医学专业英语课件_2.pptx

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1、CASE PRESENTATION Dr.LU,QINCHIn nDEPARTMENT OF NEUROLOGYDEPARTMENT OF NEUROLOGY REN JI HOSPITAL REN JI HOSPITAL SHANGHAI JIAO TONG UNIVERSITY SHANGHAI JIAO TONG UNIVERSITY SCHOOL OF MEDICINE SCHOOL OF MEDICINEn nTel:58752345-3094 Email:History A 68-year-old woman has been noted by her daughter to ha

2、ve memory loss and confusion.The daughter states that her mother has been going“downhill”for the past several months.The mother has lived on her own for many years,but recently she has begun to become unable to take care of herself.History The daughter states that her mother has become withdrawn and

3、 has lost interest in her usual activities,such as gardening and reading.Her mothers memory is poor,and she is often fatigued.The patient states that she sleeps well at night and that her appetite is good,although she has lost 10 lb over the past 6 months.She denies bowel and urinary incontinence.Hi

4、story The patients past medical history is significant for hypertension for which she has been taking hydrochlorethiazide.The patient was last hospitalized 35 years ago when she underwent a total abdominal hysterectomy with bilateral salpingo-oophorectomy.The patient has enjoyed overall good health.

5、She does not smoke or drink.Physical Exam On examination,her blood pressure is 116/56 mmHg,her heart rate is 78 bpm,her temperature is 37.5。C,and her respiratory rate is 18 breaths per minute.She weighs 88 kg and her height is 1.62m.The patient is a well-developed white women with a flat affect.She

6、is oriented to person,but she is not oriented to time and place.Pyhsical&Neuro Exam Mini Mental Status ExaminationMini Mental Status Examination gives a score of gives a score of 18 out of 30.The head and neck and cardiovascular 18 out of 30.The head and neck and cardiovascular examination are unrem

7、arkable.Abdomen is benign examination are unremarkable.Abdomen is benign without hepatosplenomegaly.The extremities are without hepatosplenomegaly.The extremities are without edema,cyanosis,or clubbing.The neurologic without edema,cyanosis,or clubbing.The neurologic examination reveals that the cran

8、ial nerves are intact,examination reveals that the cranial nerves are intact,and the motor and sensory exams are within normal and the motor and sensory exams are within normal limits.Cerebellum examination is unremarkable and limits.Cerebellum examination is unremarkable and the gait is normal.the

9、gait is normal.Questionsn nWhat is the most likely diagnosis?n nWhat are the next diagnostic steps?n nWhat is the best treatment for this condition?Summary:A 68-year-old woman has memory loss,confusion,and fatigue,and is withdrawn.She had a flat affect.She is oriented to person,but she is not orient

10、ed to time and place.The remainder of the examination,including neurological examination,is normal except for a low score on the MMSE.Most likely diagnosis:Alzheimer dementia.Next diagnostic step:Assess for depression and reversible causes of dementia.Probable treatment:Acetylcholinesterase inhibito

11、r AnalysisAnalysisObjectivesn nKnow some of the common causes of dementian nUnderstand the presentation and diagnosis of Alzheimer dementian nKnow the treatment for Alzheimer dementia is acetylcholinesterase inhibitorConsiderations This is an elderly woman without any significant past medical histor

12、y except for hypertension who was brought to your office with a history of progressive functional decline and memory loss.The first step should be to rule out depression.Depression in the elderly may have a presentation very similar to that of dementia with withdrawal,apathy,irritability,memory impa

13、irment,and confusion.Considerations The next step should be to rule out all the possible causes of reversible or arrestable dementia,such as multi-infarct dementia,hypothyroidism,drugs,B12 deficiency,normal pressure hydrocephalus,alcoholism,HIV,and syphilis.Considerations Laboratory tests will help

14、you to eliminate some of these common causes of reversible dementia:complete blood count(CBC),comprehensive metabolic panel,thyroid-stimulating hormone(TSH),urinalysis,serologic test for syphilis,and a head CT(see table 49-1).Table 49-1Table 49-1ABBREVIATED WORKUP FOR DEMENTIAABBREVIATED WORKUP FOR

15、DEMENTIAComplete blood count and consider erythrocyte Complete blood count and consider erythrocyte sedimentation rate(ESR)sedimentation rate(ESR)Chemistry panel Chemistry panel Thyroid-stimulating hormone level Thyroid-stimulating hormone level Venereal Disease Research Laboratory(VDRL)Venereal Dis

16、ease Research Laboratory(VDRL)HIV assay HIV assay Urinalysis Urinalysis Serum vitamin B12 and folate levels Serum vitamin B12 and folate levels Chest radiographChest radiographElectrocardiogram Electrocardiogram CT or MRI imaging of the head CT or MRI imaging of the head Considerations The possibili

17、ty of HIV-induced dementia is not high on the differential in this case given the patients age,but it would certainly be a consideration in younger people.Possible infectious causes of reversible dementia include not only HIV but also neurosyphilis.Therefore,a serologic test for syphilis is indicate

18、d.Considerations Because our patient does not have a history of chronic alcoholism,we can rule out this condition.The CBC and mean cell volume(MCV)are normal,as is the TSH,eliminating the possibilities of vitamin B12 deficiency and of hypothyroidism.The patient is only taking hydrochlorothiazide,whi

19、ch is not associated with the described mental status changes.A CT head scan can assess for brain lesions,multiple infarcts,and hydrocephalus.Considerations Therefore,in this case we are left with the possibility of multi-infarct dementia and Alzheimer disease.Multi-infarct dementia develops later i

20、n life and is caused by diffuse cerebrovascular disease.Most of the patients will have a history of transient ischemic attacks and strokes,and stepwise progression of dementia which our patient does not report.In this particular case,Alzheimer dementia becomes the most likely diagnosis.APPROACH APPR

21、OACH TO TO DEMENTIADEMENTIADefinitionsn nAlzheimer disease:The leading cause of dementia,accounting for half of the cases involving elderly individuals,correlating to brain atrophy with ventricular enlargement.n nDementia:Progressive and generalized decline of intellectual ability from a previously

22、attained level,usually without alteration of consciousness.Definitionsn nMultiinfarct dementia:Numerous small cerebral Multiinfarct dementia:Numerous small cerebral vascular accidents,most commonly caused by vascular accidents,most commonly caused by atherosclerotic disease,leading to dementia.ather

23、osclerotic disease,leading to dementia.n nNormal pressure hydrocephalus:Reversible form of Normal pressure hydrocephalus:Reversible form of dementia where the cerebral ventricles slowly enlarge dementia where the cerebral ventricles slowly enlarge as a result of disturbances to cerebral spinal fluid

24、 as a result of disturbances to cerebral spinal fluid resorption.The classic triad is dementia,gait resorption.The classic triad is dementia,gait disturbance,and urinary or bowel incontinence.disturbance,and urinary or bowel incontinence.Clinical Approach A patient who presents with memory and funct

25、ional impairment should be approached from the perspective that many etiologies can be causative.A thorough description of the patients cognitive,adaptive,memory,and behavioral ability over time is critical.Multiple family members are often needed to construct a complete and accurate picture.The tim

26、e frame(months to years versus days to weeks)is important.Clinical Approach A history of head trauma,neurological symptoms,a stepwise decline(multi-infarct dementia)versus a insidious gradual decline may be helpful.A record of all medications,habits,alcohol use(even remote),can potentially cause men

27、tal status changes in the elderly.A resting tremor of Parkinson disease,cold intolerance suggestive of hypothyroidism,or vitamin deficiencies may be helpful.Clinical Approach The other intracranial diseases that could cause a dementia-like picture include subdural hematoma and normal pressure hydroc

28、ephalus.Usually,a CAT(computed axial tomography)scan will allow you to rule out these disease processes.Also,remember,that normal pressure hydrocephalus is usually accompanied by gait disturbances and urinary incontinence which our patient does not have.Clinical Approach Parkinson disease is also as

29、sociated with the development of dementia but patients with Parkinson disease have symptoms and physical findings that will alert you to the diagnosis.Table 49-2 lists the neurological diseases that impair cognitive ability.Table 49-2Table 49-2NEUROLOGICAL DISEASES IMPAIRING COGNITIVE ABILITYNEUROLO

30、GICAL DISEASES IMPAIRING COGNITIVE ABILITYDISEASE DISEASE CLINICAL FEATURES CLINICAL FEATURES TREATMENT TREATMENT Alzheimer disease Alzheimer disease Slow decline in cognitive and Slow decline in cognitive and behavioral ability;pathology:behavioral ability;pathology:neurofibrillary tangles,enlarged

31、 neurofibrillary tangles,enlarged cerebral ventricles,and atrophy cerebral ventricles,and atrophy Cholinesterase inhibitors such Cholinesterase inhibitors such as donepezil or rivastigmine as donepezil or rivastigmine Normal-pressure Normal-pressure hydrocephalus hydrocephalus Gate disturbance,demen

32、tia,Gate disturbance,dementia,incontinence;enlarged ventricles incontinence;enlarged ventricles without atrophy without atrophy Ventricular shunting process Ventricular shunting process Multi-infarct Multi-infarct dementia dementia Focal deficits,stepwise loss of Focal deficits,stepwise loss of func

33、tion;multiple areas of function;multiple areas of infarct usually subcortical infarct usually subcortical Address atherosclerotic risk Address atherosclerotic risk factors,identify and treat factors,identify and treat thrombus thrombus Parkinson disease Parkinson disease Extrapyramidal signs(tremor,

34、Extrapyramidal signs(tremor,rigidity),slow onset rigidity),slow onset Dopaminergic agents Dopaminergic agents Table 49-2(cont)Table 49-2(cont)NEUROLOGICAL DISEASES IMPAIRING COGNITIVE ABILITYNEUROLOGICAL DISEASES IMPAIRING COGNITIVE ABILITYDISEASE DISEASE CLINICAL FEATURES CLINICAL FEATURES TREATMEN

35、T TREATMENT HIV defintion HIV defintion Systemic involvement;risk factors Systemic involvement;risk factors for acquisition;positive HIV for acquisition;positive HIV serology serology Treat specific infection Treat specific infection Neurosyphilis Neurosyphilis Optic atrophy,Argyll-Robertson Optic a

36、trophy,Argyll-Robertson pupils,gait disturbance;positive pupils,gait disturbance;positive cerebro-spinal fluid serology cerebro-spinal fluid serology High dose intravenous High dose intravenous penicillinpenicillinMultiple sclerosis Multiple sclerosis Brainstem signs,optic atrophy,Brainstem signs,op

37、tic atrophy,long-standing disease with long-standing disease with exacerbations and remissions;exacerbations and remissions;MRI showing white matter MRI showing white matter abnormalities abnormalities Recombinant interferon,Recombinant interferon,corticosteroids corticosteroids Intracranial tumor I

38、ntracranial tumor Focal signs,papilledema,seizures Focal signs,papilledema,seizures Corticosteroids to reduce Corticosteroids to reduce intracranial pressure,treat intracranial pressure,treat the lesion the lesion Clinical Approach The etiology of Alzheimer dementia is an unknown The etiology of Alz

39、heimer dementia is an unknown but Alzheimer disease has a genetic component.The but Alzheimer disease has a genetic component.The risk of developing the disease for an individual in a risk of developing the disease for an individual in a family with Alzheimer disease increases by a factor family wit

40、h Alzheimer disease increases by a factor of 3 or 4.The gene that codes for apoprotein E seems of 3 or 4.The gene that codes for apoprotein E seems to be associated with some prediction.The pathologic to be associated with some prediction.The pathologic changes in the brains of Alzheimer disease pat

41、ients changes in the brains of Alzheimer disease patients include neurofibrillary tangles with a deposition of include neurofibrillary tangles with a deposition of abnormal amyloid in the brain.abnormal amyloid in the brain.Amyloid Precursor ProteinA-Neurofibrillary TanglesA-AggregationNeuron DeathB

42、asal Forebrain and Brainstem NucleiNeurotransmitter DeficitsNeuritic PlaquesNeuron DeathCortexDemantia SyndromeMutations and vulnerability genes associated Mutations and vulnerability genes associated with Alzheimers diseasewith Alzheimers diseaseMutations and vulnerability genes associated with Mut

43、ations and vulnerability genes associated with Alzheimers diseaseAlzheimers diseaseClassical neuritic plaque(Bielschowsky silver stain)(Bielschowsky silver stain)Neurofibrillary TanglesNeurofibrillary tangles(H&E stain)(H&E stain)Cerebral amyloid angiopathy(H&E stain)(H&E stain)Clinical Approach The

44、 disease onset can be very insidious and the average life expectancy after diagnosis is 7-10 years.The clinical course is characterized by the progressive decline of cognitive functions(memory,orientation,attention and concentration)and the development of psychological and behavioral symptoms(wander

45、ing,aggression,anxiety,depression and psychosis)(see Table 49-3)Table 49-3Table 49-3ALZHEIMER DISEASE CLINICAL COURSEALZHEIMER DISEASE CLINICAL COURSECLINICAL STAGECLINICAL STAGE MANIFESTATIONS MANIFESTATIONS Early Early Mild forgetfulness,poor concentration,fairly good Mild forgetfulness,poor conce

46、ntration,fairly good function,denial,occasional disorientation function,denial,occasional disorientation Intermediate Intermediate Drastic deficits for recent memory,can travel to Drastic deficits for recent memory,can travel to familiar locations,suspicious,anxious,aware of familiar locations,suspi

47、cious,anxious,aware of confusion confusion Late Late Cannot remember names of family members or close Cannot remember names of family members or close friends;may have delusions or hallucinations,agitation,friends;may have delusions or hallucinations,agitation,aggression,wandering,disoriented to tim

48、e and place,aggression,wandering,disoriented to time and place,need for substantial care need for substantial care AdvancedAdvancedTotally incapacitated and disoriented,incontinent,Totally incapacitated and disoriented,incontinent,personality and emotional changes;eventually all personality and emot

49、ional changes;eventually all verbal and motor skills deteriorate,leading to need for verbal and motor skills deteriorate,leading to need for total care total care Treatment The goals of treatment in Alzheimer disease are to (a)improve cognitive function (b)reduce behavioral and psychological symptom

50、s,and (c)improve the quality of life.Treatment n nDonepezil(Aricept)and revastigmine(Exelon)are Donepezil(Aricept)and revastigmine(Exelon)are cholinesterase inhibitors that are effective in cholinesterase inhibitors that are effective in improving cognitive function and global clinical state.improvi