Student Surgery: You’re a medical student conducting a surgery list under supervision from your GP trainer. Your next patient is a retired GP who has been booked in by his wife for concerns about his memory.
A 74 year old retired GP, Dr Wallis comes to see you.His wife reports that his memory is not ‘as it was’ however the retired GP dismisses this as ‘nonsense’ and proceeds to tell you about his early research on the use of anti tuberculous medications. His wife is concerned that he may have a brain tumour. The concern about this is that she has read brain tumours can cause memory problems.
Dr Wallis is frustrated by his wife’s concerns about his memory and mentions she is always meddling in his affairs. In his history his wife tells you he has put on a stone in weight, and fractured an ankle when being run over by a car 12 months ago.
PMHx
Previous history of skin psoriasis, treated with topical preparations only.
Drug history
Vitamin D tablets ordered over the internet (patient unsure of strength, wife believes it to be 1000 international units a day)
Examination
You proceed to examine Dr Wallis to evaluate him for any neurological problems. The examination is as follows.
Observations normal. Normal Cardiovascular, Respiratory and Gastrointestinal Examination
Neurology:
| Upper Limbs | Lower Limbs | ||||
| Right | Left | Right | Left | ||
| Tone | N | N | N | N | |
| Power
|
5/5 | 5/5 | 5/5 | 5/5 | |
| Coordination | N | N | N | N | |
| Sensation
Fine touch Proprioception |
N
N |
N
N |
N
N |
N
N |
|
| Reflexes
Biceps triceps supinator
|
+
+ - |
+
+ + |
Knee
Ankle Plantar |
+
- ? |
+
+ ? |
Cranial Nerve Exam
Normal. Fundoscopy normal.
Mental Test Score:
| Question | Mark (x/10) |
| Age | Correct |
| DOB |
Correct |
| Time (nearest Hr) |
Correct |
| Person |
Correct |
| Place (house number/ name of hospital) |
Incorrect |
| Recall Address |
Correct |
| WWII |
Incorrect |
| Year |
Correct |
| Queen |
Correct |
| 20-1 |
Correct |
Adapted from Hodkinson HM. “Evaluation of a mental test score for assessment of mental impairment in the elderly.” Age and Ageing 1972;1:233-8
Recent blood tests
| Test | Result | Normal Range |
| Hb | 12.9 | (12-15g/dl) |
| WCC | 5.4 | (4-10 x109/l) |
| Plt | 152 | (150-300 x109/l) |
| MCV | 88 | (80-99 fL) |
| INR | 0.9 | (0.9-1.3) |
| Na | 137 | (135-145 mmol/l) |
| K | 4.8 | (3.5-5.1mmol/l) |
| U | 4.1 | (4-9mmol/l) |
| Creatinine | 88 | (60-100 micromols/l) |
| Albumin | 39 | (35-45g/l) |
| Alk Phos | 53 | (<110iu/l) |
| ALT | 45 | (<40 iu/l) |
| Bilirubin | 19 | (<20 micromols/l) |
| CRP | 9 | <5 |
| TSH | 5.6 | (0.5-5) |
| Fasting Blood sugar | 6.2 | (<7mmol/l) |
What is the most likely diagnosis is this just ‘old age’, and does the patient require any other investigations? You can pick a maximum of 5 answers.
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