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Texas Tech University Health Sciences Center
School of Medicine
AAMC/Hartford Geriatrics Curriculum
MS I: Case #2
Robert and Maria Johnson are both 70. They live on the family cattle ranch near Ropesville.
The ranch has been in the Johnson family for over a 100 years. Maria grew up nearby on her
family’s ranch from a Spanish land grant. They have two married sons who live on the ranch with
their families.
Robert has been less active for the past 5 years following a hip fracture when his jeep rolled
during a snowstorm. He rarely rides now and relies more and more on reports from his sons on
ranch activities. Maria has been cooking his favorite dishes but his appetitie is falling off and he
has been losing weight. She says he has been less humorous and affectionate lately.
Last week his two sons offered to take over running the ranch and suggested he and Maria
move into Lubbock to a senior living compound to be closer to medical care. Robert and Maria
have been talking about this and don’t want to move. Maria would like her brother and his family
to help run the ranch.
Medications: Atenolol 50mg qid started last month. Allergies: None. Smoking: 2 packs per
day for 40 years. Etoh: 1-2 beers each night.
PAST MEDICAL HISTORY: Usual childhood illnesses. Medical: Hypertension X 4 years.
Bronchitis each of the last 4 winters. Arthritis in hands. Surgical: Right hip pinned 1997. Spiral
fracture left tibia age 40. Psychiatric: None.
FAMILY HISTORY: Father died age 80 of MI; mother died age 85 “of old age”. Brother 65 with
hypertension; sister 68 with degenerative arthritis – hands, hips, knees. Two sons 45 and 50 in
good health.
PERSONAL/SOCIAL HISTORY: Born in Ropesville at home. Education through 11th grade.
Two years in U.S. Army in the Philippines. Married age 22. Enjoys hunting, fishing, taxidermy.
Many hunting trophies displayed at home. Likes teaching his grandchildren how to rope. Attends
the local Catholic church on rare occasions.
REVIEW OF SYSTEMS: Unremarkable except as above.
PHYSICAL EXAMINATION: Pleasant older man, appears fit but underweight. Occasional jokes,
somewhat distracted. Height 6’ 2”; weight 170 lbs. Vital Signs: BP 160/95, heart rate 96 and
regular, afebrile. Skin: Well-tanned. Scattered macular nevi, none suspicious. Nails with
cigarette stains. HEENT: Thinning hair. Scalp normocephalic/atraumatic. Pupils constrict 2mm
to 1mm, equally round and reactive to light and accommodation.
Discs flat, without
hemorrhages/exudates. TMs clear. Pharynx with mild erythema, no exudates. Neck: Supple,
without thyromegaly. LN: No lymphadenopathy. Lungs: Hyperresonant. Distant breath sounds.
Scattered wheezes on forced expiration. CV: JVP 6 cm above right atrium; carotid upstrokes
brisk, no bruits. PMI slightly sustained, 5th intercostal space, 8 cm lateral to midsternal line.
Distant S1/S2. No murmurs or extra sounds. Abd: Active bowel sounds. Soft, non-tender. No
hepatosplenomegaly. No masses. No femoral or abdominal bruits. Rectal: Rectal vault without
masses. Stool brown and guaiac negative. Exts: no edema. Neuro: Oriented x3. Cranial
Nerves II-XII intact. Motor: strength 5/5 throughout. Gait antalgic with limp on the right. Sensory:
pinprick intact. Reflexes: 2+ and symmetrical with toes downgoing.
Texas Tech University Health Sciences Center
School of Medicine
AAMC/Hartford Geriatrics Curriculum
MS I: Case #3
Mrs. Connolly is a 72-year-old retired teacher and lives alone in a three-bedroom two-story
home that she has occupied for the past 40 years. Her husband of 45 years died approximately 5
years ago. They had no children. This is her first visit to a physician in several years and she is
here on the advice of a friend. She explains that she no longer has any energy. Although active
in several church and civic groups in the past, she no longer participates in these activities. She
complains that food no longer tastes good and that she has frequent episodes of constipation.
She has not had general blood work for several years. She has had cholesterol, blood pressure,
and blood sugar screenings at the mall, which were all normal. She had a mammogram at age
45, which was normal. She states that she has not had a reason to have one again-she has
never felt a lump in her breast, and they are too expensive.
Medications:
Premarin 0.65mg was discontinued three years ago, over the counter
antihistamines, Ginseng/gingko herbal supplement. Allergies: Sulfa causes rash. Smoking: 1
ppd x 30 years. Etoh: 1-2 cocktails each evening since her husband died.
PAST MEDICAL HISTORY: Childhood – Usual childhood illnesses.
Medical: Frequent
bronchitis. Surgical: Hysterectomy age 48; appendectomy at age 40. NO history of fractures.
Psychiatric: Depression when her husband died.
FAMILY HISTORY: Father died age 55, cause unknown. Mother died age 68 from pneumonia.
One sister died age 42 from breast cancer, one brother is in good general health.
PERSONAL AND SOCIAL HISTORY: Born and has always lived in Lubbock. College graduate.
Shops and cooks for herself. Drives a car. Fixed income—primary source is social security and
limited savings. Enjoys reading to her two grandchildren and painting ceramics. Attends church
on occasion.
REVIEW OF SYSTEMS: Unremarkable except for HPI.
PHYSICAL EXAMINATION: Pleasant, well-groomed, thin; appears fatigued. Eye contact limited.
Anthropometrics: Ht: 5’6”. Current wt: 110 lbs. Wt 6 months ago: 125 lbs. Usual wt: 140 lbs.
Vital signs: BP 150/80. HR 82, regular. RR 18. Afebrile. Skin: Cool to touch, scattered bruises
on arms and legs. Skull normocephalic/atraumatic. Temporal muscle wasting. Pupils constrict 3
mm to 2mm, ERRLA. Tympanic membranes clear. Pharynx with mild erythema. No sores on
oral mucosa, some tenderness over bridgework. Several loose teeth. Neck: Supple, without
thyromegaly. LN: No lymphadenopathy. Lungs: Resonant and clear. CV: JVP 6 cm above
right atrium; carotid upstrokes brisk, no bruits. PMI tapping, non-displaced. Good S1/S2. No
murmurs, S3; S4 present. Abdomen: Well healed surgical scars. Bowel sounds active.
Abdomen soft, nontender, no hepatosplenomegaly. No masses. Extremities: Muscle wasting,
bruising on arms and legs. No lesions or sores. No edema. Rectal: Rectal vault without
masses. Stool brown, hard; guaiac negative. Neurologic: Mental status: Oriented to person,
place, time. Recalls 3/3 objects after 5 minutes. Counts backward by seven without error. Motor:
Strength 5/5. Decreased muscle bulk. Sensory: Pinprick intact to toes. Reflexes: 2+ and
symmetrical, toes downgoing (Babinski-negative).
Case 3, page 2
Diet History:
At physician’s request, Mrs. Connolly reported the following 24-hour recall of food intake. She
reports that this is a very typical day for her.
Time
Location
Food
Quantity
9:00 a.m,
Home
White toast
Jelly
Hot tea
2 slices
2 tbsp.
2 cups, plain
11:00 a.m.
Home
Glazed doughnut
1 whole
1:00 p.m.
Home
Campbell’s chicken
and rice soup
Saltine crackers
Hot tea
Butter cookies
1 cup
6
1 cup, plain
2
3:30 p.m.
Home
Pound cake
1 slice
6:00 p.m.
Home
White bread
Peanut butter
Jelly
Butter cookies
1 slice
2 tbsp.
2 tbsp.
2
INITIAL DISCUSSION QUESTIONS
1. What additional clinical history would be helpful?
2. What are your initial impressions?
3. What further evaluation might be helpful?
4. What is this patient’s Body Mass Index (BMI)? Is it adequate?
Developing Focused Questions: End of Session I
• Each student should develop one focused question at the end of Session I.
• Focused questions should include both basic science and clinical issues.
• Should entail 1-3 hours of searching relevant evidence - medical librarians
available to help.
• Results of your search should be orally presented to group during Session II.
Maximum length for your presentation - 3-4 minutes.
Case 3, page 3
For Small Group Leaders Only: Each student should identify a focused question by
the end of Session I. Your primary role will be in ensure that the question is narrow
enough to be answered within a one to three hour literature search. Below are some
suggested questions in case the students have trouble identifying questions they want to
answer.
POSSIBLE STUDENT FOCUSED QUESTIONS:
Basic Science
•
•
•
•
•
•
•
What is the biochemical link between albumin and nutritional status?
What is the biochemical link between Hg and Hct and nutritional status?
What are the links between nutrition and depression?
What immune functions are linked to nutrition that affect wound healing? Explain
their biochemistry.
What nutritional factors affect dentition?
What biochemical changes affect clotting factors and bruising?
What are the biochemical effects of vitamin A; D; C; E; calcium; magnesium, etc. Pick
one and describe in detail.
Clinical Medicine
•
•
•
•
•
•
•
•
•
•
What factors or conditions could explain her poor appetite? Pick one to investigate.
What clinical findings reflect poor nutrition?
How does the patient’s diet compare to recommendations for her age? What
is deficient or limited? What needs to be added or replaced?
What are fluid needs in 24 hours? How does the body metabolize fluid intake?
What are the links between diet and constipation? Colon cancer?
What are the risk factors for poor nutrition in the elderly?
What nutrition services are available in Lubbock?
What are recommended guidelines for physicians giving nutrition education?
What educational follow-up is needed?
Risk factors for breast cancer?
Indications for mammograms, including sensitivity and specificity?
N:\Case Module 6:GA 2/6/01
Texas Tech University Health Sciences Center
School of Medicine
AAMC/Hartford Geriatrics Curriculum
MS II: Case #4 *
Diane Linton is a 62 year old real estate agent who comes to your office for her annual physical
examination. She is in excellent health except for fibrocystic breast disease and one prior breast
biopsy at age 45 which was benign. She has found a small lump near the left axilla. She drinks
decaffeinated coffee and soft drinks. She exercises sporadically and eats out frequently. She
often has fast foods for lunch. Her last mammogram was two years ago. She checks her breasts
on occasion.
Medications: Vitamins, Tylenol and Motrin prn headaches. Allergies: None. Smoking: In
college, also tried marijuana. Etoh: 1-2 glasses of wine and a martini in the evening.
PAST MEDICAL HISTORY: Childhood: Tonsillectomy age 9. Medical: As above. Seasonal
allergies. Surgical: Breast biopsy age 45 following abnormal mammogram -- showed fibrocystic
breast disease. OB/GYN: G0P0. Infertility work-up at age 38 unremarkable except husband had
low sperm count. Has never taken birth control pills or hormone replacement therapy.
Psychiatric: None.
FAMILY HISTORY: Mother had breast cancer age 42, died age 45. Father in good health.
Brother 40 in good health. Sister 55 with fibrocystic breast disease. Maternal aunt died of breast
cancer at age 49. Grandparents died of old age.
PERSONAL/SOCIAL HISTORY: Born in Galveston. College graduate – degree in business.
Husband also in real estate. She enjoys fishing and hiking.
REVIEW OF SYSTEMS: Unremarkable except as above.
PHYSICAL EXAMINATION: Pleasant older woman, appears healthy. Neatly groomed. Seems
sad and worried. Vital Signs: 120/80, HR 80 and regular, RR 16, Temp. 98.6. Skin: No
suspicious nevi. HEENT: Normocephalic/atraumatic. Pupils constrict from 3 mm to 2 mm,
equally round and reactive to light and accommodation. Discs flat, without hemorrhages/exudates.
TMs clear. Pharynx negative. Neck: Supple, no thyromegaly. No lymphadenopathy. Breasts:
Symmetric, no nipple discharge. 1-2 cm firm nodule left breast at 2 o’clock, movable. Minor
fibrocystic changes bilaterally. Lungs: Clear. CV:
JVP 6 cm above right atrium; carotid
upstrokes brisk, no bruits. PMI tapping, non-displaced. Good S1/S2. No murmurs or S3. Abd:
Active bowel sounds. Soft, non tender. No hepatosplenomegaly. No masses. Pelvic: Deferred.
Peripheral vascular: Pulses 2+ throughout. Extremities: warm and without edema. Neuro:
Oriented x3. CrN II – XII intact. Motor: strength 5/5. Sensory: pinprick intact to toes. Reflexes:
2+ and symmetric, toes downgoing.
*Adapted from CATCHUM Project, National Cancer Institute see http:// www.catchum.utmb.edu
Case # 4 Page 2
INITIAL DISCUSSION QUESTIONS
1. What additional clinical history would be helpful?
2. What are your initial impressions?
3. What lab studies might be helpful?
Developing Focused Questions: End of Session I




Each student should develop one focused question at the end of Session I.
Focused questions should include both basic science and clinical issues.
Should entail 1-3 hours of searching relevant evidence - medical librarians
available to help.
Results of your search should be orally presented to group during Session
II. Maximum length for your presentation - 3-4 minutes.
Resources:
1. U.S. Preventive Services Task Force. Guide to Clinical Preventive Services,
2nd ed. Baltimore, Md.: Williams & Wilkins, 1996.
http://odphp.osophs.dhhs.gov/pubs/GUIDECPS/DEFAULT.HTM
2. Bickley L, Hoekelman R, eds. Bates’ Guide to Physical Examination and History
Taking, 7th ed. Philadelphia, Pa.: Lippincott, 1999.
3. Woolf S, Jonas S, Lawrence R. Healthy Promotion and Disease Prevention in
Clinical Practice. Baltimore, Md.: Williams and Wilkins, 1996.
4. Murphy G, Lawrence W Jr., Lenhard RE Jr. American Cancer Society Textbook
of Clinical Oncology, 2nd ed. Atlanta, Ga.: American Cancer Society, 1995.
5. Physicians Oncology Education Program. Cancer Resources for Education
(CARE) Box. Austin, Tx.: Texas Medical Association.
6. Boyer K, Ford M, Judkurs A, Levin B. Primary Care Oncology. Philadelphia, Pa.:
Saunders. 1999.
Case #4 Page 3
For Small Group Leaders Only: Each student should identify a focused question by
the end of Session I. Your primary role will be in ensure that the question is narrow
enough to be answered within a one to three hour literature search. Below are some
suggested questions in case the students have trouble identifying questions they want
to
answer.
POSSIBLE STUDENT FOCUSED QUESTIONS:
Basic Science
1.
2.
3.
4.
At the cellular level, is breast cancer one disease or several diseases?
What molecular factors turn on breast cancer cell proliferation?
At the molecular and cellular levels, what are the actions of tamoxiphen?
What pathologic features distinguish fibrocystic changes from malignancy? Are
there other grades of biopsy findings that would be worrisome?
Clinical
1. What are the risk factors for breast cancer? Which are the most worrisome?
2. What are the guidelines for frequency of mammograms? What is the sensitivity
and specificity of mammograms for detecting breast cancer?
3. How useful is the self-breast exam (SBE)? How should you instruct patients to
do this exam?
4. What about the clinical breast exam (CBE)?
5. What are the effects of alcohol and caffeine on breast disease?
6. What findings on mammogram are suspicious? What findings are diagnostic?
7. Treatment and its effectiveness for:
i.
ii.
iii.
iv.
Ductal carcinoma in situ
Local invasive disease
Invasive disease with lymph node involvement
Invasive disease with metastatic involvement
8. Ethics: ordering BRAC I or BRAC 2 testing; insurance company confidentiality.
9. Emotional support measures; effect of depression on treatment outcome.
N:\Case Module 4:GA 1/8/01
Texas Tech University Health Sciences Center
School of Medicine
AAMC/Hartford Geriatrics Curriculum
MS II: Case #5*
Mrs. Maria Garcia is a 64 year old teacher referred to your office by the Emergency Room for
evaluation and treatment of anemia. In the Emergency Room she had presented with a 4 day
history of fever, productive cough, sinus congestion, and malaise, and was given an antibiotic.
Her HCT was 22 (normal 36-45) with an MCV of 71 (normal 80-98 fL) and RDW of 20 (normal 1114).
She has been well until 2 to 3 months ago when she began to feel tired. Even light housework
makes her short of breath, light-headed, with pounding of her heart. Her appetite has been good
but she has lost a few pounds. Her diet is mainly hamburgers, beef, and pork. She eats cooked
vegetables on occasion, but does not like fresh vegetables. She denies any nausea, vomiting,
abdominal pain, or change in bowel habits or urination.
Medications: None. Allergies: None. Smoking: None. Etoh: Beer on occasion.
PAST MEDICAL HISTORY:
Medical: See HPI. Also had iron deficiency anemia 1987
attributed to heavy menses.
Surgical: Hysterectomy 1987 for fibroid uterus; required
transfusion. Discharged on iron pills. Ob/Gyn: G3P2 Menarche age 12. Psychiatric: None.
FAMILY HISTORY: Father 85 with hypertension x 20 years; had surgery for colon cancer age
52. Mother 84 and healthy. One brother with hypertension.
PERSONAL/SOCIAL HISTORY: Born in Laredo, Texas. BA in Education. Married age 24.
Husband is retired policeman. Enjoys home crafts and travel. Children all in the Lubbock are.
REVIEW OF SYSTEMS: Unremarkable except as above.
PHYSICAL EXAMINATION: Pleasant older Hispanic woman, appears slightly overweight at 163
lbs. Height 5’5”. Vital Signs: 110/70, heart rate 86 and regular, afebrile. Skin: No suspicious
nevi. Nails without clubbing, cyanosis. HEENT: Normocephalic/atraumatic. Pupils constrict 4
mm to 2 mm, equally round and reactive to light and accommodation. Discs flat, without
hemorrhages/exudates. TMs clear. Pharynx negative. Neck: Supple, without thyromegaly. LN:
No lymphadenopathy. Breasts: Fibrocystic changes, no masses. Lungs: Resonant and clear.
CV: JVP 6 cm above right atrium; carotid upstrokes brisk, no bruits. PMI tapping, 5 th intercostal
space, 8 cm lateral to midsternal line. I/VI systolic ejection murmur at LLSB. No S3/S4. Abd:
Active bowel sounds. Soft, non tender. No hepatosplenomegaly. No masses. Pelvic: Vaginal
mucosa pink. Absent uterus and adnexa. Rectal: Rectal vault without masses. Stool brown, 2+
guaiac positive. Exts: no edema. Neuro: intact.
*Adapted from CATCHUM Project, National Cancer Institute see http:// www.catchum.utmb.edu
Case # 5 Page 2
INITIAL DISCUSSION QUESTIONS
1. What additional clinical history would be helpful?
2. What are your initial impressions?
3. What further evaluation might be helpful?
Developing Focused Questions: End of Session I
Ÿ Each student should develop one focused question at the end of Session I.
Ÿ Focused questions should include both basic science and clinical issues.
Ÿ Should entail 1-3 hours of searching relevant evidence - medical librarians
available to help.
Ÿ Results of your search should be orally presented to group during Session
II. Maximum length for your presentation - 3-4 minutes.
Resources:
1. U.S. Preventive Services Task Force. Guide to Clinical Preventive Services,
2nd ed. Baltimore, Md.: Williams & Wilkins, 1996.
http://odphp.osophs.dhhs.gov/pubs/GUIDECPS/DEFAULT.HTM
2. Bickley L, Hoekelman R, eds. Bates’ Guide to Physical Examination and History
3.
4.
5.
6.
Taking, 7th ed. Philadelphia, Pa.: Lippincott, 1999.
Woolf S, Jonas S, Lawrence R. Healthy Promotion and Disease Prevention in
Clinical Practice. Baltimore, Md.: Williams and Wilkins, 1996.
Murphy G, Lawrence W Jr., Lenhard RE Jr. American Cancer Society Textbook
of Clinical Oncology, 2nd ed. Atlanta, Ga.: American Cancer Society, 1995.
National Cancer Institute Web site: http://www.nci.nih.gov/cancerinfo/index.html
American Cancer Society Web site: http://www.cancer.org/index.html
Case # 5 Page 3
For Small Group Leaders Only: Each student should identify a focused question by
the end of Session I. Your primary role will be in ensure that the question is narrow
enough to be answered within a one to three hour literature search. Below are some
suggested questions in case the students have trouble identifying questions they want
to
answer.
POSSIBLE STUDENT FOCUSED QUESTIONS:
Basic Science
1. What are the genetics of colon cancer?
2. What molecular mechanisms lead to colon cancer cell proliferation?
3. What bone marrow signals allow response to anemia? What membrane signals
change red cell width and distribution? How is iron incorporated into the heme
molecule?
4. What postulated cellular mechanisms linked to increased fat and folate intake
reduce risk of colorectal cancer?
Clinical
1. Identify the patient’s risk factors for colorectal cancer. Pick one and assess the
strength of the evidence supporting this characteristic as a risk factor.
2. The prevalence of iron deficiency anemia in pre and postmenopausal women.
3. Sensitivity/specificity of stool guaiacs; of flexible sigmoidoscopy.
4. Colonoscopy vs barium enema.
5. Location, staging of colorectal cancer; role of CT scan.
6. Treatments for colorectal cancer; risks/benefits.
7. Significance of colonic polyps.
8. Ethics of genetic testing and disclosure.
9. Ethics of clinical trials for radiation/chemo.
N:\Case Module 5:GA 1/8/01
Texas Tech University Health Sciences Center
School of Medicine
AAMC/Hartford Geriatrics Curriculum
MS II: Case #6*
Pastor Blackburn is a 60 year old minister who comes to your office for routine
follow-up for hypertension, diabetes, and coronary artery disease. He has followed
advice about diet and medications and states he is feeling well except for recent
problems with frequent urination. He is urinating almost hourly during the day, and up to
four times during the night. He has no fever and no burning with urination. He has no
difficulties with sexual activity. Bowel movements are regular.
Medications: NPH Insulin 20 units and Regular 10 units before breakfast and before
dinner, ASA 325mg qd, Altace 10mg qd, Saw Palmetto one tablet three times a day,
Vitamin E. Allergies: None. Smoking: None. Etoh: 1-2 cans of beer a day;
occasional glass of wine with dinner.
PAST MEDICAL HISTORY: Childhood – No scarlet fever or rheumatic fever.
Medical: Hypertension for 14 yrs. Diabetes for 6 yrs. Surgical: Angina then coronary
bypass x 1 vessel age 52. Psychiatric: Depression following bypass surgery for 6
months.
FAMILY HISTORY: Father died age 68 of MI. Mother died age 55 due to gangrene
from diabetes. Brother age 68 with prostate surgery.
PERSONAL/SOCIAL HISTORY: Born in Waco, Texas. Degree from SMU. Married for
31 years; 3 grown children. Maintains active schedule. Enjoys golf and Western
history. Walks 1 mile a day.
REVIEW OF SYSTEMS: Unremarkable.
PHYSICAL EXAMINATION: Rev. Blackburn is a pleasant moderately obese older black
male, who appears relatively fit. Vital signs: BP 155/92, HR 78 with occasional skipped
beats, afebrile. Skin: No suspicious nevi. HEENT: Normocephalic/atraumatic: Pupils constrict
4 mm to 2 mm, equally round and reactive to light and accommodation. Optic discs with sharp
margins; 1+ arteriolar narrowing. TMs clear. Pharynx without exudates. Neck: Supple, no
thyromegaly. LN: No lymphadenopathy. Lungs: Resonant and clear. CV: JVP 6 cm above
right atrium; carotid upstrokes brisk, without bruits. PMI slightly sustained in 5 th intercostal space,
10 cm lateral to midsternal line. Good S1/S2. S4 present. No murmurs or S3. Abdomen:
Obese. Active bowel sounds. Soft, non-tender. No hepatosplenomegaly. No masses.
Genitourinary: Testes descended bilaterally; no penile lesions or discharge. Rectal: Rectal
vault without masses; stool brown and guaiac negative. Prostate nontender; right and left lobes
moderately enlarged. One centimeter nodule on right lobe, no palpable direct or indirect inguinal
hernia.
Extremities:
warm and without edema.
Peripheral Vascular:
No
femoral/abdominal/inguinal bruits. Pedal pulses 1+ and symmetrical. Neurologic: Oriented x3.
Motor: Strength 5/5. Good bulk and tone. Sensory: Pinprick intact to toes. Reflexes: 2+ and
symmetrical, toes downgoing.
*Adapted from CATCHUM Project: National Cancer Institute see http:// www.catchum.utmb.edu
Case# 6 Page 2
INITIAL DISCUSSION QUESTIONS
1. What additional clinical history would be helpful?
2. What are your initial impressions?
3. What further evaluation might be helpful?
Developing Focused Questions: End of Session I
Ÿ Each student should develop one focused question at the end of Session I.
Ÿ Focused questions should include both basic science and clinical issues.
Ÿ Should entail 1-3 hours of searching relevant evidence - medical librarians
available to help.
Ÿ Results of your search should be orally presented to group during Session
II. Maximum length for your presentation - 3- 4 minutes.
Resources:
1. U.S. Preventive Services Task Force. Guide to Clinical Preventive Services, 2nd
ed. Baltimore, Md.: Williams & Wilkins, 1996.
http://odphp.osophs.dhhs.gov/pubs/GUIDECPS/DEFAULT.HTM
2. Bickley L, Hoekelman R, eds. Bates’ Guide to Physical Examination and History
Taking, 7th ed. Philadelphia, Pa.: Lippincott, 1999.
3. Woolf S, Jonas S, Lawrence R. Healthy Promotion and Disease Prevention in
Clinical Practice. Baltimore, Md.: Williams and Wilkins, 1996.
4. Murphy G, Lawrence W Jr., Lenhard RE Jr. American Cancer Society Textbook
of Clinical Oncology, 2nd ed. Atlanta, Ga.: American Cancer Society, 1995.
Case # 6 Page 3
For Small Group Leaders Only: Each student should identify a focused question by
the end of Session I. Your primary role will be in ensure that the question is narrow
enough to be answered within a one to three hour literature search. Below are some
suggested questions in case the students have trouble identifying questions they want
to
answer.
POSSIBLE STUDENT FOCUSED QUESTIONS:
Basic Science
Ÿ
Ÿ
Ÿ
Ÿ
Ÿ
What is the neuroanatomy of bladder function? Of male sexual function?
What cellular changes occur in benign prostatic hyperplasia (BPH)?
What are the genetics of prostate cancer?
What is the neurochemistry of autonomic dysfunction in diabetic neuropathy?
What molecular signals control prostate cancer cell proliferation? Why is
proliferation so slow compared to other malignancies?
Clinical Medicine
Ÿ What is the differential diagnosis of urinary frequency? Pick one and
describe in detail.
Ÿ How effective are screening questions for BPH? For prostate cancer?
Ÿ What are the risk factors for prostate cancer? Pick one and describe its
sensitivity, specificity, prevalence, and other characteristics.
Ÿ How useful is the prostate specific antigen (PSA)?
Ÿ How useful are alternative therapies?
Ÿ How sensitive is the digital exam of the prostate for prostate CA? the
prostate ultrasound?
Ÿ What are the indications for prostate biopsy?
Ÿ What are the risks for recurrence of depression?
Ÿ What are the risks and benefits of prostate surgery?
N:\Case Module 6:GA 1/8/01
8/13/01
TEXAS TECH UNIVERSITY HEALTH SCIENCES CENTER
School of Medicine
AAMC/Hartford Geriatrics Curriculum
MSIII: Case #7
HISTORY OF PRESENT ILLNESS: RG is a 74 year-old widowed cotton farmer who
comes to your office because he recently had a free prostate-specific antigen (PSA)
blood test performed at a community hospital during Prostate Cancer Awareness Week
on the advice of his daughter. His PSA test result is 3.7 ng/ml (normal <4).
Upon questioning he states that he has to get up at night to urinate at least every other
night, his urinary stream is weak, and occasionally he has to strain to begin urination.
While these symptoms are annoying to him, they have not precluded his normal daytime
activities. On rectal exam, his prostate feels rubbery and large.
After discussing his symptoms, possible causes, and options for further evaluation and
treatment, Mr. Grand decides that he does not want to pursue further evaluation or
initiate treatment for any of his symptoms at this time and decides on a course of
watchful waiting. He agrees to return for follow-up evaluation in 6 months.
One year later, Mr. Grand returns complaining of low back pain. He reports increased
urinary urgency and frequency since his last visit. He is not febrile, and his WBC is
WNL.. On examination he is noted to have an area of firmness (with no tenderness)
over the right lobe of the prostate. PSA is now 34.6 ng/ml, and a bone scan indicates
increased uptake over the fourth lumbar vertebra.
Needle biopsy of the prostate shows a poorly differentiated cancer with a Gleason score
of 8. You discuss prognosis and treatment options with Mr. Grand and, with his
daughter’s support, Mr. Grand decides to be treated with hormone therapy to control his
bone pain.
Mr. Grand remains relatively pain free and able to live independently and carry out his
normal activities over the next several months. However, approximately 1 year after you
last saw him, he calls you with report of increasing pain and nausea. However, the
HMO (through which he has supplemental health insurance through his former
employer’s health plan) was sold to a corporation with out-of-state headquarters and you
are no longer a member of their provider network. Mr. Grand is able to secure an
appointment with a doctor who is in the provider network and he prescribes pain
medications. The medications prescribed by his physician do little to help, but his
physician is reluctant to change the medication to one that is not on the formulary or to
increase the dose of his present pain medications for fear of being accused of overprescribing narcotics.
Further history and physical examination at this time are as follows:
PAST MEDICAL HISTORY: Hypertension for 5 years. Hip arthritis – increased over
the past 2 years. Duodenal ulcer – 1985.
FAMILY HISTORY: Father died of metastatic prostate cancer. Mother died of CHF.
No family history of CAD, MI, CVA, DM, thyroid or renal disease, seizures, suicide.
Alcoholism in MGF.
PERSONAL/SOCIAL HISTORY: Born in Lamesa. High school graduate. Worked on
the family cotton farm all of his life but sold it 5 years ago when his wife died. He lives
alone in a small house. He enjoys golf and skeet shooting.
REVIEW OF SYSTEMS: Negative except as above.
PHYSICAL EXAMINATION: Pleasant, underweight, elderly man. Poor eye contact.
Blood pressure 100/60, heart rate 100 and regular, respirations 16. Skin: Scattered
ecchymoses. HEENT: NC/AT. Pupils 3 to 2 mm ERRLA. Discs flat, without H/E. TMs
clear. Pharynx negative. Neck: Supple without thyromegaly. No lymphadenopathy.
Lungs: Resonant, clear. Positive kyphosis. CV: JVP 6 cm, increased RA. Upstrokes
brisk, no bruits. PMI tapping, nondisplaced. Good S1, S2. II/IV SEM at LLSB. No S3
or S4. Abdomen: Scaphoid. BS present. Soft. Epigastric tenderness. Liver firm with
edge 2 fingerbreadths below RCM span of 13 cm; spleen not palpable. GU: Prostate
enlarged, nodular. Extremities: Without edema. Musculoskeletal: tender over left
10TH posterior rib and right anterior 4th rib, L5 vertebra. Neuro: Oriented x3. Cranial
Nerves II-XII: Intact. Motor: Decreased bulk upper and lower extremities. Strength:
5/5. Antalgic gait. Sensory: Pinprick intact to toes. Reflexes: 2+ throughout. Toes
downgoing.
Distressed by his increasing level of discomfort and despair, Mr. Grand’s daughter calls
you and asks for your help. Because he is a Medicare beneficiary, you know that Mr.
Grand is eligible for hospice care and you advise Mr. Grand and his daughter of this
option. Although Mr. Grand is tired, discouraged, and in a great deal of pain, he
transfers his care to a community (non-profit) hospice program with the help and
encouragement of his daughter. The hospice doctor visits Mr. Grand at home, does an
assessment of his pain and other symptoms, and develops a care plan that emphasizes
effective pain relief and provides supportive home services. Mr. Grand is able to remain
at home, celebrate Christmas with his daughter and his grandchildren, and – despite
weakness – say his good-byes before dying in January.
INITIAL DISCUSSION QUESTIONS
1. What additional clinical history would be helpful?
2. What are your initial impressions?
3. What lab studies might be helpful?
POSSIBLE STUDENT FOCUSED QUESTIONS:
Basic Science
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What cellular changes underlie BPH?
What molecular signal changes occur in cancerous prostate cells?
What neural signaling results in low back pain? Of bone pain?
What are the genetics of prostate cancer?
What is the pathophysiology of cachexia?
What therapeutic options are available for prostate cancer? What is their
pathophysiology and biochemistry?
Clinical:
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What are the principles and objectives of a screening program?
What is “watchful waiting”?
How does (or should) the patient’s reimbursement affect your relationship (and
responsibility) to the patient?
What do people fear most as they age?
What do men fear most as they age?
What (and how) would you present the laboratory confirmation of a terminal
illness?
What is important for the patient to know about his disease?
What is important for you (the doctor) to know about the patient?
What fears are likely to be present in a patient who is dying?
What is the role of a patient’s family or family member in discussing the
diagnosis, prognosis, and treatment of a disease?
What is “end-of-life care” and when should it begin?
INITIAL DISCUSSION QUESTIONS
1. What additional clinical history would be helpful?
2. What are your initial impressions?
3. What lab studies might be helpful?
8/14/01
Texas Tech University Health Sciences Center
School of Medicine
AAMC/Hartford Geriatrics Curriculum
MS III: Case #8
Mrs. Rodriguez is a 64-year-old teacher with a longstanding history of diabetes and
hypertension. Her daughter calls for an urgent appointment in your office – her mother
has had strange speech all day and has trouble getting out of a chair.
You meet the patient and her daughter at the Emergency Department. Mrs. Rodriguez
looks distressed and is trying to greet you by name. Her daughter says sometimes she
skips her medications if she is in a hurry to get to school.
Medications: Lisinopril 5 mg q.d., glipizide 10 mg q.d., Glucophage 500 mg b.i.d., ASA
325 mg q.d., Premarin 0.625 mg q.d., Tylenol 650 mg p.r.n. arthritis. Allergies: Sulfa –
rash. Smoking: 1 pack per day x20 years until age 50. ETOH: Rare.
PAST MEDICAL HISTORY: Childhood: No history of scarlet fever/rheumatic fever.
Medical:
diabetes x12 years, moderately controlled; hypertension x10 years,
moderately controlled; arthritis – primarily knees. Surgical: hysterectomy at age 43.
OB/GYN: G3, P3. Psychiatric: None.
FAMILY HISTORY: Father with diabetes, insulin dependent – died of massive CVA.
Mother with hypertension, breast cancer. Twin brother alive and well. Three children in
good health.
PERSONAL/SOCIAL HISTORY: Born in Alpine, Texas. Education - college graduate.
Married at age 24. Husband is retired police dispatcher. Enjoys gardening, cooking,
caring for grandchildren.
REVIEW OF SYSTEMS: Unremarkable except that daughter states her mother has
complained of incontinence over the past year and a half.
PHYSICAL EXAMINATION: Ms. Rodriguez appears healthy, slightly overweight and of
medium stature, but with an obvious right facial droop. She is breathing comfortably but
holds her head at times. Blood pressure 170/88, heart rate 96 and regular, respirations
20. Temperature 98°. Skin: No petechiae, ecchymoses. HEENT: NC/AT. Pupils 3
mm, constricting 2 mm, ERRLA. Discs flat with silver wiring and microaneurysms; no
hemorrhages or exudates. TMs clear. Dentition good. Pharynx without exudate.
Neck: Supple without thyromegaly. No lymphadenopathy. Breasts: Without masses.
Lungs: Resonant and clear. CV: JVP 7 cm above right atrium; carotid upstrokes
brisk, no bruits. PMI sustained in 5th intercostal space, 8 cm lateral to midsternal line.
Good S1, S2. No murmur. S4 present. Abdomen: Bowel sounds present. Soft,
nontender, no hepatosplenomegaly or masses. No abdominal or femoral bruits.
Extremities: Warm, without edema. Musculoskeletal: Good range of motion of all
joints. Degenerative changes in the knees. Neuro: Orientation: Cannot assess – has
difficulty finding words. The patient is alert, responds to command. Cranial nerves:
Right VII weakness, otherwise II-XII intact. Motor: Strength 3/5, RUE, RLE; 5/5 LUE,
LLE. Normal bulk; increased tone on right. Cerebellar: RAMs, finger-to-nose intact on
left, cannot perform on right. Sensory: Decreased pinprick right face, arm, leg; intact
on left. Reflexes: Hyperreflexia -- right biceps, triceps, knee, and ankle jerks. Babinski
– right large toe upgoing; left – down. Has right pronator drift.
INITIAL DISCUSSION QUESTIONS
1. What additional clinical history would be helpful?
2. What are your initial impressions?
3. What lab studies might be helpful?
8/14/01
Texas Tech University Health Sciences Center
School of Medicine
AAMC/Hartford Geriatrics Curriculum
MS III: Case #9
Mr. Johnson is an 81-year-old retired engineer, who was widowed year ago. He lives
alone and has been referred to you by his daughter who is a patient of yours. She notes
that the patient has been increasingly confused, having occasional falls and bruises.
She is concerned that several weeks ago he fell and broke his wrist but refused medical
treatment and did not go the Emergency Center or seek care from a physician. The
patient comes in with his daughter for a first visit to your office with a brown bag full of
all of the medications he has been taking. It is clear during the initial interview that the
patient is not there on his own accord and has been brought in by his daughter, as he is
somewhat defensive and claims, "There's nothing wrong—I want to go home." He
denies other recent falls except one at a grandson’s wedding reception. He is not sure
why he fell.
Medications: Inderal 80 mg b.i.d., Synthroid 0.1 mg p.o. q.d., Antivert 25 mg p.o. t.i.d,
Benadryl 25 mg t.i.d. for allergy, Lasix, 80 mg q.a.m., Potassium Chloride 20 mg p.o.
q.d., Digoxin 0.25 mg p.o. q.d. Allergies: None known. Smoking: Quit smoking 20
years ago with 40-pack year history. ETOH: Drinks cognac to go to sleep each evening.
PAST MEDICAL HISTORY: Childhood: Unremarkable. Medical: Hypertension x10
years, hypothyroidism, osteoarthritis-shoulders and hips, dizziness requiring medication,
decreased hearing. Surgical: Left total hip replacement-1995. Psychiatric: No
history of treatment for depression.
FAMILY HISTORY: Mother died of MI at age 81, father died of car accident at age 40;
has one sister who died of breast cancer; one brother with coronary artery disease, and
a second brother with history of liver disease.
PERSONAL/SOCIAL HISTORY: Born in Plainview. Educated through college.
Prepares own meals. Enjoys stamp collections, gardening.
REVIEW OF SYSTEMS: Unremarkable except for decreased urinary flow with nocturia
x5 at night on average. 15 pound weight loss in the last year.
PHYSICAL EXAMINATION: Appearance: Underweight older male with kyphosis; well
groomed; appears angry. Vital signs: Blood pressure: 146/60, Heart rate: 100, and
regular. Respirations 16. Skin: Several telangiectasias over the chest and abdomen.
HEENT: Pupils constrict 3 mm to 2mm ERRLA. Cataract-right eye; left disc flat, with
H/E . Cerumen bilaterally. Pharynx without exudates.. Neck: Supple, thyroid not
palpable. No lymphadenopathy. Lungs: Resonant, a few crackles in the bases. CV:
JVP 6 cm above RA. Carotid upstrokes brisk, no bruits.
Good S1, S2. Grade I/VI
systolic murmur at LLSB. Abdomen: Soft, nontender, no organomegaly, no mass.
GU: Uncircumcised, with testicular atrophy. Rectal: Prostate 3+ enlarged, no palpable
nodules; stool brown, guaiac -negative, vault without masses. Extremities:
acrocyanosis, trace edema bilaterally. Pulses 2+ bilaterally.
Neuro: Mental status: irritable but alert; oriented to person, place, and time. Affect flat.
Cranial Nerves: II – XII intact. Motor: Strength 5/5 throughout, bulk generally
decreased. RAMs, F to N with dysmetria. Gait and balance: able to get up from chair
without assistance on second attempt; shuffling steps prominent on turns, reaches for
wall once. Sensory: decreased pinprick in lower extremities. Reflexes 2+ and
symmetrical. Toes downgoing.
LABORATORY: Hemoglobin 11.9, hematocrit 36.1, MCV 101, platelet count 212,000.
Electrolytes within normal limits. GGT 178, alkaline phosphatase 264, AST 97, ALT 29.
EKG shows left ventricular hypertrophy, chest x-ray mild cardiomegaly no infiltrates,
TSH 0.39.
INITIAL DISCUSSION QUESTIONS
1. What additional clinical information is needed?
additional physical examination findings?
What additional history? What
2. What are your initial impressions?
3. What information do you need to assess and manage this patient’s problems?
POSSIBLE STUDENT FOCUSED QUESTIONS
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Bone matrix – biochemistry of osteoporosis
Cortical versus cancellous bone
Neurochemistry of depression
Neural networks/memory loss
Biochemistry of macrocytosis
Functional assessment – what should be included? Is it cost-effective? Targeted
interventions – are they effective?
Use of assistive devices
Predictors of and prevention of falls
Evaluation of geriatric depression scale how good is it
Epidemiology of substance abuse in the elderly
Changes in drug metabolism in the elderly
Preventive health care
Social and financial resource assessment
Health promotion and preventive medicine measures
Effectiveness of gait training, exercise
Indications for home visit
Nutritional assessment
Mini-mental status exam how good is it
Screening for substance abuse
Screening for elder abuse
8/21/00
Texas Tech University Health Sciences Center
School of Medicine
AAMC/Hartford Geriatrics Education Grant
MS III: Case 10
Myrtle Uetz is a 77-year-old G4, P4, LMP- age 49 who presents with complaints of back
pain and decreased ability to walk due to shortness of breath. Her back pain has been
getting progressively worse over the past 10 years and she has lost a few inches in
height. She is not on HRT(D/C’s by her Internist when her husband died 8 years ago;
he said she didn’t need it anymore.) No complaints of hot flashes, sleeps pretty well.
No urinary incontinence.
Medications: Azulfidine 500 BID; Vitamins with iron, calcium
PAST MEDICAL HISTORY: Vaginal hysterectomy – age 56 for prolapse. A&P repairs.
Ulcerative colitis. Rheumatic fever as a child—rheumatic heart disease.
FAMILY HISTORY: Mother lived to 100, fractured hip at age 86. Father died of
Alzheimer’s & CVA at age 76. Two sisters (one older and one younger) both died of
stroke (CVA). Three sons all living and well; one daughter living and well
PERSONAL/SOCIAL HISTORY: Born in Philadelphia, PA. College graduate, retired 5th
grade teacher, widowed after 49 years of marriage. Never smoked or drank ETOH.
Active in church work, reads, and plays word games.
REVIEW OF SYSTEMS: Negative except for HPI.
PHYSICAL EXAMINATION: Frail elderly female with Dowager’s hump. 4’9”, 102#,
126/72, 84, 98
HEENT within normal limits
HEART – systems murmur, LLSB, regular rhythm
LUNGS – clear A&P
BREASTS – atrophic, no mass
ABD – protuberant, soft, increased BS; no mass, non-tender
PELVIS – atrophic; Cx, Ut, Adnex – surgically absent
EXTRIMITES – no edema; strong pulses
INITIAL DISCUSSION QUESTIONS
1. What additional clinical history would be helpful?
2. What are your initial impressions?
3. What lab studies might be helpful?
4. POSSIBLE STUDENT FOCUSED QUESTIONS:
Osteoporosis
Anatomic bone considerations (bone anatomy, bone physiology)
Biochemical factors in osteoporosis
Therapeutic
Estrogens
Bisphosphonates
Exercise
Calcium
Risks
Small frame
Caucasian
Early Menopause
Steroids
Family history
Menopause – hormone replacement
Effects of HRT (benefits)
Bone
Cardiovascular
Vaginal tissue
Vasomotor symptoms
Reproductive calendar (when menopause begins & ovarian/pituitary axis
functions)
Sexuality
Psychological aspects
Medication effects
Physical limitations
Vaginal dryness
Impotence
Crippling effect of arthritis and osteoporosis
8/14/01
Texas Tech University Health Sciences Center
School of Medicine
AAMC/Hartford Geriatrics Curriculum
MS IV: NEUROLOGY CLERKSHIP
Case # 11
Mr. and Mrs. Garcia visit your office with concerns that “Ms. Garcia is losing her
memory”. She is 65 years old. Mr. Garcia states that she has been forgetful for the
past two years. She forgets dates, appointments, and names of friends. She has left
the stove on several times. She is confused when they are driving about how to get
home. She feels she is “just a little forgetful” and thinks her husband worries too much.
Two weeks ago, their daughter was seriously injured in an MVA. Mrs. Garcia has begun
to awaken during the night and sometimes wander about the house. Since the car
accident, she has seemed more anxious. Sometimes she cries when she is alone in the
house. She worries that she is unable to help take care of her grandchildren now that
her daughter is recovering in the hospital.
Medications: Hydrochlorothiazide 25 mg q.d., Benadryl 25 mg q.h.s. to help with sleep.
Allergies: None. Smoking/ETOH: None.
PAST MEDICAL HISTORY: Usual childhood illnesses. Medical: Hypertension for 10
years. Head injury 20 years ago in MVA. No obvious residual. Surgical: None.
OB/GYN: G3, P3. Psychiatric: No family history of suicide, depression, alcohol
abuse.
FAMILY HISTORY: Mother died of MI at age 74; father died of colon cancer at age 70.
One older sister, who lives out of state in a nursing home. Three children and
grandchildren, alive and well.
PERSONAL/SOCIAL HISTORY: Born in Hobbs, New Mexico. Educated through 12th
grade. Married at age 20 after working two years as a grocery store clerk. Enjoys
cooking, handwork which she is no longer able to do, and watching television. Used to
attend church regularly.
REVIEW OF SYSTEMS: Unremarkable except for bladder leakage.
PHYSICAL EXAMINATION: Ms. Garcia appears healthy with a slightly flat affect.
Blood pressure 160/92, heart rate 88 and irregular. Afebrile. Skin: No petechiae,
ecchymoses. HEENT: NC/AT except for 2-inch vertex scar. Pupils 3/2, ERRLA. Discs
flat, without a/e. TMs clear. Pharynx negative. Neck: Supple without thyromegaly. No
lymphadenopathy. Lungs: Clear. Breasts: Without masses. CV: JVP flat; carotid
upstrokes brisk, faint bruit over right carotid, none over left carotid. PMI tapping,
nondisplaced. Good S1, S2. 2/6 SEM at LSB. S4 present. Abdomen: Soft, without
HSM or masses. Extremities: Warm and without edema. Neuro: Although hesitant,
she is oriented to person and place. She doesn’t know the year. Cranial nerves II-XII:
Intact. Motor: Strength 5/5, normal bulk and tone. Cerebellar: RAMs, finger-to-nose
intact. Gait: Somewhat shuffling. Sensory: Pinprick intact to toes. Reflexes: 2+ and
symmetrical with toes downgoing. Mini-mental status test: Score is 20/30. Recall is 1/3
objects. Cannot draw a clock.
INITIAL DISCUSSION QUESTIONS
1. What additional clinical history would be helpful?
2. What are some treatable causes of dementia?
3. What lab studies might be helpful?
4. For next week choose a question and get at least 3 references other than your text
(i.e. Genetic basis of Alzheimer's, Neuropathology, treatment, etc.). Be prepared to
give a 5-minute presentation on your topic.
8/14/01
Texas Tech University Health Sciences Center
School of Medicine
AAMC/Hartford Geriatrics Curriculum
MS IV: NEUROLOGY CLERKSHIP
Case # 12
A 75-year-old woman is brought to the emergency room by police when she was found
wandering the streets in her nightgown. The police report that she was confused and
could not tell them where she lived. As she came into the emergency room, she
became abusive and agitated. She looked frightened and pale. She is unable to give
additional history as to where she lives, but does give her name as Mrs. Homer. She is
unable to give her date of birth, but thinks she is “70 something”.
MEDICATIONS: “Something for blood pressure.”
PAST MEDICAL HISTORY: Unknown.
FAMILY HISTORY: Unknown.
PERSONAL/SOCIAL HISTORY: Unknown.
REVIEW OF SYSTEMS: Review of systems is unable to be obtained.
PHYSICAL EXAMINATION: This is an elderly woman who appears preoccupied and
confused, and generally does not answer any questions at all. Occasionally she is able
to focus on a question and then starts rambling in a disorganized way. Her speech
sometimes is almost incoherent. At other times, she is somewhat drowsy and nearly
falls asleep during the interview. When awake, she seems to be talking about things
that are in the room with her and is unable to describe where she is, who she is or
where she lives.
Pulse is 100, temperature 99.1° F., blood pressure 160/90. She is somewhat
diaphoretic. Since the patient is only intermittently cooperative, a full mental status
examination is unable to be done. She appears generally clean, well nourished, and
there is no sign of injury or falling. There are no carotid bruits. No heart murmur.
Lungs are clear. Abdomen is soft and non-tender, but she resists the exam. Rectal
exam not performed because of patient’s agitation. On neurological examination, there
is diffuse hyperreflexia and a mild tremor in her hands. During the Babinski
examination, she withdraws bilaterally and screams at the stimulus. You decide to
observe her in the emergency room for an hour and she is basically unchanged.
INITIAL DISCUSSION QUESTIONS:
1. What are your initial impressions? How would you proceed in this case?
2. What laboratory studies or imaging studies would you do initially?
3. Is there any immediate treatment that you would start without knowing any further
information?
4. For next week choose a question related to delirium and get at least 3 references.
Be prepared
to give a brief presentation.
POSSIBLE STUDENT FOCUSED QUESTIONS
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Neurobiology of learning
Neurobiology of memory
Neuropathology of Alzheimer's disease
Neurofibrillary tangles – are they still relevant?
Differential diagnosis of dementia: Alzheimer's disease/multi-infarct/Lewy body;
metabolic/endocrine–hyperthyroidism or hypothyroidism, B12 deficiency;
infectious-neurosyphilis;
psychiatric-depression;
other:
other-delirium,
medication mix up.
Criteria for diagnosis of Alzheimer's disease.
Criteria for depression for diagnosing depression in the elderly.
Genetics of Alzheimer's disease.
Treatment of Alzheimer's disease (HRT).
Treatment of depression in the elderly.
Association of head trauma to Alzheimer's disease.
Criteria for establishing competence.
Treatment of osteoporosis.
Treatment of urinary incontinence.