The Man Who Lost Interest

 

A 64 yo automobile salesman was brought to your office because of problems where he works. He had been the top salesman in the state until about five years ago. In the last year things had gotten so bad that he had sold only a few cars and was in danger of being fired. His boss insisted that he have a checkup. His wife had not noticed anything until a few months ago when he seemed to loose interest in the family. He had been an avid gardener, but his Spring he had paid little attention to his garden and it had become quite overgrown. He did not sleep well at night often watching television until 4 or 5 AM, but was sleeping during the day. His boss had found him sleeping in his office on several occasions. He often fell asleep during the day on weekends when he was home. He had become more irritable. He argued with several customers over their politics. He had gotten into a huge argument with his best friend and his best friend's wife because of something they said that he misunderstood. He had become so distraught over this argument that he had lost his way home twice in the past month because his mind "was elsewhere". He was no longer able to regularly balance their checkbook and his wife had taken over the chore.

 

He was a normal appearing gentleman with a sad countenance. He spoke only when spoken to and occasionally could not find the right word for something. He admtted to feeling depressed. His physical and neurological examination were normal except that he had some difficulties of the mental status exam. He could not spell the word "WORLD" backwards. He could only remember 4/5 objects at 3 minutes and could only do presidents back to Bush. A MRI showed mild cerebral atrophy "out of proportion" for his age. An EEG was normal.

Questions:

  1. What test would you order to evaluate this gentleman's problem?

  2. His family physician raised the possibility that the patient was depressed and a history of bipolar disorder in his mother's family was uncovered. How would you decide if his symptoms were caused by a mood disorder?

  3. His apo-lipoprotein E profile came back. The patient had 1 allele E4 and 1 allele E3. How does this result influence your diagnostic impression?

  4. Over the next 6 months, the patient worsened despite anti-depressant therapy. He began to have difficulty eating because he was confused with how to use his tableware. His examination changed in that he developed prominent snout, suck and palmomental reflexes. He became disriented to time and place and could only remember 1/4 objects at 3 minutes. He now appeared stiffer, had bradykinesia, masked facies and mild resting tremor of both hands. What diagnoses would you consider?
Last updated by Webmaster on August 18, 2009

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