Memory Loss and Dementia
Memory loss is a real symptom and sign, but organic brain syndrome should be dropped from usage because it is a wastebasket term. Unless the memory loss is functional (“supratentorial”), the cerebrum is the principal anatomic site of diseases that produce memory loss. Applying the mnemonic VINDICATE to this area provides a method for the prompt recall of causes.
V—Vascular disease includes cerebral arteriosclerosis, thrombi, emboli, and hemorrhages.
I—Inflammatory disorders include syphilis, chronic encephalitis (inclusion body encephalitis and Jakob–Creutzfeldt disease), and cerebral abscess.
N—Neoplasms include primary and metastatic neoplasms of the brain and meninges.
D—Degenerative and deficiency diseases suggest senile and presenile dementia, Pick disease, Wernicke encephalopathy, and pellagra. Pernicious anemia may be associated with dementia.
I—Intoxication brings to mind alcoholism, bromism, lead poisoning, and a host of other toxic or drug-induced encephalopathies. I may also stand for idiopathic and suggest normal-pressure hydrocephalus.
C—Congenital disorders include the encephalopathies, Tay–Sachs disease, cerebral palsy, Down syndrome, Wilson disease, and Huntington chorea. Congenital hydrocephalus and many other causes must be considered. Porphyria is often forgotten in the differential.
A—Autoimmune disease suggests lupus erythematosus and multiple sclerosis, although severe dementia is uncommon in the latter.
T—Trauma should prompt the recall of concussion and epidural, subdural, and intracerebral hematomas. Heat stroke may cause temporary memory loss. The dissociative reaction of psychoneurosis may be precipitated by trauma.
E—Endocrine disorders with memory loss are myxedema, insulinoma with chronic hypoglycemia, and hypoparathyroidism. If a pituitary tumor invades the hypothalamus, there may be memory loss. Addison disease and aldosteronism may affect memory by the associated disturbance in potassium balance.
Approach to the Diagnosis
Once again, the presence or absence of other neurologic signs and symptoms is important. A mini-mental status examination is done. If one does not have the skills or the time for a complete neurologic examination, immediate referral is indicated. Next, a careful drug history is done. Withdrawal of all drugs may clear the dementia. An electroencephalogram (EEG), skull x-ray film, computed tomography (CT) scan, or magnetic resonance imaging (MRI), spinal tap (if there is no papilledema), and psychometric tests are basic to any workup. If the CT scan or MRI shows dilated ventricles, a spinal fluid nuclear flow study is indicated to exclude normal-pressure hydrocephalus. In the absence of other neurologic signs and negative spinal fluid analysis for syphilis and other chronic encephalopathies, one should do an endocrine workup and look for systemic diseases such as porphyria. Blood lead levels to rule out lead intoxication and a urine drug screen should also be done.
Other Useful Tests
Complete blood count (CBC) (pernicious anemia)
Chemistry panel (uremia, liver disease, electrolyte disorder)
Serum B12 (pernicious anemia)
Serum thiamine and B2, B3, and B6 are now available (Wernicke encephalopathy, etc.)
Drug screen (drug or alcohol abuse)
Human immunodeficiency virus antibody titer (acquired immunodeficiency syndrome)
Schilling test (pernicious anemia)
Free thyroxine (FT4), sensitive thyroid-stimulating hormone (hypothyroidism)
Fluorescent treponemal antibody absorption (FTA-ABS) test (neurosyphilis)
Apolipoprotein E testing (Alzheimer’s)
MR angiography(vascular dementia)
Case Presentation #65
A 62-year-old blue-eyed white man complained of increasing forgetfulness. He would occasionally leave a faucet running and when he drove to town he would have to ask directions to get back home. He also suffered indigestion and occasional shortness of breath after walking half a block.
Question #1. Utilizing the mnemonic VINDICATE, what would be your differential diagnosis?
Neurologic examination revealed that he was oriented in time and place but could not name the current president. He has slightly diminished vibratory sense in the lower extremities but no other focal neurologic signs. His hemoglobin was 13.2 g/100 mL.
Question #2. What is your diagnosis?
(See Appendix B for the answers.)
Visualizing the anatomy of the female reproductive system will give an appropriate differential diagnosis:
Cervix: Cervical stenosis (congenital or acquired), cervical polyp, cervicitis
Uterus: Fibroids, retroverted uterus, adenomyosis
Fallopian tubes: Pelvic inflammatory disease (PID), ectopic pregnancy, endometriosis
Ovary: Ovarian neoplasm (especially functional tumors), ectopic pregnancy, endometriosis, and PID
Physiologic analysis would bring to mind the endocrinologic causes of menstrual cramps such as thyroid or pituitary disorders. Finally, do not forget psychogenic causes in the differential diagnosis.
Approach to the Diagnosis
A thorough pelvic and rectal examination must be performed to rule out secondary causes such as ovarian cyst, uterine fibroids, and ectopic pregnancy. A sonogram and pregnancy test should be performed if there is an adnexal mass, as well as a smear and culture for gonococcus and Chlamydia. A gynecologist should be consulted. If test results are negative, the patient may be tried on oral contraceptives. Diuretics may be used to treat pelvic congestion. Resistant cases may need laparoscopy and ultimately a dilatation and curettage. A psychiatric consult may be necessary.
This is the accumulation of gas in the intestines causing distention. The mnemonic VINDICATE lends itself well to facilitate the recall of most of the possible causes.
V—Vascular would prompt the recall of mesenteric thrombosis or embolism. Aortic aneurysms may precipitate bouts of meteorism by causing mesenteric vascular insufficiency.
I—Inflammatory conditions cause meteorism, most notably peritonitis and pancreatitis. However, lobar pneumonia, typhoid, fever, and dysentery should not be forgotten.
N—Neurologic conditions such as transverse myelitis, spinal cord trauma, and anterior spinal artery occlusion may cause meteorism. Conversion hysteria may present with pseudopregnancy and phantom tumors.
D—Degenerative conditions of the intestinal tract or nervous system do not usually cause distention until late in their course.
I—Intoxication should bring to mind the many parasympatholytic drugs (i.e., Pro-Banthine) that cause paralytic ileus.
C—Congenital conditions that may cause this symptom are Hirschsprung disease and malrotation.
A—Allergy would suggest food allergies such as sensitivity to chocolate, peanuts, and so forth. Autoimmune conditions such as granulomatous colitis and ulcerative colitis may produce meteorism.
T—Trauma to the spinal cord has already been mentioned, but penetrating wounds, contusions, and intraperitoneal bleeding may cause meteorism.
E—Endocrine disorders such as myxedema may cause gaseous distention of the bowel.
Approach to the Diagnosis
A flat plate of the abdomen, chest x-ray, and routine laboratory tests including a CBC; sedimentation rate; chemistry panel; serum amylase and lipase; and stool for occult blood, ovum, and parasites may be indicated depending on the clinical picture. A general surgeon or gastroenterologist may need to be consulted in the acute cases. CT scans, ultrasonography, or contrast radiography may be necessary before the diagnosis can be certain. An exploratory laparotomy is occasionally the only way to pin down the diagnosis.
Other Useful Tests
Quantitative stool fat (malabsorption syndrome)
Thyroid panel (myxedema)
MRI of the thoracolumbar spine (spinal cord trauma, transverse myelitis)
Peritoneal taps (intraperitoneal hemorrhage, peritonitis)
Miscellaneous Sites of Bleeding
Bleeding from the ear: This is not usually a serious condition. Anatomy is again applied to formulate a diagnosis. The blood may be from the external or middle ear, and usually is caused by diseases of the skin or drum. Trauma is the most significant cause and is usually related to self-inflicted lacerations from digging at wax with hairpins or pencils, for example, which may occasionally rupture the eardrum. Children are prone to lodge foreign bodies in their ears. Skull fractures of the posterior fossa may present with bleeding from the ear. External otitis and otitis media may cause a bloody discharge, but this is not common. If the drum is ruptured by infection, there is usually bleeding from the ear. Carcinomas of the skin of the external canal may cause a bloody discharge, and cholesteatomas will cause bleeding when they ulcerate through the tympanic membrane. Coagulation disorders rarely present with bleeding from the ear, in contrast to epistaxis and bleeding from the gums.
Bleeding from the gums: No anatomic breakdown is necessary here. The causes may be divided into local and systemic categories but, by using the word VINDICATE, one can cover all the etiologic categories adequately.
V—Vascular would suggest the hemorrhagic disorders, especially hemophilia, thrombocytopenia, heparin and warfarin (Coumadin) therapy, and fibrinogenopenia, as in disseminated intravascular coagulopathy. In children, idiopathic thrombocytopenic purpura may present with bleeding gums and petechiae following an upper respiratory infection.
I—Inflammatory includes acute gingivitis, dental abscesses, pyorrhea, actinomycosis, or syphilis.
N—Neoplasms suggest both local neoplasms (e.g., odontoma, papillomas, and epulis) and systemic neoplasms (Hodgkin lymphoma and leukemia).
D—Degenerative disorders include aplastic anemia and deficiencies such as scurvy and vitamin K deficiencies.
I—Intoxication recalls mercury, phosphorus, and diphenylhydantoin intoxication, in which the gums are usually severely hypertrophied as well.
C—Congenital conditions, other than congenital blood dyscrasias (e.g., sickle cell anemia), include erythema bullosum.
A—Autoimmune suggests thrombocytopenic purpura, Henoch purpura, and lupus erythematosus.
T—Trauma indicates bleeding from vigorous brushing or picking with a toothpick.
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