontinence, trouble walking
* Items noted from history: 60 pack-year smoking history, alcohol abuse issues, head injury within the last year
* Abnormalities noted from the physical and neurological exam:
- decreased strength bilaterally in lower extremities,
- diminished vibratory sensation bilaterally in lower extremities,
- increased reflexes bilaterally on patellar and ankle reflexes,
- plantar reflex was extensor bilaterally,
- mild ataxia,
- shuffling gait,
- patient is confused and not oriented to place or time,
- impaired immediate recall,
- task apraxia,
- impaired judgment,
- could not follow simple commands.
Once the diagnosis of NPH was made, a neurosurgical consult was obtained and placement of a shunt was recommended. After discussing the risks and benefits with Mr. X and his wife, they agreed to the placement of a ventriculoperitoneal shunt.
Two Weeks Later
Mr. X returns 2 weeks after surgery during a follow-up appointment. He reports that his walking has become much easier since the his operation. This is evident on observation of the patient’s gait. He also notes that his incontinence has resolved. Mrs. X states that his memory is a little better but not back to normal.