Case 3 :

William Howard is a 75 year old man with a history of Type II diabetes mellitus, hypertension, peripheral vascular disease, and atrial fibrillation.   He has a history of falls secondary to a peripheral neuropathy and decreased vision from diabetic retinopathy.   You are called by Mr. Howard's wife who reports that he has been quite sluggish over the last few weeks, frequently sleeping during the day, having some difficulty walking, and occasionally confused.   She is concerned since he seems to be getting worse and has had some trouble waking him this afternoon.

His medications include Nifedipine in an extended release preparation, 60 mg/day, NPH insulin 20 units in AM and 10 units in PM, and coumadin 4 mg/night.   A blood test last week revealed his INR to be 2.5.

Mr. Howard will occasionally have a drink and has a 50 pack year history of smoking, stopping five years ago.

On physical exam, Mr. Howard is a very sleepy older man who sometimes falls asleep while being questioned.   Vital signs include an irregularly irregular pulse of 60, blood pressure of 160/80, and temperature of 99 rectally.   Pertinent physical findings include no evidence of trauma, clear lungs, a   2/6 holosystolic murmur radiating from the left sternal border to the axilla, a benign abdomen, and no   peripheral edema.

Neurological examination reveals a paucity of spontaneous speech.   Cranial nerves are within normal limits.   Motor exam is non-focal but there is poor cooperation.   Gait is unsteady.   Reflexes were 1+ throughout with both toes up-going on plantar stimulation.

A Folstein Mini-Mental State Exam was remarkable for disorientation to place and time, poor attention, inability to cooperate with comprehension, repetition, registration, naming, writing, and copying a diagram.   A score of 10 was obtained.   Mr. Howard had a score of 27 one year ago.