Medical-Mystery Writing Guide for Developing Clinical Teaching Cases for Geriatric Education

Kevin Craig, MD, MSPH Assistant Professor Curtis W. and Ann H. Long Department of Family and Community Medicine University of Missouri

Michael Hosokawa, EdD Professor Curtis W. and Ann H. Long Department of Family and Community Medicine University of Missouri

Steven Zweig, MD, MSPH Professor and Chair Curtis W. and Ann H. Long Department of Family and Community Medicine and Director, Interdisciplinary Center on Aging University of Missouri

David Oliver, PhD Deputy Director Interdisciplinary Center on Aging University of Missouri

Ronald Freeman, PhD Emeritus Professor Medical Pharmacology and Physiology University of Missouri

This document is available through POGOe. Permission to duplicate in bulk must be obtained through the Curtis W. and Ann H. Long Department of Family and Community Medicine, University of Missouri. Contact: Michael Hosokawa, [email protected]. The Medical-Mystery Writing Guide for Developing Clinical Teaching Cases for Geriatric Education

The inquiry-based learning strategy is focused on three components: An authentic clinical case modified as a teaching tool, the group of 6-10 learners, and a facilitator-usually a faculty member. Creating a case requires clinical acumen, a strong foundation in the basic sciences, experience in caring for the elderly and the talents of John Grisham, Patricia Cornwell, James Patterson and Tess Garritson.

The purpose of this guide is to help case writers achieve better consistency in their approach to authoring teaching cases. A case should provide the information in a way that prompts the students to problem solve and learn without leading them to the answers. The key is to provide a timely unfolding of information to facilitate learning—the case becomes the catalyst.

Principles of Inquiry-based Learning

 Life is about solving problems  Not all problems have one right answer or one pathway to the answer  An important skill to learning is seeking information. The information needed for a case may reside within the group (not always correct information) or must be researched  To research information, it is essential to formulate the questions  Members of the group teach each other.  The facilitator is not a content expert, but rather uses Socratic questioning to stimulate thinking.  The case unfolds simulating clinical problem solving

University of Missouri Principles of Geriatric Care

 Multidisciplinary: Value the unique contributions of each team member  Family caregivers: Respect the importance of family caregivers and their needs.  Evidence-based: Strive to be evidence-based in the conduct of practice  The right drugs: Attend to the principles of geriatric pharmacology and avoid polypharmacy.  Cost effective: Consider costs in diagnosis/treatment of acute/chronic disease  Quality of life and function: Improve/sustain quality of life and function  Relationships: Acknowledge the doctor-patient relationship based on mutual respect, communication, trust and continuity.  Advocacy: Advocate across settings of care, eliciting and implementing goals of care, and committing to service/quality principles  Ethics: Uphold ethical principles of autonomy/beneficence/non-maleficence/justice.  End-of-life care: Preserve the health and autonomy of older persons knowing that decline, disability, and death are inevitable stages of aging.

-2- Developing a Case

Select a patient chart that contains ample information that can be de-identified and included in the case. In the initial draft, provide as much of the information as possible. Some additional information may be needed and you can make notations. Some information will not be needed as you refine the case, but at this stage having more information than you need is more helpful.

Each case contains notes and helpful hints to the facilitator strategically placed throughout the case. Notes and hints to the facilitator may include questions to ask the group, basic science information (some facilitators may not be current in the basic sciences), information about the clinical-decision process (some facilitators are not physicians) or up-dated, evidence-based information relevant to the material presented in the case.

Developing Case Objectives and Take-home Points

Benjamin Bloom’s taxonomy described a hierarchy of learning beginning at the basic level of knowledge or memorized information, comprehending or understanding, application of information in the appropriate context, analysis of information by breaking into component parts, synthesis by creating new information by combining parts and evaluation by placing relative value on information. More recently, (see below), the Bloom’s Taxonomy has been revised so evaluating information precedes the synthesis or creation of information

Terminology changes "The graphic is a representation of the NEW verbage associated with the long familiar Bloom's Taxonomy. Note the change from Nouns to Verbs [e.g., Application to Applying] to describe the different levels of the taxonomy. Notoe that the tp two levels are essentially exchanged from the Old to the New version." (Schultz, 2005) (Evaluation moved from the top to Evaluating in the

-3- second from the top, Synthesis moved from second on top to the top as Creating.) Source: http://www.odu.edu/educ/llschult/blooms_taxonomy.htm .

Applying Bloom’s Taxonomy

What important points do you want the students to know when they complete the case? These intended outcomes or objectives should guide the development of your case.

Objectives might be written as: The student will be able to ______.

Verbs such as describe, identify, list, label, solve, compare, demonstrate, compute, perform, and draw make an objective measurable or observable. Verbs such as understand, know, appreciate, improve, perceive, reflect, master, and comprehend are more difficult to measure.

The objectives should be further defined by setting performance standards such as: correctly identify 3 of 5, or correctly compute the incidence rate.

 Basic-Science Objectives: What are the basic-science objectives for your case?

 Clinical Objectives: What are the clinical objectives for your case?

 Psychosocial Objectives: What are the psychosocial objectives for your case?

 Other Objectives: What other objectives should students learn from your case?

Geriatric Competencies for Medical Students

Incorporate appropriate geriatric competencies into your case. The following list of 26 competencies was developed by a systematic, multi-method process of identifying and defining the minimum competencies needed by a new intern to adequately care for older adults. It was published in Academic Medicine in 2009 (Leipzig RM, Granville L, and Simpson D: Keeping Granny Safe on July 1: A Consensus on Minimum Geriatrics Competencies for Graduating Medical Students. Acad Med. 2009; 84:5:604-10).

Medication Management

1. Explain impact of age-related changes on drug selection and dose based on knowledge of age-related changes in renal and hepatic function, body composition, and central nervous system sensitivity. 2. Identify medications, including anticholinergic, psychoactive, anticoagulant, analgesic, hypoglycemic, and cardiovascular drugs that should be avoided or used with caution in older adults, and explain the potential problems associated with each. 3. Document a patient’s complete medication list, including prescribed, herbal, and over-the-counter medications, and, for each medication, provide the dose, frequency, indication, benefit, side effects, and an assessment of adherence.

Cognitive and Behavioral Disorders

4. Define and distinguish among the clinical presentations of delirium, dementia, and depression.

-4- 5. Formulate a differential diagnosis and implement initial evaluation in a patient who exhibits dementia, delirium, or depression. 6. In an older patient with delirium, urgently initiate a diagnostic workup to determine the root cause (etiology). 7. Perform and interpret a cognitive assessment in older patients for whom there are concerns regarding memory or function. 8. Develop an evaluation and nonpharmacologic management plan for agitated demented or delirious patients.

Self-Care Capacity

9. Assess and describe baseline and current functional abilities (instrumental activities of daily living, activities of daily living, and special senses) in an older patient by collecting historical data from multiple sources and performing a confirmatory physical examination. 10. Develop a preliminary management plan for patients presenting with functional deficits, including adaptive interventions and involvement of interdisciplinary team members from appropriate disciplines, such as social work, nursing, rehabilitation, nutrition, and pharmacy. 11. Identify and assess safety risks in the home environment, and make recommendations to mitigate these.

Falls, Balance, Gait Disorders

12. Ask all patients _ 65 years old, or their caregivers, about falls in the last year, watch the patient rise from a chair and walk (or transfer), and then record and interpret the findings. 13. In a patient who has fallen, construct a differential diagnosis and evaluation plan that addresses the multiple etiologies identified by history, physical examination, and functional assessment.

Health Care Planning and Promotion

14. Define and differentiate among types of code status, health care proxies, and advance directives in the state where one is training. 15. Accurately identify clinical situations where life expectancy, functional status, patient preference, or goals of care should override standard recommendations for screening tests in older adults. 16. Accurately identify clinical situations where life expectancy, functional status, patient preference, or goals of care should override standard recommendations for treatment in older adults.

Atypical Presentation of Disease

17. Identify at least three physiologic changes of aging for each organ system and their impact on the patient, including their contribution to homeostenosis (the age-related narrowing of homeostatic reserve mechanisms). 18. Generate a differential diagnosis based on recognition of the unique presentations of common conditions in older adults, including acute coronary syndrome, dehydration, urinary tract infection, acute abdomen, and pneumonia.

Palliative Care

19. Assess and provide initial management of pain and key nonpain symptoms based on patient’s goals of care. 20. Identify the psychological, social, and spiritual needs of patients with advanced illness and their family members, and link these identified needs with the appropriate interdisciplinary team members. 21. Present palliative care (including hospice) as a positive, active treatment option for a patient with advanced disease.

Hospital Care for Elders

22. Identify potential hazards of hospitalization for all older adult patients (including immobility, delirium, medication side effects, malnutrition, pressure ulcers, procedures, peri- and postoperative periods, and hospital acquired infections) and identify potential prevention strategies. 23. Explain the risks, indications, alternatives, and contraindications for indwelling (Foley) catheter use in the older adult patient. 24. Explain the risks, indications, alternatives, and contraindications for physical and pharmacological restraint use. 25. Communicate the key components of a safe discharge plan (e.g., accurate medication list, plan for follow-up), including comparing/contrasting potential sites for discharge. 26. Conduct a surveillance examination of areas of the skin at high risk for pressure ulcers, and describe existing ulcers.

-5- The Development of the Case

Case History and Physical Exam

How did the patient present? If relevant, include the patient’s affect, appearance and comfort. Also, use the patient’s language (e.g., very few patients use words such as with “syncope” or “lymphadenopathy.”

History

 Age, gender, race/ethnicity, if relevant

 Time of the day, month or season, if relevant

 Setting if relevant (primary care, ER, consult service, community hospital, tertiary-care center). Cases should be consistent with the healthcare system, i.e., a patient would not present for the first time to a sub-specialist without background on the referral.

 History of the Present Illness (HPI)

 Chief Complaint (CC)

 Pertinent positive and negative review of systems (ROS)

 Allergies

 Medications

 Past medical history (PMHx) with dates and details (controlled HTN, uncontrolled DM Type II)

 Past surgical history (PSHx)

 Social history (SHx) including SES

 Family history (FmHx)

 ROS (not already mentioned in the HPI)

In your notes to the facilitator, it is helpful to suggest other Hx questions that might be asked, a problem list and the DDx based on the Hx and other thoughts and observations a physician might make with this patient.

-6- The facilitator would ask “What would you do next?” List helpful information for the facilitator on appropriate and inappropriate next steps. As an example, a focused or comprehensive physical exam is usually an appropriate next step. An MRI as the next step is usually not appropriate.

Include notes to the tutor on what the students should especially look for in the physical examination (based on the history that was taken and on the problem list that is being formed). Include pertinent positive and negative findings. How would the differential diagnosis be modified by the physical examination?

Physical Exam

 Ht, Wt

 Vital signs: BP, P, R, Temp. Pain (0-10 scale)

 Appearance: Describe the way the patient looks, i.e., sick, toxic, in extremis, well, disheveled, pale, flushed, etc.

Physical Exam Findings (Subjective)

 A description of the physical examination findings.

Objective Data  Lab tests  Diagnostic tests  Imaging studies  Past records

Providing lab-test results, diagnostic tests such as an EKG or images help the students to learn the purposes, appropriate use, interpretation and costs of these tests.

Patient data should be presented as completely as possible. Interpreting these data and incorporating the information with the H&P are part of hypothesis testing.

Normal ranges should be provided for special tests or tests not used commonly in the hospital and clinics. The more common lab values and test interpretations should be researched by the students.

Make notes to the facilitator on what objective data the students should want and the medical justification for each. Tutors should require the students to create priorities, and it would be helpful to the tutors to have information on how the priorities would be developed.

-7- Changes in the DDx

New data may change the differential diagnosis by deleting, adding or re-ordering the possible Dx.

Comprehensive Problem List

Assist facilitators in guiding the student to a working diagnosis by using a questioning strategy weaving in the HPI, PMHx, Px, and basic science principles.

Working Diagnosis

Interpreting lab tests, diagnostic tests and images are skills the students should have developed. Provide assistance to the tutor on the pertinent negatives and positives and how they are related to the DDx. Tutors need to know how the DDx might change with the addition of the objective data. Students should put together a comprehensive problem list and the tutor may need assistance in guiding the students.

Provide a working Dx incorporating the available information. Include the patient's status, the response and roles of family members, psychosocial issues that must be addressed, issues with compliance, cross-cultural information, and health beliefs.

Based on the working diagnosis, what were the next steps in the diagnosis and management of the patient?

Provide the facilitator with information useful in promoting a discussion. In some cases, the Dx is not definitive and initiating treatment is the way the diagnosis is confirmed. This may be a difficult concept for a non-physician facilitator. How was the management plan developed? Students need to understand evidence-based medicine and they should search the literature and also be able to critically read the medical literature. A good review article may be included in the tutor guide as a way of providing background.

-8- Diagnosis and Management Plan

Once the diagnosis is confirmed, challenge the students to develop a management plan. Selection of drugs, cost effectiveness of the interventions, invasiveness and the patient's discomfort are factors to be considered. Students should be motivated to seek evidence- based data sources and critically read the literature.

It is helpful to the facilitators to have questions or prompts for the students. These questions are most valuable when they require the students to be analytical in their thinking, to evaluate alternative strategies and problem solve.

Wrap-up

The purpose of the PBL cases in the pre-clerkship years is to teach the basic sciences in a clinical context. As examples:

 It is more important for students to learn the action of drugs rather than knowing brand names and generics.

 The focus for a case should be on describing the normal electrophysiology of the heart and the consequences when the electrical function is disturbed than to diagnose and manage atrial fibrillation.

 Emphasis should be placed on the basic science behind an elevated BUN rather than polycystic kidney disease.

 Why is a patient acidotic?

 Does a low hematocrit always mean anemia?

 What is the physiology of disseminated intravascular coagulation (DIC) and what are the basic science principles underlying the management?

 What is the physiology of restrictive and obstructive lung disease?

Going back over the information you have provided, how did this case unfold? What was the timing of the significant events?

At what point should the students begin to narrow the DDx? What are the key findings that should lead the student to the possible diagnoses, and how should the hypotheses be developed? What are the most important findings in the Hx, physical exam and tests that led to the diagnosis?

-9- What information would rule in or rule out other diagnoses? Be sure to include information about the patient's emotional state, the costs of care, and the roles of family members, social supports, community resources and health beliefs.

Page by page, the case should unfold modeling your clinical problem solving. A red herring or two makes a case interesting and challenges the students.

Make your case interesting. You may be the next John Grisham!

At this point, key basic-science concepts should be reviewed as well as the clinical problem solving. Unless the patient is cured, a follow-up plan should be discussed.

Finally, referring back to your objectives, eight-to-ten "take-home" points should have been covered in the case.

Common weaknesses in clinical teaching cases:

1. Many cases present patients with a single problem.

Few actual patients present with one problem. Consider co-morbidity, stressors, compliance issues, psychosocial dilemmas, risk factors, family medical histories, substance abuse and community factors that contribute to the case presentation.

2. The complexities of diagnosing and managing chronic diseases are overlooked

Patients with chronic conditions must adapt their lifestyles to accommodate treatment regimens, medications, and risk factors.

3. The importance of a history and physical exam are overlooked.

4. Many cases guide the learners through only a limited differential diagnosis.

Students need to learn to take the history of the present illness, develop a problem list and apply basic science principles to the development of an appropriate differential diagnosis.

-10- 5. Cases are too directive and provide information rather than facilitate problem solving.

To ask, "What would you do next?" stimulates thinking rather than, "A PFT was ordered.”

6. The importance of pertinent negative lab tests is often overlooked.

Novice learners commonly peruse the lab results looking for findings outside the normal ranges they have been given. Rather than developing an overview that incorporates positive and negative findings, the students focus on the positives. A negative or normal test can be as important as an abnormal test.

7. Selecting diagnostic tools and justify tests consistent with good patient care and cost are important skills that should be incorporated into the case.

Learners should be required to select appropriate diagnostic tools with the knowledge of the basic science and clinical justification as well as justifying the costs. The timing of tests and procedures should be clinically correct as well as consistent with guidelines for reimbursement. Learners should be able to discuss specificity and sensitivity and incorporate evidence-based medicine.

8. Too often cases focus on attaining the diagnosis and do not carry forward to developing the management plan including medications, procedures, convalescence, discharge to home and community and follow-up care.

Learners should be encouraged to seek evidence-based management data sources, read critically in the literature and weigh costs and quality care and understand the health-care system.

9. Students often ignore psychosocial issues, family dynamics, community resources and health-care costs.

There is a tendency to gloss over these issues as not relevant to medicine. Frequently, patients' problems improve or resolve if psychosocial issues are addressed.

10. Cases should model team care and knowledge and appreciation for the contributions other health professionals make to the care of patients.

Each member of the health care team makes a special contribution to the care of the geriatric patient. The physician is not always the team leader.

-11- Checklist

Does the introductory information provide enough information (HPI) to stimulate thinking and identification of additional information needed (such as family history, medications or occupation)?

Does information included in the next pages include information that might be requested by the students? Do these pages provide relevant information that prompts thinking and problem solving which moves the case forward? Do these pages also include possibly irrelevant or extraneous information that prompts thinking and problem solving?

Does information provided in the case prompt requests for tests and additional objective information? Information should require students to identify specific laboratory tests or other tests although a CBC or Lipid Profile includes a set of measures. Is the information, such as lab test results) authentic? Test results can be borderline rather than clearly positive or negative.

Does information provided advance the clinical problem-solving through the development of a differential diagnosis and working diagnosis?

The working diagnosis does not always have to be the final diagnosis.

Are the students required to develop a treatment plan from possible choices that are evidence-based?

Are students required to develop a follow-up plan?

Does the case include the roles of other health professionals?

Are family or other caregivers included in the diagnosis and treatment of the patient?

Are students required to evaluate the literature developing the diagnosis and management of the patient.

Are the students required to consider relative costs and effectiveness in the choice of tests, additional health services, drugs and devices and admissions, referrals and consults.

Is there a transition plan from clinic/hospital to home or community resources?

Is quality of life and function considered in the treatment plan?

Is there evidence of the advocacy role of health professionals?

Are the concepts and details of end-of-life care, palliative care and allocation of health care resources included in the case where appropriate?

-12- Below is a sample case developed by the University of Missouri as part of their first Donald W. Reynolds Foundation grant project.

History of Present Illness

Douglas Kramer, a 67 year-old man, presented for Senior Assessment Geriatric Evaluation (SAGE) visit. His daughter, Jamie, who accompanied him, scheduled the visit. He had no particular concerns, but Jamie had concerns regarding his failing memory, some near miss motor vehicle accidents, and her dad getting lost driving from Arkansas to visit her in Columbia. She also commented that several people who knew him when he worked had told her that his memory was failing and that she should be pursuing guardianship. She had taken over paying some of his bills, with his permission, and he seemed to appreciate this greatly.

Review of Systems He had intentional weight loss with diet from 277 lbs. a year ago, down to 243 lbs. six months earlier. Back up to 246 lbs. last month. He denied anorexia, fatigue, headaches or insomnia. He has long-standing visual impairment in right eye from glaucoma diagnosed two years ago. No dental or denture discomfort. Denied chest pain or orthopnea. Long- standing edema that had been controlled with use of support hose. No claudication. Possible syncopal episode in 1995. No abdominal pain or constipation. Occasional urge incontinence for about the last year. Nocturia which had been stable once to twice per night. He had aching in hips, more so in knees, for years and Naprosyn helped this. He related this to trauma as a child when he fell out of trees and broke bones in legs. He had some problems with dizziness and unsteadiness several months ago which had been gradually improving without medical intervention. He tripped and fell over dog a few months ago when working on a trailer. No focal weakness or sensory loss. He denied forgetfulness but daughter indicated that wife had some concerns about memory as long as two years ago, and that carotid surgery was done last summer in hopes of improving his memory. No history of disruptive behavior or wandering. He denied depression, and his daughter did not think he was depressed.

Past Medical History

Allergies: Penicillin – causes hives, swelling.

Hospitalizations: In Texas two years ago for assessment of syncope.

Surgery hospitalizations: Right mastoidectomy at age 5. Tonsillectomy. Open Reduction/internal fixation of right finger fracture at 14 years old, and left lower leg Fracture at about 15 years old. Bilateral carpal tunnel release ten years ago. Carotid endarterectomy on left 1 year ago.

Injuries: Right finger fracture at 14 years. Left lower leg fracture at about 15 years old.

Chronic conditions: High blood pressure since age 50 years, well controlled.

-13- Arthritis in knees and hips with aching at times. Type 2 diabetes mellitus diagnosed at age 65 years; diet and oral agent controlled.

Immunizations: Doesn’t recall having received pneumococcal vaccine. Td booster 4 years ago. Gets flu shot every fall.

Medications: Lisinopril 20 mg qd, glyburide 5 mg qd, terazosin 2 mg qd, and naproxen 375 mg bid PRN for joint pain.

Family History: Adopted: History unknown

Social History: He received a law degree from UMC. Worked for the State of Missouri for his entire law career, eventually heading up legal service for Social Services, retired at age 62 when he moved to Arkansas with his wife. His wife died 6 months ago after 45 years of marriage. His hobbies include woodworking, carving and fishing – has not pursued these interests in last few months. Habits: quit smoking 11 years ago after two to three packs per day, onset about age 23 years. No recent use of alcohol with only a drink or two at dinners or meetings in the past.

For students:

What are your hypotheses? Why is consideration of depression important? What are potential causes of syncope? What are the next steps in management? Pharmacology- lisinopril, terazosin, naproxen, glyburide- classes, mechanisms. What is terazosin, how does it work, side effects, and what is it used for?

FACILITATOR GUIDE ONLY:

His history suggests progressive cognitive impairment over time. He seems to lack awareness of impairments.

Depression may present as “pseudodementia”, but generally these patients complain of memory loss. He has risk factors for vascular dementia (diabetes, hypertension, carotid artery disease). He has irritative voiding symptoms of Benign Prostatic Hypertrophy. Medications should always be considered as a possible cause for cognitive impairment. Students should demonstrate an ability to acquire information pertaining to drug side effects and drug-drug interactions by computer searches or other methods.

-14- Students should determine differential diagnosis for causes of syncope Table: Kapoor WN. Syncope. N Engl J Med; and be able to describe evaluations used to assess syncope. 2000:343(25):1856-1862.

Evaluate with history, physical exam with orthostatic BP’s, EKG.

Look for symptoms of pulmonary embolus, signs of aortic stenosis, history of palpitations or chest pain, signs of myocardial ischemia or infarction. Consider continuous cardiac monitoring (24 hr Holter or event monitor), echo, and stress testing.

Carotid sinus massage may be helpful.

Electroencephalogram may be helpful.

Physical Exam

Vital signs: Ht: 66 ½ ". Wt: 244 lbs. T: 97.80 F. R: 18/min. BP: 130/64 mmHg, P:74/min supine; 158/70 mmHg P: 80/min. standing

General: Alert, pleasant, white male in no acute distress. Appeared approximately his stated age.

Skin: Clear except for some superficial excoriations on forearms, right more than left and mild seborrhea over central brow area.

HEENT: He wore glasses with bifocals. Normal conjunctivae and sclerae. Pupils equally round and reactive to light and accommodation. Extraocular movements intact. No nystagmus. Fundi appear grossly normal; possible mild increased cup: disc ratio. Nose and throat are normal. He had upper denture and lower partial plate with remaining lower teeth in good repair. Ears with normal canals and TMs. Nose normal with septum midline. Mouth and throat normal with good native dentition.

Neck: Neck was supple with no masses or adenopathy. Scar on left. High pitched bruit over right carotid. No evident adenopathy. No jugular venous distension.

Lymphatic: No cervical, supraclavicular, axillary, or inguinal adenopathy.

Back: Normal, nontender, with no costovertebral angle tenderness.

Lungs: Clear to auscultation and percussion.

Heart: Regular rate and rhythm with no murmur. Normal S1 and S2, with S4 present.

Chest: Symmetrical, nontender. No obvious deformity.

-15- Abdomen: Normal bowel sounds. Soft with no palpable masses or organs. A bit protuberant, obese, supple and benign with no rebound tenderness or guarding.

Rectal: Normal tone and sensation. No masses. Prostate 40 grams, firm, smooth, nontender. Some light brown stool specks on exam glove; Hemoccult negative.

Extremities: No clubbing or cyanosis. 1+ pretibial edema bilaterally. Good and equal pulses throughout. No evident joint inflammation, but slight crepitation in knees. R knee has sagging with elevation and posterior drawer sign. Hips with good ROM.

Neurologic: Cranial nerves II through XII intact. Cerebellar testing showed normal finger- to-nose and rapid alternating movements. Deep tendon reflexes were 2+ and equal throughout except a bit diminished in ankles. Vibratory sense was normal throughout. No pathologic reflexes noted. Sharp/dull discrimination was intact in all extremities. Light touch sensation was intact but he had decreased sensation distally in feet and toes. Romberg was normal. Pt. had good strength throughout with normal get up and go test, normal gait, arm swing, and normal turns.

Mental Status: Mini-Mental State Exam score was 21 of 30, with deficits in time and place orientation (-3, or 7 of 10), recall (-3, or 0 of 3), and attention (-3, or 2 of 5). Yesavage Geriatric Depression Scale score was 4/15.

—What is the Mini-Mental Status Exam? How are scores affected by age or education? —What are the abnormalities? —What are the pertinent negatives? —What is your differential diagnosis at this point? —What could be causing the mental status abnormalities? —Could a single CNS lesion account for his deficits? —What are the next steps in management? What tests do you want?

FACILITATOR GUIDE ONLY:

Age and education level affect mental status scores. There are different cut-off scores for probable dementia based on these variables.

MMSE-Rev. Cutoff Scores Years of Education Age 6-8 9-11 12 13-16 17-18 19+ 60-64 26 27 27 28 29 29 65-69 25 26 27 27 28 29 70-74 24 25 26 27 27 28 75-79 23 24 25 26 27 27 80-84 23 23 24 24 25 26 85-89 23 23 23 24 25 26 90-95 23 23 23 23 24 25

-16- He has a 4th heart sound that is not uncommon in elders with HTN. His prostate is symmetrically enlarged (normal size is ~20 gm). Lack of jugular venous distension and lack of a 3rd heart sound suggest his edema is dependent rather than due to CHF.

He does not have any localizing findings on neurological exam to suggest he has had a stroke. He has findings suggesting diabetic peripheral neuropathy with loss of light touch in toes and feet.

The work-up of dementia includes blood work for serum chemistries, complete blood count with indices, serum B12, thyroid status, and may also include erythrocyte sedimentation rate and syphilis serology. Most authorities also recommend a neuroimaging study – certainly if there are reasons to suspect intracranial pathology based on history or exam findings.

Scores of 5 or less on geriatric depression scale are considered normal; scores of 10 or more indicate depression; scores of above 5 to 10 suggest depression.

Laboratory Results:

Chemistry: Na 141 mEq/L GGTP 38 U/L K 4.5 mEq/L AST 53 U/L Cl 102 mEq/L ALT 49 U/L HCO3 28 mEq/L Alk 150 U/L Glucose 94 mg/dL Calcium 10.1 mg/dL BUN 22 mg/dL Phosphorus 4.0 mg/dL Creatinine 1.2 mg/dL Total Bilirubin 0.3 mg/dL Total Protein 7.9 g/dL Direct Bilirubin 0.1 mg/dL Albumin 4.2 g/dL Uric Acid 6.6 mg/dL CK 94 U/L Cholesterol 234 mg/dL LDH 237 U/L Triglyceride 615 mg/dL

HPD Hct 43.1 % RBC 5,110,000/mm3 Hgb 14.6 g/dL WBC 9,000/mm3 MCV 84 fL Neutrophils 66.8% MCH 29 pg Lymphocytes 9.6% MCHC 34 g/dL Monocytes 12.5% Platelets 311,000/mm3 Eosinophils 10.1% Reticulocytes 1.2% Basophils 1.0% Peripheral smear: Normal Stool hemoccult: Negative

-17- Urinalysis Color Yellow Microscopic: Appearance Clear Specific Gravity 1.029 Epithelial cells few/lpf Leukocytes Negative Mucous Present Nitrite Negative Casts 1-2/lpf –coarse pH 5.0 WBC 2-3/hpf Protein 30 mg/dl RBC 3-4/hpf Glucose Negative Bacteria Moderate Ketone Negative Crystals Uric acid Urobilinogen 0.2 mg/dl Amorphous Present Bilirubin Negative Blood Trace FACILITATOR GUIDE ONLY:

Labs essentially unremarkable except for elevated lipids. These should be tested further with a fasting lipid profile.

Proteinuria suggests diabetic nephropathy.

Fewer than 3-5 WBC’s or RBC’s per high-power field is acceptable as “normal” in UA.

Radiologic Studies

CT – head (EXHIBIT 1) [6/5/97]

For students:

—What are the abnormalities? —What is the differential diagnosis? —What further testing do you want to evaluate his mental status changes?

FACILITATOR GUIDE ONLY:

Diffuse cerebral atrophy with enlargement of the ventricle, sulci, and basilar cisterns. Prominent atrophy in the temporal lobes.

Students should discuss significance of CT abnormalities. Temporal lobe atrophy is very suggestive of Alzheimer’s disease. There is also evidence of small vessel disease (white matter changes) that raises the possibility of vascular dementia, such as Binswanger’s Disease. George, et al., found in a study of 34 AD and 20 controls that atrophy of the temporal lobes was a strong indicator for diagnosis of the AD (George AE, de Leon MJ, Stylopoulos LA, et al. CT diagnostic features of Alzheimer disease: importance of the choroidal/hippocampal fissure complex. AJNR 1990: 11(1):101-07).

-18-