Neurology Concept Case Study CC: 69 yo man who’s son states is complaining of being more forgetful and I’m not picking up my feet when I walk.

QUESTION

Neurology Concept Case Study
CC: 69 yo man who’s son states is complaining of being more forgetful and
I’m not picking up my feet when I walk.
HPI: In with his oldest son today. Both have noticed that he has gradual
slowing of his gait and difficulty picking up his feet over the past 6 months.
He has fallen twice in his home a without injury. He denies feeling weaker,
just feels “clumsy” and says, “my legs won’t do what I want them to.” Also,
reports some cognitive changes over the year; more forgetful, more agitated
at times. Denies being ill recently or overall changes in health. Denies any
new medications/ vitamins.
PMH: Considers himself healthy, HTN for 12 years, elevated cholesterol for 6
yrs, Appendectomy at age 38.
Meds: Lisinopril 20mg daily, Simvastatin 20mg daily.
FH: Father killed in the military at age 30. Mother past following CVA at age
84. 2 brothers aged 73 and 67. One with Diabetes and HTN, the older with
dementia. He has 3 children alive and well, ages 45, 41 and 39.
SH: Retired anatomist/professor. Widower of 10 years. Lives alone in single
family home. Drives still. Hobbies include bird watching, Sudoku and model
building. He consumes 1 alcoholic drink every couple of months, denies
tobacco or illicit drugs use.
NKDA: NKDA, environment, food or material allergies.
ROS:
General: no fevers, night sweats, +fatigue, + 8-pound weight loss in past 2
months.
Skin: Reports as dry. Denies changes moles or new lesions.
HEENT: Reports voice as softer, no vision changes, wears hearing aids x 10
years, denies ear pain, denies sore throat, denies swallowing difficulty,
partial dentures for 20 years, denies congestion, does report a decrease in
smell and taste.
Cardio: denies chest pain or palpitations, edema, DOE or orthopnea.
Pulmonary: denies cough or shortness of breath
GI: denies abdominal pain, denies nausea, vomiting or diarrhea. Does have
occasional constipation. + decreased appetite.
MSK/Neuro: denies joint pain or loss of range of motion, denies numbness
tingling that changes in sensation, reports slight periodic tremor in left
hand/upper extremity for about a year.
Psych: Reports being more forgetful and more agitated at times.
VS: BP: 128/70 P: 70 RR: 15 T: 98.6 Ht: 68in Wt: 165lbs Pain: 0/10
PE: Alert, white male with slightly flat affect appears older than stated age,
soft voice and slow movements. Clean and dressed appropriately for
weather, A&0 times 3.
Skin: dry, intact without any lesions.
HEENT: PERRLA, eyes clear, w/o discharge, TM’S intact, canals clear, mouth
moist, w/o lesions, tonsils 2+ no erythema, dentition fair, partial upper
dentures noted. Neck supple without LAD. No thyrommegaly.
Heart/CV: Regular rate and rhythm, no murmurs rubs or gallops, pulse is
equal and intact distally both upper and lower extremities.
Lungs: CTA Bilat. Resonant breath sounds, no crackles
Abdominal: Soft, round, non-tender to palpation, bowel sounds in all
quadrants.
MSK: ROM of upper extremities and lower extremities upper extremity
strength 4+/5. lower extremity strength 4/5. Noted trace resting tremor in
left hand/upper extremity. Gait is wide based and occasional shuffling with
ambulation. Slow to initiate ambulation on command.
Neuro: Romberg negative, negative pronator drift, RAM with poor
coordination due to tremor, upper extremity DTR’s normal, lower extremity
DTR’s slow. CN II-XI intact.

Using the above case scenario, form a list of three to five differential diagnosis (or you may develop a VINDICATE differential list if preferred)  based on the patient’s presentation, HPI, and PE.

Explain, for each differential diagnosis, what in the presentation, HPI, or PE led to your decision to select the differential diagnosis that you chose. (Medical Decision Making)

Select the most likely diagnosis you think the patient could have and select a second possible diagnosis.

Create a pathophysiology flow chart (you may use either an image format or written words). In that flow chart compare and contrast these two diagnoses documenting how the two diagnoses are similar in looking at their symptoms, physical examination and labs, and document how the two diagnoses are different.

Also analyze and write a brief paragraph indicating what your differential diagnoses list could include (list all other possible diagnoses) if your patient is  (1) 80 years old or if the patient was (2) a 23 year old patient. Use evidence based information with citations to support your answers.

ANSWER

Differential Diagnoses for the Case

Parkinson’s Disease (PD)

Presentation: Gradual slowing of gait, difficulty picking up feet, wide-based gait, and shuffling ambulation are indicative of parkinsonian features.
HPI: Cognitive changes, forgetfulness, and agitation may also be seen in PD due to its impact on the central nervous system.
PE: Resting tremor in the left hand/upper extremity and slow lower extremity deep tendon reflexes are classic signs of Parkinson’s disease.

Dementia

Presentation: Cognitive changes, forgetfulness, and agitation, along with a family history of dementia in the older brother, raise suspicion for dementia.
HPI: The gradual onset of cognitive decline over the past year is consistent with the progressive nature of dementia.
PE: Flat affect, decreased appetite, and difficulty initiating ambulation are also characteristic features seen in patients with dementia.

Multiple System Atrophy (MSA)

Presentation: Gradual slowing of gait, difficulty picking up feet, wide-based shuffling gait, and resting tremor are features that overlap with Parkinson’s disease but can also occur in MSA.
HPI: The report of periodic tremor in the left hand/upper extremity over the past year is an atypical feature seen in MSA.
PE: The presence of slow lower extremity deep tendon reflexes is consistent with autonomic dysfunction, a hallmark of MSA.

Most Likely Diagnosis: Parkinson’s Disease (PD)
Second Possible Diagnosis: Dementia

Pathophysiology Flow Chart

PD Dementia
Symptoms Gradual slowing of gait, Cognitive changes, forgetfulness, agitation,
difficulty picking up feet, flat affect, decreased appetite
wide-based gait, shuffling
ambulation, resting tremor

Physical – Resting tremor in left – Flat affect
Examination hand/upper extremity – Cognitive impairment
Slow lower extremity – Difficulty initiating ambulation
deep tendon reflexes

Labs Diagnosis is based on Diagnosis is based on clinical assessment
clinical assessment, and cognitive testing. No specific lab
no specific labs needed tests are needed for diagnosis.

Comparisons

Both PD and dementia present with cognitive changes and agitation.
PD and MSA share some motor symptoms like resting tremor and difficulty initiating ambulation.
Distinguishing features include the presence of slow lower extremity deep tendon reflexes in MSA, which is not typical in PD.

Differential Diagnoses for Different Age Groups

If the patient were 80 years old, additional differential diagnoses could include age-related gait changes, vascular parkinsonism, and Lewy body dementia, considering the higher prevalence of these conditions in older individuals (Ahlskog, 2011; Emre et al., 2007).
If the patient were 23 years old, differential diagnoses could include drug-induced parkinsonism, Wilson’s disease, and early-onset dementia, as young-onset presentations are more likely to be associated with these conditions (Williams et al., 2007; Isaacson, 2021).

In conclusion, the patient’s presentation, HPI, and PE point towards Parkinson’s Disease as the most likely diagnosis. However, considering the age of the patient and family history of dementia, dementia is also a possible second diagnosis. Parkinson’s Disease and dementia share some common symptoms, and a thorough evaluation is essential to arrive at a definitive diagnosis. The pathophysiology flow chart highlights the similarities and differences between the two diagnoses. Additional differential diagnoses could vary based on the age of the patient, and age-specific considerations must be taken into account in clinical practice.