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6.08 WHERE AM I?

SESSION 1: 90 minutes
The PBL group should select a different STUDENT CHAIRPERSON each week. Tutors should give the student
chairperson in each group a copy of the student guide to help them lead the discussion with assistance from
circulating tutors. The group should check-in with a tutor during each major section to ensure that appropriate
content has been covered and key learning points have not been missed. Discussion questions are provided as a
guide only and no prior preparation needs to be undertaken. Questions (ie learning topics) raised by the group that
cannot be answered during the tutorial session should be allocated to group members for investigation and report
back to the group during PBL session 2. Student attendance at PBL sessions is compulsory.

Key learning outcomes:

To understand the mechanisms of attention, learning and memory


To understand the anatomy and functions of the forebrain
To understand the central cholinergic nervous system
To understand the causes and types of dementia
To understand the clinical features and causes of delirium

1. TRIGGER, CUES AND PROBLEM FORMULATION


(10 minutes)
Tutor/Chairperson should present the trigger to PBL group.
Eugene Lim is an 84 year old man who has been brought into the Emergency Department
with acute confusion. He was found wandering outside the block of units where he lives.
His neighbour became concerned when Mr Lim told her that he couldnt find his mother.
Mr Lim lives alone, and was unable to remember his daughters phone number, so the
neighbour called an ambulance to take him to hospital.

IDENTIFY CUES
Identify and list the major symptoms, signs and other relevant issues.

84 year old man


Acute confusion
Lives alone in a home unit
Wandering outside
Looking for his mother
Unable to recall contact details for his daughter
Ambulance called by concerned neighbour

PROBLEM FORMULATION
Synthesise your thoughts into a summary statement about the patient. This statement should be
concise, as if you are reporting the case to your Emergency Department Supervisor.

Sydney Medical School, University of Sydney


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6.08 WHERE AM I?

2. DISCUSSION OF STRUCTURES AND FUNCTIONS


(~20 minutes)
In their groups students should discuss the structures and mechanisms that may be involved in the signs
and symptoms. Student discussions should go from the molecular, cellular and tissue mechanisms
through to the psychosocial.

Which brain centres are involved with memory?


What are the neural mechanisms of memory? Consider the roles of the hippocampus, secondary cortical

areas, cerebellum and pre-frontal cortex.


What are the different types of memory? Consider short-term vs long-term memory, non-declarative vs
declarative memory.
Is memory loss a normal part of ageing? What mechanisms are involved in age-related memory loss?

What are the potential causes of his confusion?


What is meant by confusion? Consider the roles of memory, orientation and attention.
What are the most likely causes of confusion in a man of this age? Consider:
o Dementia
o Delirium
o Drugs
o Depression
How does the time-course and pattern of his confusion help us to establish a diagnosis?
What is dementia?

What are the major types of dementia? What are the underlying mechanisms? Consider Alzheimerss
Disease, vascular dementia, Lewy-body dementia, alcohol-related brain damage.
How is dementia diagnosed? Is memory loss alone sufficient for diagnosis? How does the time-frame assist
diagnosis?
Do different types of dementia affect different types of memory?
Is dementia reversible?

What is delirium?

What are the clinical features of delirium?


How does delirium differ from dementia? Can delirium and dementia co-exist?
What are the potential triggers for delirium? Consider infection (eg UTI/respiratory/skin/CNS), cerebrovascular
lesions (eg intracranial haemorrhage/tumour), metabolic (eg organ failure/hypoxia/electrolyte
disturbance/hyper- or hypo-glycaemia), drug reactions (eg new medication/alcohol/withdrawal)

How can we assess Mr Lim?

Is Mr Lim able to make decisions about his own medical care?


How do we approach assessment of a confused patient? Do we need the patient to consent?
Is there anyone else who should be involved in his assessment and treatment?

3. HYPOTHESIS GENERATION AND ORGANISATION


(~10 minutes)
On the basis of the above discussions, generate hypotheses to explain the signs and symptoms.
Then organize your hypotheses in order of likelihood

Acute confusional state:


o Likely delirium need to consider potential triggers such as infection, CNS haemorrhage/mass,
metabolic derangement, adverse drug reaction
Acute presentation may be superimposed on a background of chronic cognitive impairment
o Consider potential underlying chronic dementia and possible causes such as Alzheimers Disease,
vascular dementia, alcohol-related brain damage etc

Sydney Medical School, University of Sydney


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6.08 WHERE AM I?

4. ENQUIRY PLAN AND INFORMATION GATHERING


(~20 minutes)
Prepare an enquiry plan to distinguish between your hypotheses (ie decide what you need to know in order
to reach a firm diagnosis). List issues that you should explore in the patients HISTORY, identify signs that
you will need to elicit in physical examination and then list INVESTIGATIONS that you will request. Ensure
that you understand how each piece of information will help you in the diagnosis and/or assessment of the
problem and possibly also contribute to the management.
After completion of your enquiry plan the student chairperson should play the role of the patient and release
information from patient data below when asked the appropriate questions by the other PBL group members. Then
the student chair can also present the results of examinations and investigations.
Please see Talley and OConnor, Clinical Examination for structure of history and physical exam.

History
Consider relevant question for initial rapid assessment

History from Mr Lim:


NB: taking a direct history from Mr Lim is likely to be very difficult focus on immediate symptoms which may
point to a potential trigger for delirium
o potential sites of infection: dysuria/frequency/incontinence, cough/fever/chest pain/dyspnoea,
rashes/swelling, headache/peripheral numbness or weakness/visual changes, vomiting/diarrhoea
o medication and drug/alcohol use
Collateral history from relative/friend/GP:
o acute symptoms as above
o changes in behavior/mood/memory, previous similar episodes and triggering events
o past medical history
o detailed medication history including current and recent past medications

Physical examination
Consider the physical signs you need to elicit
NB: Careful and detailed physical examination is necessary given the wide range of potential causes for this
presentation and the difficulty of obtaining a detailed history

General inspection: appearance, grooming, psychomotor disturbance

Vital signs: heart rate, blood pressure, temperature, oxygen saturations, respiratory rate

Cardiovascular: heart sounds, JVP, carotid bruits, pulmonary or peripheral oedema, evidence of peripheral
vascular disease

Respiratory: chest percussion and auscultation looking for evidence of infection

Gastrointestinal: peritonism, masses, organomegaly, signs of organ failure

Neurological: pupil reactions, cranial and peripheral nerves, gait and coordination

Skin/musculoskeletal: rashes, pressure areas, cellulitis, signs of recent injury, joint swelling/tenderness

Mini-mental state examination (MMSE): to assess cognition, orientation, attention and memory

Confusion Assessment Method (CAM): to assess for delirium

Investigations
Consider the investigations that you will require in the light of the history and physical examination findings.

Bedside: blood glucose level (BGL), urinalysis to screen for infection, ECG to screen for cardiac
ischaemia/arrhythmia/electrolyte disturbance

Laboratory: full blood count (anaemia, elevated white cell count), electrolytes/urea/creatinine (electrolyte
disturbance/uraemia/renal impairment), calcium/magnesium/phosphate, liver function tests, C reactive protein
(general screen for infection/inflammation), blood cultures (if febrile), urine microscopy and culture

Imaging: chest x-ray (infection/pulmonary oedema), CT brain (CNS pathology)

Sydney Medical School, University of Sydney


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Reviewed February 2014 (Skinner/Kurrle)

6.08 WHERE AM I?

PATIENT DATA: CLINICAL ISSUES AND FINDINGS


(~20 minutes)

History
History of the presenting condition

Yue Yong Eugene Lim is an 84 year old man who lives alone in a second-floor home unit in Hornsby. His
neighbour found him wandering around the bins at the front of the block of units today, and realised that Mr Lim
was confused when he said he was looking for his mother. The neighbour suggested that Mr Lim contact his
daughter, who visits Mr Lim frequently, but Mr Lim was unable to recall her phone number or her married name.
The neighbour was concerned that Mr Lims behaviour was out-of-character for him and called an ambulance.
Mr Lim has a very short attention span, and tells you that he is fine or good when you question him about
acute symptoms. He denies any recent infective symptoms. He is unable to tell you which medications he
takes. His only major complaint is chronic pain in his hips and knees.
Mr Lim is able to tell you that he has a daughter called Linda, but he cannot tell you her surname, her phone
number, her husbands name, or the suburb in which she lives.
When you look up Mr Lim on the hospitals computerised medical record system, you find details from an
admission for left hip replacement five months ago. The discharge summary states that Mr Lim had suffered a
minor stroke about 18 months prior, and had been commenced on regular low-dose aspirin. He was also on
medications for longstanding hypertension and hyperlipidaemia. You obtain contact details for Mr Lims
daughter and General Practitioner through the hospital medical record.
When you phone Linda Chan, Mr Lims daughter, she confirms that Mr Lim had a minor stroke involving his left
side about two years ago, but that he has no ongoing problems from this. She tells you that the hip surgery
went well, but Mr Lim became very confused after surgery and she feels he has been going down-hill ever
since. She reports that her father lives alone in his unit and she is concerned about how he is coping. Over
the last few months, he has become very unreliable about paying his bills or attending appointments, and he
has stopped meeting up with his friends for tea and cards at the local club, where he has been a regular
member. He has lost weight, and she is worried that he is forgetting to shop, cook and eat. She also tells you
that she often finds him wearing dirty clothes, and he is not shaving or washing his hair as frequently as he
used to. Linda last saw her father two days ago and says he was well at the time, with no obvious infective
symptoms.

Past history

You contact Mr Lims GP, who confirms his past medical history of stroke, osteoarthritis with left total hip
replacement, hypertension and hyperlipidaemia. Mr Lims medications include aspirin 100mg daily, amlodipine
5mg daily, atorvastatin 20mg daily and paracetamol 1g as needed. There have been no recent medication
changes. Mr Lim does not smoke, drinks very little alcohol, and has no allergies. His GP reports that he has
always been in good health for his age, and had no history of memory problems prior to his hip surgery five
months ago.

Personal history

Mr Lim travelled to Australia from Hong Kong in the 1950s to undertake tertiary study through the Colombo
plan. After studying civil engineering at university in Sydney, he briefly returned to Hong Kong, but later
returned to Australia with his wife and daughter to work on major infrastructure projects. The family eventually
settled in north-western Sydney, and Mr Lim became a senior associate in an engineering firm. Mr Lim retired
from this job aged 68, and became active with the local Chinese community group. Mr Lim moved from the
family house into a home unit when his wife died five years ago. Mr Lim speaks very good English. He
mobilises without aids and has no home services. His daughter, Linda (aged 53 years), visits 1-2 times per
week and helps him by doing the occasional load of washing and preparing some meals. Mr Lim has three
adult grandchildren who visit him occasionally. He is in regular contact with his neighbours from the adjacent
unit.
Mr Lim has had little contact with his family beyond Australia since leaving Hong Kong permanently in the
1960s. There is no known family history.

Discussion

Do any points in the history provide a clue to potential triggers for Mr Lims acute confusional state?
Does Mr Lim have any features which suggest an underlying chronic dementing illness? What are the
potential causes?
What is the significance of Mr Lims history of stroke, hypertension and hyperlipidaemia?

Sydney Medical School, University of Sydney


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6.08 WHERE AM I?

Physical examination

General inspection: Mr Lim is neatly-dressed in a collared shirt and trousers, although his clothes appear
slightly too large for him, and there is a stain on his shirt. He becomes quite agitated and restless during
questioning and examination. He appears alert and generally well.
o
Vital signs: HR 72 regular, BP 135/80, temperature 37.2 C, SaO2 96% in room air, RR 18
Cardiovascular: heart sounds dual, no murmurs; JVP not raised; no carotid bruits; no oedema, peripheral
pulses present, but faint
Respiratory: chest clear and resonant
Gastrointestinal: abdomen soft and non-tender, bowel sounds present, no masses, no organomegaly, no
stigmata of chronic liver disease
Neurological: pupils equal and reactive; cranial nerves difficult to formally test due to inattention, but no gross
abnormalities identified; grossly normal tone/power/sensation to limbs; reflexes intact; slight antalgic
component to gait with good balance; coordination not formally testable due to inattention
Skin/musculoskeletal: no rashes or areas of cellulitis/ulceration; no signs of recent trauma to head, trunk or
limbs; skin appears frail, and you note that Mr Lim has several bruised areas on his shins, where the skin
appears shiny and thin, and he has very little hair
MMSE: orientated to person, but not to time (1978) or place (Hong Kong), unable to complete further testing
due to lack of attention
CAM: Feature 1 (acute onset/fluctuating course), Feature 2 (inattention) and Feature 3 (disorganised thinking)
and Feature 4 (vigilant/hyperalert) present
Mr Lims daughter Linda arrives at the bedside just as you are completing your examination. Mr Lim hugs her
enthusiastically and starts speaking to her in Cantonese. Linda later tells you that he addressed her as Mei
Lian, which was her mothers name. She also tells you that she and her father always converse in English.

Investigations
Bedside:

BGL (random) 7.9

Urinalysis leucocytes +++ nitrites ++ protein +

ECG (see results) sinus rhythm 69 bpm, changes consistent with left ventricular hypertrophy
Laboratory:
9

Haematology (see results) Haemoglobin 121g/L (120-180), White Cell Count 11.2x10 /L (3.5-11), Platelets
9
9
242x10 /L (150-400), Neutrophils 8.1X10 /L (2.0-8.0)

Biochemistry (see results) Sodium 136mmol/L (135-145), Potassium 3.6mmol/L (3.5-5.0), Urea 4.2mmol/L
(3.1-8.1), Creatinine 85micromol/L (64-104); Calcium 2.42mmol/L (2.10-2.55), Magnesium 0.89mmol/L (0.671.05), Phosphate 0.78mmol/L (0.74-1.52); Bilirubin 17micromol/L (<20), Protein 62g/L (60-83), Albumin 34g/L
(32-46), ALT 41 U/L (<55), AST 31 (12-36), ALP 65U/L (41-119), GGT 61U/L (41-119); CRP 24mg/L (<5.0)

Urine culture (see results) (result 3 days later) E. coli sensitive to


cephazolin/trimethoprim/gentamicin/norfloxacin
Imaging:

Chest x-ray (see results) The heart is mildly enlarged. The lung spaces are clear. There is no consolidation
or effusion.

CT brain (see results) No acute intracranial haemorrhage or infarct is seen. Gliosis involving the right frontal
lobe is consistent with old right MCA territory infarct. The CSF spaces and ventricles are prominent consistent
with age-related atrophy. There is periventricular loss of grey/white matter differentiation consistent with
chronic small vessel ischaemia.

Discussion

Do these findings point to a clear cause for Mr Lims presentation?


Can a urinary tract infection be diagnosed on the basis of abnormal urinalysis alone? Are there agreed
diagnostic criteria for urinary tract infection?

5. DIAGNOSTIC DECISION
(~ 5 minutes)
List the condition that could plausibly explain the symptoms and signs of the case. Identify learning topics
for investigation that help to explain your diagnosis (ie differentials). Students will need to report on these
learning topics in PBL session 2.

Sydney Medical School, University of Sydney


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6.08 WHERE AM I?

6. ALLOCATE LEARNING TOPICS


(~5 minutes)
Tutors should ask all students to allocate learning topics for individual study related to basic medical
sciences questions, as well as prepare individual case summaries to be presented to their group in
Session 2.
For example, using the following format prepare a summary of case as if presenting to a consultant:
A x year old female/male presented to her/his GP with on a background of She/He reported (history ) .On
physical exam (-mention important positive and negative findings). The most likely diagnosis (provisional
diagnosis)..We ordered (investigations) which showed This confirmed our provisional diagnosis.

Sydney Medical School, University of Sydney


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Reviewed February 2014 (Skinner/Kurrle)