Grup B7 Tutor 4 Blok 16

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Scenario D block 16

Group B7

Tutor: dr Ramli

Medical FacultySriwijaya University



Feb 5th 2010 B7 tutorial 4 2

Group Members Erisca Ayu Utami 54071001042

Zikrina Istifarani 54071001060

Magista Febra N 54071001062

Annisa Mulyandini 54071001079 Rendi ER Pratama 54071001081

Tinton Ardiyan 54071001092

Febi Stevi A 54071001093

Mohammad Shahir 54071001104

Rashidah bt M Jalil 54071001113 Azri M F 54071001116

Nor Azlan 54071001117




ScenarioMr No 53 years old was brought by his wife to a clinic with the main complaintthat her husband always repeating certain work unawarely. Whenever someoneremind him, he always answered that he did it just once. For example, locking the house door,. In every night he always locked the same door for severaltimes. This condition had already been happened around 7 months ago and

becoming proggresively worse week by week.Mr No is a senior official of a private company for 4 years and he wasgraduated from a famous National University. Although this condition hasalready happened with him but in activity of daily living such as leading themeeting, managing family financial, he was still normal except sometimes hecould not express some words orally. This condition happened in the last 1month.

Physical examination was normal. GCS was 15. Neurological examinationshowed no deficit in hard neurological function. Mental health was normal. CTscanning of the head was normal. MMSE score was 22.

Additional information: 4 years ago he got traffic accident and hospitalized for3 days.




Term Clarification

Repeating certain work unawarely

Proggresively worse

Could not express some words orally GCS

Hard neurological function

MMSE




Problem Identification1. Mr No 53 years old was brought by his wife to a clinic with the

main complain that her husband always repeating certain work unawarely.

2.

This condition had aready been happened around 7 month agoand progressively worse.

3. His activity of daily living is normal but sometime he could notexpress some word orally in the last 1 month.

4. His GSC was 15

5. Neurological examination showed no deficit in hard

neurological function6. His MMSE score was 227. He got traffic accident 4 years ago and hospitalized for 3 days




Problem Analysis1. What are cause and mechanisme of repeating certain work unwarily?

2. What are the correlation, between age and gender with his condition?

3. How his condition become progressively worse?4. What is the correlation between his activity and his condition?

5. What is the correlation between normal activities and his condition?6. What is the cause and mechanisme of could not express word orally?

7. What is interpretation of examination

8. What is correlation of abnormal result with his condition?

9. What is correlation between he got trafict accident 4 years ago with hiscondition now?

10. Differential diagnosis in this case?11. How to diagnose?

12. Management?13. Prognosis?

14. Complication?15. GP competency.




Hypothesis

Mr No, 53 years old man, suffered from minimalcognitive impairment & proggresively became a

mild dementia




Synthesis




Anatomy & Physiology of

Neurobehaviour 4 kinds of memory:

Immediate-term memory

Few seconds

Short-term memory

Seconds to minutes; limitedstorage capacity

Intermediate-term memory

It describe the memories thatoverlap short-term and long-term memory.

Long-term memory

Days, weeks, or a lifetime;requires transfer (consolidation)from short-term; rapid recall.

2 forms of memory:

Explicit/declarative memory

correlates with knowledge of people, places, and things

involves evaluation,comparison, and interference.

Im plicit/ proceduralmemory

correlates with ´howµ to dothings

acquired slowly throughmultiple repetitions.

Both of explicit & implicit memorieshave short-term forms & long-termforms.




...Ana tomy & Physiology




...Ana tomy & Physiology

Anatomic areas that correlate with memory:

Explicit

Immediate: prefrontal cortex & dorsal medial thalamus or

primary & secondary sensory cortex. Short-term: hippocampus ad temporal lobe, mammilary bodies,midline diencephalic structures.

Long-term: diffuse throughout the cerebrum.

Im plicit

Motor: cerebellum, basal ganglia, secondary motor cortex.

Emotion-associated: amygdala.




Chief complaint: repeating certain

work unawarely, around 7 months,

proggresively worse

Disturbance in the neuron at the first time, there was a bit damage in theneuron (not really make his conditions become worse) followed by otherneuron damage itself spread progressively worse




Normal daily living except sometimes

he could not express some words

orally, happened in the last 1 month

It is caused by the accumulation of plaque beta amyloid protein,

tangles (tau protein) the accumulation will spread communication

between cells disturb sometime forget few words

Happening in the last 1 month means the proggresivity of the disease.




Correlation between his job, educational

background & his condition

Graduated from famous national university might show probability of lack of sleep

His job as senior officer might be really busy (stressor). Lack of sleep & really busy easily forget & contribute to

progressively worsen the damaging of nerve.




Examinations

Physical examination normal

No physical abnormality that play role in this case

No deficit in hard neurological function normal

No hard neurological disorder that play role in this case




...E xamina tion s

GCS was 15 normal = com pos mentis

Is a scale to assess level of consciousness 3 things to be assessed:

Eyes opening reaction

Verbal response

Motoric response

The highest value is 15 ( E4V5M6); the lowest value is 3( E1V1M1)




...E xamina tion s

Mental health normal

No psychosis is happened What things must be examined:

Common appearance Mood & affect Speech Perception Thinking

Sensorium & cognitive Impulse control Judgement & insight Realibility




...E xamina tion s

CT scanning of the head normal

No hard abnormal appearance. CT scan and MRI are used to "see" the brain and

surrounding organs. They don·t give a definitive diagnosis of

MCI.

They may show abnormalities in the brain that areconsistent with Alzheimer-like dementia. They also are usedto rule out potentially reversible causes of MCI.




...E xamina tion s

MMSE score was 22 ABNOR MAL

It is to indicate the presence of cognitive impairment

It is an 11-question measure that tests 5 areas of cognitive function:

Orientation (sekarang?, di mana?)

Registration (sebut 3 buah benda)

Attention & calculation (Kurangi 100 dengan 7 sebanyak 5x)

Recall (sebut 3 buah benda tadi) Language (sebut nama benda, ulang kata, lakukan perintah, baca &lakukan perintah, menulis spontan, menggambar bentuk)




Additional Information: traffic

accident 4 years ago & hospitalized

for 3 days

Concussion (Latin: to shake violently ) is the most common type

of traumatic brain injury

Concussion may be caused by:

blow to the head, or

acceleration forces without a direct impact.

It causes a variety of physical, cognitive, and emotional symptoms




Differential Diagnosis Normal aging

mild degree of forgetfulness it doesn·t disturb daily activities

MCI

turunnya penampilan kognitif (hendaya daya ingat, daya belajar, sulitberkonsentrasi)

tidak sampai memenuhi kriteria diagnosis demensia, sindromamnestik organik, atau delirium

dapat mendahului/menyertai/mengikuti berbagai macam gangguaninfeksi, fisik baik serebral maupun sistemik.

Dementia penurunan kemampuan daya ingat & daya pikir, mengganggu

kegiatan harian clear consciousness gejala sudah nyata 6 bulan




...Differen tial Diagno si s

Organic A mnestic Syndrome

penurunan daya ingat jangka pendek amnesia retrograde anterograde riwayat cedera otak atau penyakit otak lainnya (terutama di

diensefalon & temporal medial) tidak kurang daya ingat segera atau immediate recall tidak ada gangguan kesadaran dan gangguan perhatian

Delirium

ganguan kesadaran dan perhatian gangguan kognitif secara umum, gangguan psikomotor, gangguan

siklus tidur bangun, gangguan emosional Onset cepat perjalanan penyakit hilang timbul setiap hari, keadaan 6 bulan




How to diagnose Multiaxial diagnosis

Axis I : F06.7 gangguan kognitif ringan

Axis II : Z03.2 tidak ada diagnosis axis II Axis III : -

Axis IV : -

Axis V : 70 ² 61




Working diagnosis Diagnosis: Minimal Cognitive Impairment Definition: Gangguan memori (ingatan) nyata, bahasa, tetapi tidak

mempengaruhi aktifitas atau kegiatan sehari-hari penderitanya. MCImerupakan fase degenerasi otak ( otak mengalami kemunduran).

Etiology: Process of brain degeneration Abnormality of metabolism Vitamin deficiency Plaque

Hippocampus atrophy

Parkinson disease Epidemiology

Average age of patient is more than 75 years old




...Working diagno si s

Stage of brain deterioration:1. SENESCENCE (physiological)

Ditandai dengan mudah lupa (forgetfulness) Merupakan proses fisiologis (normal) pada usia lanjut

Prevalensi: 35% di usia > 65 tahun 39% kelompok usia 59-60 tahun 85% usia > 80 tahun

2. SENELITY (in between group)

Ditandai dengan memori dan language nyata tanpa demensia Pada Mild cognitive impairment (MCI) merupakan fasetransisi ke demensia





3. DEMENSIA (pathological)

Minimal adanya 3 gangguan fungsi luhur

Gangguan memori yang paling menonjol: pikun

Merupakan medical illness





Examination that is required:1. Anamnesis

Alloanamnesis Autoanamnesis

2. Physical examination3. Examination

Neurologic examination Mental status

4. Additional test Additional anamnesis

history of disease history of

medication history of alcohol

Blood Test

full blood count

thyroid function test

B12 and folat Biochemical (beta amyloid)

EEG : to know the function of brain

PE T(positron emission tomography)-> untuk mengidentifikasi adanyaamiloid atau tangles

CT scan dan MRI untuk membedakan MCI dan alzeimerdengan derajat atropi hipokampus

KIE(komunikasi, informasi, edukasi )yang ditujukan untuk keluarga.

GLO : gerak dan latih otak atau braingym.




Complication The next level of brain deterioration: Alzheimer·s dementia




Prognosis Quo ad vitam bonam

Tidak mengancam jiwa

Quo ad functionam

malamProgresif menjadi demensia




GP Competence

Neurobehaviour Disorders

MCI (Mild Cognitive Impairment) 1 2 3A 3B 4

Level 2Be able to established diagnosis based on physical examination &additional examinations

Refer to relevant specialistBe able to follow up this patient



Thank You

For Your Kind

Attention

Grup B7 Tutor 4 Blok 16

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