Case History #45

Date of Admission: 3-3-1986

HISTORY OF PRESENT ILLNESS:

This 61-year-old right-handed white female home health worker was admitted to the hospital for evaluation of the acute onset of confusion.  She was well neurologically until approximately 4 hours prior to admission, when she was found to be acutely confused and disoriented while in a bank. 

The patient’s past medical history was significant for a longstanding history of hypertension, moderate obesity, and a past history of heavy smoking.

NEUROLOGICAL EXAMINATION:

Mental Status Exam:  The patient was oriented to person and place.  She could not recall the month, day, or year.  Her fund of general information was adequate.  Long term memory testing was performed adequately.  Short term memory testing revealed the inability to recall 3 simple items (rose, penny, and envelope) after 3 minutes, 10 minutes, 15 minutes, and 20 minutes with repeated prompting.  She was able to register the 3 items but could not recall any of them after only a few minutes.  She was also unable to recall other events that had occurred earlier in the day or even events that had occurred a few minutes ago.  She was able to perform calculations adequately.  There was no evidence of language dysfunction, apraxia, or agnosia.  Tests for constructional apraxia were intact.  The patient’s mood was pleasant and cheerful.  However, she was extremely concerned about her memory, and she was constantly asking if she had had a stroke, why she was in the hospital, and what she was doing there.  She was able to recognize her son and daughter-in-law without difficulty.

Cranial Nerves:  Intact.

Motor System:  Intact. 

Reflexes:  Intact. 

Sensory System:  Intact. 

Cerebellar Function:  Intact.

Gait and Stance:  Intact

Questions:

1.  This patient exhibited a restricted deficit of higher intellectual functioning.  What was that deficit?

2.  What specific area(s) of the brain is involved with this higher function?  Would you expect the neurologic lesion in this case to be unilateral or bilateral?  If unilateral, what side of the brain would be involved?

3.  The findings in this case represent a classic neurologic syndrome.  What is the name of that syndrome?

4.  In general, what type of pathologic process is involved in this case?

5.  What is the prognosis?

6.  What diagnostic procedure(s) would you undertake at this point?