Friday, February 29, 2008


It is your first day on your internal medicine rotation! You are super excited and vow to impress your preceptor with extensive, thorough notes.

A 70 year old man is brought into your clinic by his daughter. As they both enter, you notice that he has a slow shuffling gait. It almost seems that he has trouble lifting his feet with each step. He holds onto her arm to keep his balance.

The daughter is worried about her father because she's noticed some changes. She says, "He used to love crossword puzzles, telling stories, and playing with his grandkids, but now, he just doesn't seem interested in much anymore. He watches TV, but his favorite things are the commercials. I think it's because he's having trouble concentrating." You ask the patient a few questions, and he reports that he's been feeling pretty tired and weak lately. He thinks its old age. He's also concerned that he's feeling a lot of urgency in urination and has to go to the bathroom pretty frequently.

Past medical history is significant for an appendectomy when he was 18, Guillain-Barre when he was 30 which required 2 weeks on a mechanical ventilator, MI several years ago. Family history is significant for Alzheimer's on the mother's side and Parkinson's on the father's side. His sister passed away and had frontal-temporal dementia. His brother had lung cancer. He has two kids, both healthy.

Current medications include aspirin, a beta-blocker, an ACE inhibitor, and a statin. He also takes a multivitamin daily. He drinks half a glass of wine with dinner every evening and smokes about a pack a day. He has a 50 pack year history. He went through a mid-life crisis in his 60s when he tried heroin and cocaine. His previous job was a painter.

The patient lives with his wife who helps him take his medications. He does not exhibit any signs of depression. He is able to do most of the activities of daily living, but he cannot walk very well and has trouble remembering where he puts things. He stopped driving after his MI.

When you do a Mini Mental State Exam, he does pretty poorly for his age and education level. In particular, when you ask him to remember a few objects, he cannot recall them 5 minutes later, but he can recognize them if you give him a list. His neurologic exam is normal. In particular, there is no rigidity or tremor.

You pack up your five pages of notes and go to your preceptor. After you present the case to him, he says, "Hmm...let's order an MRI." This is what the MRI shows:

Too bad radiology didn't label the arrows. The preceptor says, "That's a good history you have. In it, there is a triad of three symptoms that point to his diagnosis."

Challenge: Can you identify the trifecta? What's the diagnosis? What's the treatment?

Related Questions:
1. What does the MRI show?

Image shown under fair use.

1 comment:

Craig said...


The triad of gait instability, urinary incontinence, and dementia is typically found in patients with normal pressure hydrocephalus. This causes 5% of dementias. MRI demonstrates ventricular dilation with preservation of brain parenchyma. The increased ventricular size (hydrocephalus) deforms white matter tracts, leading to the triad. Treatment is ventriculoperitoneal shunt. Normal pressure hydrocephalus is due to decreased CSF absorption; thus, it is a communicating hydrocephalus.

Sources: Wikipedia; “Management of Normal Pressure Hydrocephalus” Verrees and Selman. American Family Physician.