Case 17: Forgetfulness

Opening scenario

Grace Ramirez, a 70-year-old female; , comes to the doctor’s office because of forgetfulness.

Vital signs

• Temperature: 97.7°F (36.5°C)
• Blood pressure: 125/70 mm Hg
• Heart rate: 70/min
• Respirations: 18/min

Examinee tasks

• Take a focused history.
• Perform a relevant physical examination (do not perform corneal reflex, breast, pelvic/genitourinary, or rectal examinations).
• Explain the preliminary differential diagnoses and initial workup plan to the patient.
• Write the patient notes after leaving the room.

Patient instructions

• Act forgetful but do not seem overly concerned about it.
• When the examinee tests your orientation and memory, respond with the answers provided in the examination section.
• You are not aware of the meanings of medical terms (e.g., CT, MRI) and ask for clarification if the examinee uses them.
• Use the checklists below for history, physical examination, and communication and interpersonal skills.

Challenge: Be very talkative and try to tell a story about your life once or twice when the examinee asks you about your family. If the examinee is friendly, appears interested, and does not interrupt you, quickly finish the story and let him/her ask the next question.

Hovering over or clicking on the speech bubbles in the lists below will reveal extra information about the adjacent term. However, clicking on links will cause you to navigate away from the current case, at which point your progress (i.e., your check marks) will be lost. If you do want more information on a subject, either open the link in a new tab or wait until you and your partner have finished the case and reviewed the check marks. Following the link to the patient note form or the abbreviation list will not interrupt your progress.

History of present illness

• Chief complaint
• My daughter wanted me to come. She says I have been very forgetful lately.
• Onset
• For about 2 years.
• Constant/intermittent
• She says I am always this forgetful. I believe she is being a little bit dramatic.
• Precipitating events
• None.
• Progression
• My daughter says it has gotten worse.
• Previous episodes
• None.
• Alleviating factors
• I think it is a little bit better if I get enough sleep.
• Aggravating factors
• None.
• Associated symptoms
• I cannot think of anything right now.

Review of systems specific to forgetfulness

• Trauma
• None.
• Headache
• None.
• Fatigue
• Yes, I have been feeling really tired lately.
• Urinary problems
• Sometimes I cannot get to the bathroom in time.
  • How often
  • Maybe once per day. Especially when I wake up in the morning and really have to go.
• Bowel problems
• No.
• Sleep problems
• I do not sleep much. I cannot fall asleep, and then I usually wake back up around 4:00–5:00 AM.
• Appetite
• I do not have much of an appetite.
• Weight changes
• I would not know, I do not weigh myself.
• Recent infections
• None.
• Dizziness
• Sometimes, if I stand up too quickly.
• Problems walking
• No.
• Falls
• No.
• Cold intolerance
• No.
• Dry hair
• No.
• Getting lost
• I did, maybe once or twice. My neighborhood is just changing so much. I always ended up running into my daughter, though, so it was no problem.
• Hallucinations
• No.
• Weakness
• No.
• Numbness
• No.
• Tingling
• No.
• Assistance required for dressing, eating, walking, going to the bathroom, or personal grooming
• I do all of this with no problems. Well, other than my accidents on the way to the bathroom.
• Assistance required for shopping, housework, personal accounting, cooking, transportation, or medications
• My daughter does all of those things for me.
• Mood
• My mood has not been great since my poodle died about a year ago.
  • Loss of interest
  • I used to play backgammon; with my girlfriends, but I no longer go.
  • Guilt/low self-esteem
  • No.
  • Low energy
  • Like I said, I always feel tired. I think it comes with the age.
  • Poor concentration
  • I cannot seem to concentrate on anything. I constantly forget to finish things I start working on, like my crossword in the morning.
  • Psychomotor agitation or retardation
  • No.
  • Suicidality
  • No.
  • Social support
  • My daughter takes very good care of me.

Past medical history, family history, and social history

• Past medical history
• I have high blood pressure.
• Allergies
• None.
• Medications
• I take hydrochlorothiazide.
• Hospitalizations
• I had to go to the hospital for the delivery of my two kids and when I had my gallbladder removed about 20 years ago.
• Past surgical history
• Just the times when I had to go to the hospital.
• Family history
• My father died in World War II but was healthy, as a far as I know. My mother was healthy, too, but she caught pneumonia when she was very old and died about 3 years ago.
• Work
• Well, I am retired now. But I owned and ran my own café downtown for many years.
• Home
• I live by myself, but my daughter lives in the house right next door.
• Alcohol
• No.
• Recreational drugs
• Never.
• Tobacco
• Never.
• Exercise
• No.
• Diet
• My daughter cooks for me, but she does not have much time. We mostly eat freezer meals.

• Washed hands
• Used respectful draping
• Head, eyes, ears, nose, and throat examination
  • Inspection of the head
  • Palpation of the head
• Neck examination
  • Examination of the thyroid gland
• Extremities
  • Inspection of the hands
  • Inspection of the lower extremities
• Skin examination
• Neurologic examination
  • Focused examination of the cranial nerves
  • Focused examination of passive and active motion
  • Focused examination of sensation
  • Focused examination of deep tendon reflexes
  • Focused examination of gait
  • Rapid alternating movement test
  • Finger-to-nose test
  • Babinski sign
  • Romberg test
• Mini-mental state examination
  • Orientation to time
  • (Answer with incorrect day, date, and month; , but correct season and year; or answer with incorrect president of United States)
  • Orientation to place
  • (Answer with the correct state; , but only say “I am at the hospital close to home” to all other questions.)
  • Orientation to person
  • My name is Grace Ramirez. I am 70 years old. My birthday is on May 14^th.
  • Repeat these three words: house, ball, tree
  • House, ball, tree.
  • Spell world (W-O-R-L-D) backwards
  • D-L-R-W-O
  • Repeat the three words I told you earlier
  • I only remember “house”.
  • Show patient your pen and the paper and ask her to name the objects
  • Pen and paper.
  • Repeat the phrase: “No ifs, ands, or buts”
  • (Do as the examinee says.)
  • Read what I wrote on this piece of paper, and do what it says
  • (Read out loud correctly.)
  • Write any sentence on the paper
  • (Write: “I am Grace Ramirez.”)
  • Now fold the piece of paper and put it on the floor
  • (Do as the examinee says and fold the piece of paper and put it on the floor.)
  • Copy picture of two intersecting pentagons
  • (Copy the picture incorrectly.)

Patient interaction

• Examinee knocked on the door.
• Examinee introduced him- or herself and identified his/her role.
• Examinee correctly used the patient's name.
• Examinee asked open-ended questions.
• Examinee listened attentively (did not interrupt the patient).
• Examinee showed interest in the patient as a person (i.e., appeared caring and showed respect).
• Examinee demonstrated the ability to support the patient's emotions (i.e., offered words of support, asked for clarification).
• Examinee discussed initial diagnostic impressions with the patient.
• Examinee explained the management plan.
• Examinee used non-medical terms and provided reasons for planned steps in management.
• Examinee evaluated the patient's agreement with the next diagnostic steps.
• Examinee asked about concerns or questions.

Counseling and challenge

• Examinee offered counseling for patients with memory loss and/or cognitive impairment.
• Examinee reacted appropriately to challenge (was friendly, appeared interested in the patient's story, and did not interrupt the patient).

Patient note

Differential diagnoses

1. Alzheimer disease: Memory impairment is the cardinal symptom of Alzheimer disease. It is typically insidious and affects memory of recent events (i.e., the ability to remember 3 words a few minutes after repeating them). Other cognitive domains are typically also affected, presenting in this case with impaired spatial orientation (i.e., getting lost), impaired orientation (to time in this case), and impaired attention (i.e., inability to spell a word backwards). This patient is also at higher risk of Alzheimer disease because of her age, sex, history of hypertension, and lack of exercise.
2. Normal pressure hydrocephalus (NPH): The triad of normal pressure hydrocephalus consists of urinary incontinence, dementia, and gait impairment, and this patient does have the first two features. However, her lack of gait impairment makes this diagnosis less likely than Alzheimer disease.
3. Pseudodementia: Depression can cause memory impairment (which is then called pseudodementia) among many other symptoms, some of which this patient has: fatigue, low mood, loss of interest, lack of energy, inability to concentrate, poor sleep, and poor appetite. However, depression symptoms can also be symptoms of Alzheimer disease, which is more likely in this case because the patient's forgetfulness pre-dates her depression symptoms. Moreover, the onset of pseudodementia is usually sudden, rather than insidious, as in this case.

Diagnostic studies

• MRI brain: In the case of Alzheimer disease, generalized or focal cerebral atrophy may be visible. Normal pressure hydrocephalus would show dilatation of ventricles with periventricular hyperintensities. Vascular dementia would show multiple lacunar and white matter lesions. A neoplastic cause of dementia would be best visualized via MRI.
• CBC: Vitamin B₁₂ deficiency would manifest with megaloblastic anemia on CBC as well as thrombocytopenia and/or leukopenia in some cases. Anemia can cause fatigue.
• TSH: to rule out hypothyroidism as a cause of this patient's cognitive symptoms
• Serum B₁₂: to rule out B₁₂ deficiency as the cause of memory impairment
• Glucose, electrolytes: to rule out imbalances in glucose and electrolytes as causes of the patient's cognitive symptoms (e.g., hypoglycemia, hypernatremia)
• Cranial CT: In the case of Alzheimer disease, generalized or focal cerebral atrophy may be visible. Normal pressure hydrocephalus would show dilatation of ventricles with periventricular hyperintensities. Vascular dementia could result in microangiopathic lesions in the white matter as well as multiple lacunar lesions.
• Lumbar puncture: would alleviate the symptoms in NPH (both diagnostic and therapeutic); would show ↓ amyloid beta and ↑ phosphorylated tau in Alzheimer disease

Other differential diagnoses to consider

• Vascular dementia
• Lewy body dementia
• Hypothyroidism
• Vitamin B₁₂ deficiency
• See also “Differential diagnosis” of major neurocognitive disorder.