Key History
Must include history from family members/caregivers when available. Detailed time course of cognitive deficits (acute vs. chronic/gradual onset); associated symptoms (constitutional, incontinence, ataxia, hypothyroid symptoms, depression); screen for delirium (waxing/waning level of alertness); falls, medications (and recent medication changes); history of stroke or other atherosclerotic vascular disease, syphilis, HIV risk factors, alcohol use, or vitamin B12 deficiency; family history of Alzheimer’s disease or other neurologic disorders.
Key Physical Exam
Vital signs; complete neurologic exam, including mini-mental status exam and gait; general physical exam, including ENT, heart, lungs, abdomen, and extremities.
|
Presentation |
Differential |
Workup |
|
|
■ 81 yo M presents with progressive confusion for the past several years accompanied by forgetfulness and clumsiness. He has a history of hypertension, diabetes mellitus, and 2 strokes with residual left hemiparesis. His mental status has worsened after each stroke (stepwise decline in cognitive function). |
Vascular (“multiinfarct”) dementia Alzheimer’s disease Normal pressure hydrocephalus Chronic subdural hematoma Intracranial neoplasm Depression B12 deficiency Neurosyphilis Hypothyroidism |
CBC VDRL/RPR Serum B12 TSH MRI—brain CT—head LP—CSF analysis |
|
|
CONFUSION/MEMORY LOSS (cant'd) |
|||
|
Presentation |
Differential |
Workup |
|
|
■ 84 yo F brought by her son c/o forgetfulness (eg, forgets phone numbers, loses her way back home) and difficulty performing some of her daily activities (eg, bathing, dressing, managing money, using the phone). The problem has progressed gradually over the past few years. |
Alzheimer’s disease Vascular dementia Depression Hypothyroidism Chronic subdural hematoma Normal pressure hydrocephalus Intracranial neoplasm B deficiency Neurosyphilis |
CBC VDRL/RPR Serum B12 TSH MRI—brain (preferred) CT—head LP—CSF analysis |
|
|
■ 72 yo M presents with memory loss, gait disturbance, and urinary incontinence for the past 6 months. |
Normal pressure hydrocephalus Alzheimer’s disease Vascular dementia Chronic subdural hematoma Intracranial neoplasm Depression B12 deficiency Neurosyphilis Hypothyroidism |
CT—head MRI—brain LP—opening pressure and CSF analysis Serum B VDRL/RPR TSH |
|
|
■ 55 yo M presents with a rapidly progressive change in mental status, inability to concentrate, and memory impairment for the past 2 months. His symptoms are associated with myoclonus, ataxia, and a startle response. |
Creutzfeldt-Jakob disease Vascular dementia Lewy body dementia Wernicke’s encephalopathy Normal pressure hydrocephalus Chronic subdural hematoma Intracranial neoplasm Depression Delirium B12 deficiency Neurosyphilis |
CBC Electrolytes, calcium Serum B12 VDRL/RPR MRI—brain (preferred) CT—head EEG LP—CSF analysis Brain biopsy |
|
|
CONFUSION/MEMORY LOSS (cant'd) |
|||
|
Presentation |
Differential |
Workup |
|
|
■ 70 yo insulin-dependent diabetic M presents with episodes of confusion, dizziness, palpitations, diaphoresis, and weakness. |
Hypoglycemia Transient ischemic attack Arrhythmia Delirium Angina |
Glucose CBC Electrolytes CPK-MB, troponin Echocardiography ECG MRI—brain Doppler U/S—carotid |
|
|
■ 55 yo F presents with gradual altered mental status and headache. Two weeks ago she slipped, hit her head on the ground, and lost consciousness for 2 minutes. |
Subdural hematoma SIADH (causing hyponatremia) Creutzfeldt-Jakob disease Intracranial neoplasm |
CT—head CBC Electrolytes MRI—brain LP—CSF analysis |
|
Key History
Acute vs. chronic, progression, ability to see light; associated symptoms (eye pain, discharge, itching, tearing, photophobia, redness, headache, weakness, numbness, floaters, sparks); history of cardiac, rheumatic, thrombotic, autoimmune, or neurologic disorders; jaw claudication, medications, trauma.
Key Physical Exam
Vital signs; cardiovascular, HEENT, funduscopic, and neurologic exams.
|
Presentation |
Differential |
Workup |
|
■ 73 yo M presents with acute loss of vision in his left eye, palpitations, and shortness of breath. He has a history of atrial fibrillation and cataracts in his right eye. He has no eye pain, discharge, redness, or photophobia. He has not experienced headache, weakness, or numbness. |
Retinal artery occlusion Retinal vein occlusion Acute angle-closure glaucoma Retinal detachment Temporal arteritis (giant cell arteritis) |
Fluorescein angiogram Echocardiography Doppler U/S—carotid Intraocular tonometry ESR Temporal artery biopsy CBC |