Reference no: EM133868715
A 78 year-old man is brought to your office by a friend who is concerned about his progressive decline in function. She reports that the patient's memory has deteriorated and that he has trouble walking, often complaining of pain in his hip. She knows that he takes medications for his pain and wonders if these medications are causing his memory problems.
The patient is aware of his memory disorder and is actually concerned that he is getting "Alzheimer's disease," which his mother had, although at an older age. He focuses, however, on his "leg problem," for which he was supposed to have surgery. He is looking forward to discussion this with you because he wanted to have a "second opinion."
The friend reports that the patient still goes to work every day, but the office functions poorly because of his inability to manage the work and his confusion about existing projects. Without the patient present, she confides to you that the business is in a "shambles" and that she has notices problems with his self-care, noting that there is often a "smell of urine."
The friend is particularly concerned about his driving, but, when she mentions this, the patient becomes angry, stating that the patient has made serious errors on the street, on more than one occasions turning into incoming traffic. She says, "It is only a matter of time before there is a bad accident. I won't drive with him anymore!"
The patient is a widower who lives alone and has no know living relatives. He has a small publishing business and the friend has been a client for a number of years. He lives in a major urban area which has excellent public transportation, with access to persons with disabilities. When asked why he doesn't use the bus instead of driving, he says, "Oh, I still have a special pass and can have free parking - the parking lot attendants all know me, and my driving is just fine!" He mentions this rationale several times during the visit.
On physical examinations, the patient ambulates independently using a cane. An odor of urine is noticeable. He is alert and interactive, fully cooperating with the examination and his memory is grossly intact. He shows you a list of medications (tamsulosin, donepezil, oxycodone with acetaminophen, cyclobenzaprine, and tolterodine), but the doses on the list that he hands you are different from those on the bottles, and medication bottles contain the wrong medications or mixtures of pills. He knows the indications for his medications, but is unable to match the indication with the correct drug.
Mini-Mental Status Examination (MMSE) was performed. He was able to recall only one of three objects and couldn't recall the date, giving a score of 27 of 30 possible points. Except for a limited range of motion in his left hip, the remainder of the examination, including visual acuity, is normal.
- What is your diagnosis and differentials?
- What tests would you order?
- What could be impairing the patient's driving?
- What can the NP do about this situation?
- What does the law require?