Immune System


{"ops":[{"insert":{"image":"\/storage\/case-images\/cs\/M72_F1.jpg"}},{"insert":"\n\nYou are driving to the nursing home you frequently visit as a general practitioner. You dread the complicated drug charts and overlapping symptoms that can often be confusing and confounding, but you also love resolving the problems of the elderly, who often share invaluable life wisdom.\n"}]}


{"ops":[{"insert":{"image":"\/storage\/case-images\/cs\/M72_F2.jpg"}},{"insert":"\n\nWhen you arrive, you are shown to Mrs. Niambi, a 77-year-old widow whom you\u2019ve been seeing for the last couple of years, ever since she was diagnosed with moderate dementia. Her primary symptoms were problems with behavior and short-term memory distortion.\n\nMrs. Niambi was a nurse before retiring, never had any children, and is very respectful towards you and the other doctors. However, she can be very abusive towards the nursing staff at the home. The latter say that she hasn\u2019t been the same over the last couple of weeks. Mrs. Niambi is refusing to eat or drink and doesn\u2019t want to get out of bed. This behavior is slowly becoming worse.\n"}]}


{"ops":[{"insert":"When you enter Mrs. Niambi\u0027s room, you expect to see her eyes light up immediately, as they usually do \u2013 but not today. She isn\u2019t able to recognize you or make eye contact. \n\n\u201cShe wasn\u0027t able to recognize me in the morning either, but by the end of my shift, she started making nasty comments about how my uniform wasn\u0027t up to standard,\u0022 says the nurse.\n\nThe nurse further informs you that Mrs. Niambi\u0027s bowel habits have been regular and that she passed urine earlier today, although it was slightly foul-smelling. She has not noticed Mrs. Niambi complaining of any pain.\n"}]}


{"ops":[{"insert":{"image":"\/storage\/case-images\/cs\/M72_F4.jpg"}},{"insert":"\n\nYou try to engage Mrs. Niambi in a conversation, but she quickly drifts off and closes her eyes. You remember that she has stage 3 chronic kidney disease and hypertension. She is currently on furosemide 40mg od, lisinopril 40mg od, and slow-release potassium bd. \n\nOn examination, her temperature is 98.9 \u02daF (37.1 \u02daC). Her pulse is 60 bpm, regular, and strong. Her blood pressure is 115\/75 mmHg when lying down; and 100\/70 mmHg when sitting up. Her respiratory rate is 12\/min. \n\nMrs. Niambi is drowsy but "},{"insert":"arousable","attributes":{"color":"#000000","background":"transparent"}},{"insert":". She is not oriented to place, person or time, and is unable to follow commands. On counting the months of the year backwards she gets to September, but then loses focus and starts talking about something else. Neurological examination is negative for meningism or focal signs. Cardiorespiratory and abdominal examination show no abnormalities.\n\nYou request fingerprick glucose testing and urine dipstick testing. Mrs. Niambi\u0027s capillary glucose is 95 mg\/dL. The urine dipstick test is positive for nitrites and leukocytes.\n"}]}


{"ops":[{"insert":"\u0022What\u2019s wrong, doctor?\u0022 the nurse asks you.\n\nHow do you respond?\n"}]}
1. "Seems to be pseudodementia"
2. "Seems to be delirium"
3. "Seems to be dementia progression"