Grand Rounds: Progressive Memory Loss in an Elderly Female

What are Grand Rounds?

In the late 19th century, Sir William Osler, the father of modern medicine, one of the founders of Johns Hopkins Medical School, and John Hopkins’ first professor of medicine, introduced an innovative physician-to-physician teaching forum to disseminate cutting-edge medical knowledge at the bedside. This became known as grand rounds.

During grand rounds a patient’s problem is presented to medical students, residents, interns, attending physician and other staff. The goal is to teach by using the patient’s presenting problem as a vehicle to learn patient management at the bedside.

Progressive Memory Loss in an Elderly Female

Mrs Singh lives in Traverse City, Michigan. She has lived alone for the past several years, doing her own cooking and caring for herself. Her daughter, Pragya, who lives in Suva, calls Mrs Singh several times a week, although she has not seen her mother for about six months.

During the last phone call, Pragya became concerned. Her mother seemed distracted, frequently interrupted the conversation and repeatedly said that she was “so worried.” When asked what worried her, Mrs Singh said, “I just don’t know.” She repeatedly asked the same question.

Alarmed, Pragya drove to her mother’s home six hours away. When she arrived, Pragya was shocked to see how thin her mother had become. There was little in the house to eat except tapioca pudding. Pragya was able to figure out that Mrs Singh had broken her dentures, and was having difficulty chewing.

Mrs Singh’s skin turgor was sluggish. Mrs Singh said the coffee maker and the TV did not work. The daughter used both and found them to be working. Mrs Singh often started tasks but did not finish them, she seemingly forgot what she was doing and often could not think of words, such as the name of the dresser in her bedroom.

As evening approached Mrs Singh became more agitated and was unable to sleep. She said she had to “see about the children and your father’s tea,” even though all of her children are grown and her husband had died several years ago.

Pragya brought her mother home with her the following day and made an urgent appointment with her family physician to evaluate Mrs Singh’s condition. During the examination, Mrs Singh was unable to focus on the questions and instructions. She knew her own identity, but was unsure of her exact location and did not know the current date. She became visibly agitated with the questions and said she didn’t want to answer or said, “I don’t know, well I do know but I am not going to answer.”

Mrs Singh thought the physician was the son of one of her friends from home and asked him several times about his mother. She complained of fatigue and epigastric tenderness. She was 20 pounds under her ideal body weight and she was pale. Lab tests revealed iron deficiency anemia, low albumin, and dehydration.

What’s the Diagnosis?

UHSA Students: If you know the most likely diagnosis, email Dr Mangum, along with an explanation for your diagnosis, for additional points on an upcoming examination.

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