CENTRAL LUZON DOCTORS’ HOSPITAL

EDUCATIONAL INSTITUTION, INC.

Romulo Highway, San Pablo, Tarlac City
🕾 (045) 982-5019/982-5052/982-0264 🖷 (045) 982-0780/982-2757

COURSE TITLE: Advance Pathophysiology

NAME: FLORA M. TEL-EQUEN

YEAR & SEC. MSN 1-D
DATE:6/16/23
INSTRUCTION:
ANSWER THE FF. QUESTIONS AS BRIEFLY AS POSSIBLE.

PATIENT CASE STUDY

Patient’s Chief Complaints “I got lost in the grocery store and my children think that I need
those diapers that old people have to wear.”
HPI
R.M. is an 83-year-old woman who presents to the geriatric care clinic for a routine visit. She
is accompanied by her two oldest daughters. The patient was diagnosed with probable
Alzheimer disease nine years ago when her children reported short-term memory loss and
several cognitive manifestations. They noted that she was constantly misplacing her glasses,
hearing aid, and keys and that, on several occasions, had placed familiar household items in
illogical places—like the coffee pot in the refrigerator. They also reported that she had taken
walks in the neighborhood where she had lived for nearly 45 years and got lost. Neighbors
had helped her home on more than one occasion.
It was at about this same time that her children and friends also noticed several changes in
her personality. She had become very quiet and passive and seemed to have lost all
motivation and interest in everything that she had previously enjoyed, including her flower
garden. A complete clinical workup with neuroimaging studies revealed no significant new
medical conditions that were causing her neurologic manifestations. However, she scored
only 25 out of a possible 30 points on a Folstein Mini-Mental State Examination. She was
started on tacrine, but when adverse effects became intolerable (nausea, vomiting, and
abdominal pain), her medication was changed to donepezil. Donepezil helped significantly
with both memory and mood for several years.
Four years ago, family members noticed another significant change in the patient. Not only
had previous manifestations become more severe, she also began developing new features of
Alzheimer disease. She started having difficulty with numbers, could no longer balance her
checkbook, and even forgot how to play bridge—a game that she had enjoyed for more than
60 years. She also began showing signs of poor judgment—one time leaving the house on a
cold, winter morning without a coat and shoes, another time going to the store in her
nightgown. Furthermore, there was a small kitchen fire that occurred when she forgot to turn
off the stove. Fortunately, her neighbor had come over to check on her and put the fire out. At
this time, she was again tested for new systemic disease, but no significant abnormalities
were detected other than a mild case of iron deficiency anemia. A CT scan of the brain
revealed moderate-to-severe cerebral atrophy in the temporal and parietal lobes bilaterally.
Her Folstein Mini-Mental State Examination score had significantly decreased to 18/30.
Shortly thereafter, the oldest daughter sold her mother’s home and moved her mother in to
live with her family. The two oldest daughters shared caregiving responsibilities and the
youngest son also contributed significantly to his mother’s safety and well-being.
Within the past six weeks, the patient has demonstrated multiple, sudden outbursts of anger.
While shopping for groceries earlier this week with her second oldest daughter, the patient
became separated, lost, confused, angry, and then violent when store employees and several
customers tried to help her. Before she could be calmed, she had thrown several tomatoes at
the store manager. She broke into a violent rage again at check-out when the grapes that she
was purchasing fell out of the bag onto the floor. Within the last two weeks, she also began
having occasional urinary accidents. Caring for their mother is now becoming unmanageable
and the children are currently considering admitting their mother into a long-term nursing
care facility.
PMH
• HPN x 20 years
• Episode of nephrolithiasis 2 years ago, stone passed without intervention, uric acid was
primary component of stone
• Gout x 2 years
• Hypercholesterolemia x 6 months
• Plantar fasciitis of left foot x 3 months
• Occasional constipation
Patient Case Question 1. What is plantar fasciitis?
 Plantar fasciitis is one of the most common conditions causing heel pain. It involves
inflammation of the plantar fascia — a tough, fibrous band of tissue that runs along
the sole of the foot. The plantar fascia attaches to the heel bone (calcaneus) and to the
base of the toes. It helps support the arch of the foot and has an important role in
normal foot mechanics during walking.
FH
• Both parents are deceased
• Father died from CVA
• Mother developed Alzheimer disease in her 70s
• Brother died from heart disease
• Sister also had Alzheimer disease, died 5 years ago at age 76
SH
• Lives with daughter
• Has been widowed for 14 years (husband died from cancer)
• Does not smoke or drink alcohol
ROS
• No history of trauma or recent infection
• Patient reports occasional bladder incontinence
• No complaints of chest pain, shortness of breath, dizziness, joint pain, foot pain, or bowel
incontinence
Medications
• Donepezil 10 mg po Q HS
• Allopurinol 100 mg po QD
• Pravastatin 40 mg po QD
• Lisinopril 20 mg po QD
• Ensure drinks PRN
• Ibuprofen 200 mg q4h PRN
• Docusate sodium 100 mg po BID
All
Co-trimoxazole → rash
Patient Case Question 2. Identify this patient’s two major risk factors for Alzheimer disease.
 Immediate family members with a history of Alzheimer disease; her sister and her
mother. Research shows that those who have a parent or sibling with Alzheimer
disease are more likely to develop the disease than those who do not have a first-
degree relative with the disease.
Patient Case Question 3. Why is the patient taking allopurinol, and why is this medication
effective in individuals with this condition?
 Allopurinol is an antigout agent. Considering this patient's medical history (episode of
nephrolithiasis 2 years ago, stone passed without intervention, uric acid was primary
component of stone & gout X 2 years), allopurinol helps to prevent the effects of the
build-up uric acid crystals that form by lowering serum uric acid levels. Additionally,
 there remains current research investigations on the effects of increased uric acid
levels and the use of allopurinol on Alzheimer disease protection.

 Allopurinol is a medication used to treat gout, a condition characterized by high levels

of uric acid in the blood. Allopurinol works by inhibiting the enzyme xanthine
oxidase, which is involved in the production of uric acid. By reducing uric acid levels,
allopurinol can prevent gout attacks and reduce the risk of complications such as joint
damage and kidney stones.
Patient Case Question 4. Why is the patient taking lisinopril, and why is this medication
effective in individuals with this condition?
 Lisinopril is an ACE inhibitor and is generally a first-line medication prescribed to
treat primary hypertension. Research has also demonstrated that for those who already
have dementia or Alzherimer disease, use of ACE inhibitors may delay deterioration
of brain function and help keep patients out of nursing homes. Researchers are unsure
why ACE inhibitors might be especially beneficial for those with Alzheimer's or at
risk for it, but they speculate that the drug may protect against blood vessel damage in
the brain.

Patient Case Question 5. Why is the patient taking docusate sodium, and why is this
medication effective in individuals with this condition?

 The patient is taking docusate sodium to treat diarrhea. Docusate is an osmotic

laxative that draws water into the large intestine, helping to soften stool and reduce
constipation. The medication is effective in individuals with this condition because it
helps them produce more regular bowel movements, which reduces their risk of
developing fecal impaction, a condition where stool becomes hard and difficult to
pass.

PE and Lab Tests

Gen
• Slightly confused but cooperative elderly woman in NAD
• Becomes less confused with slowly repeated questions and simple explanations
• The patient has a significant tic of the upper lip (2–3 twitches/minute)
Vital Signs
BP 140/80 left arm, RR 15, unlabored HT 5’6”
sitting
P 85, T 98.8°F WT 114 lbs
regular
Skin
• Pale and dry with senile lentigines
• Poor turgor
• Multiple minor ecchymoses noted on forearms; no other lesions or abrasions
Patient Case Question 6. What are senile lentigines?
 Senile lentigo or age spots are hyperpigmented macules of skin that occur in irregular
shapes, appearing most commonly in the sun-exposed areas of the skin such as on the
face and back of the hands. Senile lentigo is a common component of photoaged skin
and is seen most commonly after the age of 50.

Patient Case Question 7. What are ecchymoses?

 “Ecchymosis” is the medical term for bruises. These form when blood pools under
your skin. They’re caused by a blood vessel break. Bruises look like a mark on your
skin that’s black and blue or red to purple. Bruises change color as they heal and most
don’t need treatment.
HEENT
• Fundi WNL
• TMs intact
• Dentures present
• Buccal and pharyngeal membranes moist and without lesions or exudate
Neck/LN
• Neck supple
• No thyromegaly or lymphadenopathy
• Trachea mid-line
• Carotid pulses full and equal bilaterally without bruits
• No JVD
Chest/Lungs
• Mildly increased chest anteroposterior diameter with mild kyphosis
• Lungs clear to auscultation throughout
Heart
• RRR
• Normal S1 and S2
• No murmurs or rubs
Abdomen
• Soft, NT/ND, and symmetric with no apparent masses or hernias
• No scars, lesions, or bruits
• Bowel sounds present
• Tympany to percussion in all quadrants; no masses or organomegaly
Breasts
No masses, tenderness, discoloration, discharge, or dimpling
Genitalia
Normal external female genitalia
MS/Extremities
• No redness, swelling, or cyanosis
• Extremities warm bilaterally
• All peripheral pulses present and equal bilaterally
• No inguinal adenopathy
• With exception of left great toe, which was tender with movement, joints showed full,
smooth ROM; no crepitus or tenderness
• Able to maintain flexion and extension against resistance without tenderness
Neurological
• Pinprick, light touch, vibration intact
• Able to feel key in both hands with eyes closed, but unable to identify it as such
• Rapid alternating movements have deteriorated since the patient’s last visit
• DTRs all 2+
• Negative Babinski sign bilaterally
• Gait slightly wide-based and awkward; unable to tandem walk
• No Romberg sign
Folstein Mini-Mental State Examination
The patient’s examination score was 9/30
Patient Case Question 8. Have the results of the patient’s mini-mental state exam improved,
worsened, or remained the same since her last mental state test?
 The results demonstrate that the patient's exam have worsened since her last exam
(from 18/30 to 9/30). Laboratory Blood Test Results (Fasting) Na 144 meq/L ALT 22
IU/L HDL 39 mg/dL K 4.3 meq/L Alk Phos 124 IU/L LDL 117 mg/dL Cl 105 meq/L
T Bilirubin 1.2 mg/dL Uric acid 5.7 mg/dL HCO 3 29 meq/LD Bilirubin 0.4 mg/dL
Vitamin B12 288 pg/mL Hb 14.9 g/dL BUN 14 mg/dL Ca 9.2 mg/dL Hct 44% Cr 1.2
mg/dL PO 4 4.5 mg/dL RBC 4.85 X10 6 / mm 3 Glu 87 mg/dL Mg 2.4 mg/dL Plt 161
 X 10 3 /mm 3 Cholesterol 185 mg/dL TSH 3.6 µU/mL WBC 7.34 X 10 3 /mm 3
Trig147 mg/dL T4 5.9 µg/dL AST 28 IU/L T Protein 6.5 g/dL Alb 4.1 g/dL
Laboratory Blood Test Results (Fasting)
Na 144 meq/L ALT 22 IU/L HDL 39 mg/dL
K 4.3 meq/L Alk Phos 124 IU/L LDL 117 mg/dL
Cl 105 meq/L T Bilirubin 1.2 mg/dL Uric acid 5.7 mg/dL
HCO3 29 meq/L D Bilirubin 0.4 mg/dL Vitamin B12 288 pg/mL
Hb 14.9 g/dL BUN 14 mg/dL Ca 9.2 mg/dL
Hct 44% Cr 1.2 mg/dL PO4 4.5 mg/dL
RBC 4.85 x Glu 87 mg/dL Mg 2.4 mg/dL
106/mm3
Plt 161 x Cholesterol 185 mg/dL TSH 3.6 µU/mL
103/mm3
WBC 7.34 x Trig 147 mg/dL T4 5.9 µg/dL
103/mm3
AST 28 IU/L T Protein 6.5 g/dL Alb 4.1 g/dL

Patient Case Question 9. Identify all of the abnormalities associated with this patient’s
CBC.
 There are no abnormalities noted in her CBC result.
Patient Case Question 10. Is this patient’s renal function normal or abnormal?
 This patient's renal function tests (BUN/Creatine) appear to be within normal range.
However, based on her age and race, her calculated GFR is 42; demonstrating CKD
stage 3.

Patient Case Question 11. Is this patient’s hepatic function normal or abnormal?
 AST – slightly elevated
Patient Case Question 12. Is this patient’s serum lipid profile normal or abnormal?
 The patient 's total cholesterol, triglyceride, and LDL levels are in desirable range .
Her HDL are near desirable levels.
Patient Case Question 13. Is this patient’s thyroid function normal or abnormal?
 Thyroid function test is normal.
Patient Case Question 14. Identify any laboratory blood test results in Table 38.2 that might
explain the patient’s deteriorating neurologic function.
 The laboratory values presented so far does not imply any deteriorating neurologic
function. Although the triglycerides is slightly elevated it is not enough to cause
blockage of her cerebrovascular areas. The only abnormal value is an elevated
magnesium level of 2.4 compared to the normal range of 1.3-2.1.
Patient Case Question 15. Are there any indications for treating this patient with
memantine?
  No data given for any indication that patient was treated with memantine. In her
history her symptoms have been progressively worsening. If she had started
Memantine her memory loss could have been treated.
Patient Case Question 16. Multi-infarct dementia has to be ruled out as a possible cause of
this patient’s changes in cognitive function, because this condition presents in a similar
manner. Identify two risk factors that predispose this patient to multi-infarct dementia.
 Two risk factor that predisposed the patient to multi-infarct dementia is Hypertension
and Hyperlipidemia.
Patient Case Question 17. Does multi-infarct dementia present in the same manner with a
CT scan study as does Alzheimer disease?
 No. Multi-infarct dementia may present with one or multiple areas of infarction in the
brain on CT, Alzheimer's disease does not present with infarcts.
 CT diagnosis of Alzheimer disease include diffuse cerebral atrophy with enlargement
of cortical sulci and increased ventricle size.
Patient Case Question 18. Clinical depression in an elderly patient is often mistaken for
Alzheimer disease. Is there any way to distinguish depression from Alzheimer disease in the
geriatric population?
 Depression is weeks to months development and Alzheimers is months to years.
Depression also is not necessarily associated with memory loss whereas,
Alzheimers is.
 The answer to the given question provides two ways to distinguish clinical
depression from Alzheimer's disease in elderly patients. The first way is based on
the duration of symptoms, where depression takes weeks to months to develop
while Alzheimer's takes months to years. The second way is based on the presence
of memory loss, which is typically associated with Alzheimer's but not necessarily
with depression. This information can help healthcare professionals differentiate
between these two conditions and provide appropriate treatment for their patients.

Patient Case Question 19. Why might a trial of risperidone be appropriate for this
patient?
 A trial of risperidone would be appropriate for this patient because she has shown
signs of aggression. Risperidone is licensed for the short - term treatment of
aggression in Alzheimer 's disease.