fleisher cases latest
TRANSCRIPT
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8/13/2019 Fleisher Cases Latest
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Case 1
62yo right handed man, Manager for anengineering firm.
Gradual cognitive decline for 3 years
Planning, decision making, word finding,reading, writing, misplacing objects
Finding objects (e.g. car keys) even when in
plain sight. Seen by Ophthalmologist,WNL.
ADLs: Intact, except difficulty with work due toproblems reading and typing reports on the
computer. Mild navigation problems, not getting
lost. Otherwise independent.
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Case 1
PMHx: Obstructive sleep apnea, not using CPAP. no
chronic anhedonia or depression. well-controlled
hypertension, hyperlipidemia, chronic back pain,
gastro-esophageal reflux, and osteoarthritis.
Meds: amlodipine, atorvastatin, dexlansoprazole and
cetirizine. Tramadol for management of chronic back
pain. Flaxseed oil, glucosamine, chondroitin, a
multivitamin, vitamin B complex and garlic
supplementation. FamHx: Mother with Vascular dementia
Soc Hx: No substance abuse, 14 yrs education
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8/13/2019 Fleisher Cases Latest
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Case 1
Physical Exam:
Visual acuity and color vision were grossly intact
Mild L5 radiculapathy
Positive palmo-mental reflex
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Case 1
Bedside cognitive testing:
MMSE 26/30: Pentagon copy (drew squares),
writing a sentence minor error
Category retrieval: 22 animals in one minute Fund of Knowledge: 5/7 correct
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Case 1
MOCA 21/30:
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Physical Exam:
Cortical Vision:
No prosopagnosia, neglect or simultagnosia
Bisecting lines, and identifying symbols on a page symetrical, but slower on right side of page
Difficulty with picture interpretation and object
identification: Self corrected with time and prompting
e.g. This is either
French fries or carrots
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8/13/2019 Fleisher Cases Latest
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Case 1
Working Diagnosis:
MCI: Lewy Body Disease,
AD-posterior cortical variant, Vascular,
non-neurodegenerative (space occupying lesion, NPH, ,etabolic, etc)
Tests:
Labs: CBC, CMP, B12, TSH
Repeat Sleep study for OSA
MRI brain
Formal Neurocognitive testing
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Case 1
Labs: normal
Repeat Sleep study: OSA resolved
MRI (Brain, non-contrast):
moderate atrophy of the hippocampi
global atrophy with a posterior predominance
There was no significant cerebrovasculardisease.
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8/13/2019 Fleisher Cases Latest
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Case 1
Formal Neurocognitive testing:
Impaired concentration, attention and decision
making, symbol digit identification
Poor calculations Impaired visual memory, but recall of encoded
items intact
Visual-motor speeds reduced
Difficulty with complex figure copy Semantic language mildly impaired, mild anomia
Low avg verbal memory, normal logical memory
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8/13/2019 Fleisher Cases Latest
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Case 1
Clinical diagnosis:
MCI: AD-posterior cortical variant
Lewy Body Disease (no EPS, RBSD)
Other non-neurodegenerative
Next Steps:
Consider FDG PET and/or Amyloid PET
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8/13/2019 Fleisher Cases Latest
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Case 1
Biomarker-based diagnostic assessment:
Amyloid PET (evidence of A)
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8/13/2019 Fleisher Cases Latest
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Case 1
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8/13/2019 Fleisher Cases Latest
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Case 1
Biomarker-based diagnostic assessment:
FDG PET (evidence of Neuronal Dysfunction)
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8/13/2019 Fleisher Cases Latest
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Case 1
Final NIA-AA Clinical diagnosis:
MCI due to AD with two biomarker evidence:
AD-posterior cortical variant
Outcomes:
Discussed role of current approved meds for
AD in MCI
Referred to support services and educationalresources
Discussed AD research opportunities
Follow clinically for cognitive decline, mood
disorders, behavioral changes
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8/13/2019 Fleisher Cases Latest
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8/13/2019 Fleisher Cases Latest
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Case 2
62yo right handed women, HR dept manager
for the US state department, Russian
translator.
Short term memory decline for 5 years forgetfulness to events and conversations and
occasional repetition
mild delayed word-finding
increased dependence on calendars
ADLs: Intact, remains independent with
increased effort
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Case 2
PMHx: Mild depression/anxiety,
B12 deficiency
Meds: B12 QD, MCI, Levapro, asa 81mg
FamHx: No family history of dementia
Physical Exam: No abnormalities
Bedside cognitive testing:
MMSE 30/30, MOCA 27/30 (2/5 on recall) 9 animals in 1 minute
AVLT: total score 37, 7/15 words on delayed
recall17
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Case 2
Working Diagnosis:
MCIpossibly due to AD
Tests:
Labs: CBC, LFTs, B12, TSH
MRI Brain
Neurocognitive testing
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Case 2
Labs: Normal
Neurocogntive testing: mild decreased
delayed recall and visual perceptual skills,
good attention.
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Case 2
MRI: No significant atrophy. 2 Venous
cavernous angiomas in the medial basal
frontal lobe and anterior rostral caudate.
Surrounding hemosiderin staining.
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GRE Heme FLAIR T1 post gad
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8/13/2019 Fleisher Cases Latest
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Case 2
Clinical diagnosis:
MCI: possible AD vsMCI due to structural brain lesion
Next step? Amyloid imaging
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8/13/2019 Fleisher Cases Latest
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Case 2
Biomarker-based diagnostic assessment
Amyloid PET (negative for A)
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Case 2
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Case 2
Final Diagnosis and recommendations:
Mild Cognitive Impairment, non-AD
Recommendations:
Follow clinically for decline
Repeat MRI in 6 and 12 months
Discuss risk of bleeding
Stop taking aspirin