Solve the Medical Riddle: She Kept Losing Her Balance and She Had Memory Lapses, First Week

By Marie Savard MD

Editor’s note: Welcome to our ThirdAge feature that gives you a chance to play medical sleuth as we share the details of what happened when a patient presented with a problem that stumped the physician at first.

We’ll start this week by letting you know what the patient told her PCP and how the doctor proceeded with the examination. Next week, the PCP and a neurologist will continue to look for clues to the medical riddle. The third week, we’ll let you know what some people have suggested as possible diagnoses. The fourth week, the doctor will reveal the actual diagnosis. Then we’ll move on to a new riddle for the following month!

The Patient Reports Her Symptoms

Carol, age 71, a former gymnast who still exercises regularly, has been having trouble with her balance. She has also noticed some memory lapses.

As always in ThirdAge Medical Riddles, the doctor uses the classic S-O-A-P notes as follows:

S=Symptoms or Chief Complaint

O=Objective Findings

A=Assessment or Analysis

P=Treatment Plan or Recommendations

This week, we’ll learn what Carol told her PCP:

“I used to be a competitive gymnast, so my balance has always been really good. I was a champ on the balance beam in my youth! I don’t attempt that these days, obviously, but I mall walk three times a week and I go to a barre fitness class on Saturdays. I’ve always felt really fit. Then about three months ago, I started having the sensation that I was losing my balance even when I was just standing up from a chair or going from the kitchen to the dining room. My gait is suddenly kind of funny, too, like I’m shuffling. Also, I’ve been having a lot more senior moments. Since I’m getting older, maybe my symptoms are just part of normal aging. Still, I thought I’d better get checked out!”

Subjective

In addition to hearing Carol explain her symptoms, Carol’s doctor checked her health records and also questioned her. The doctor ascertained that Carol has no history of chronic headache or prior brain hemorrhage, no history of meningitis, and no major trauma or motor vehicle accidents.

The doctor explained to Carol that her symptoms are complex enough to require a complete evaluation. Fortunately, when Carol called to report her reasons for making an appointment, the doctor recommended a longer than normal visit to accommodate a thorough examination. In today’s busy practices, physicians often have a “panel” over 1,000 patients, and a doctor may get only six or seven minutes of contact time with each patient at a routine visit.

“You could be correct that your symptoms are simply part of normal aging,” the doctor told Carol. “However, you’ve always been healthy and active so I have reason to believe we need to look for possible conditions that could be causing the changes you’ve experienced. That’s why I made sure to tell the receptionist to give us a good block of time for this appointment.”

The doctor continued with an ROS (review of symptoms) consisting of a head to toe, system by system check. She also asked about any other symptoms Carol might not have mentioned, and she asked about new or chronic medications. Carol said she only took the occasional acetaminophen. Carol had not been traveling.

She did not feel depressed, which could have masqueraded as mild dementia. Carol’s sleep, appetite, weight, and mood were all fine. She had no gastrointestinal symptoms including no diarrhea or loss of bowel function and no constipation.

She did, however, admit to urge incontinence and even occasionally losing her urine. She was wearing full menstrual pads to compensate but she had been too embarrassed to tell the doctor about her urinary symptoms until the doctor gently questioned her. As a side note, the doctor let Carol know that products designed for incontinence – the dreaded “adult diapers” – are much better for that purpose than menstrual products in terms of absorption. The doctor suggested that Carol could order incontinence products online in order to avoid standing in line at the drug store checkout counter with them in full view of other customers.

Objective

The doctor did a physical examination including a neurological exam. Blood pressure and cardiovascular (heart) results were normal, as were Carol’s lungs.

The gait disturbance was evident when Carol walked back and forth. Apraxia of gait means the patient can’t initiate a movement when requested or has difficulty “planning” a certain movement. Carol also had trouble getting out of a chair although her muscle strength was fine. In addition, she couldn’t do “tandem walking” in which the toes of the back foot touch the heel of the front foot with each step.

Carol had no tremors and her muscle and sensory testing were fine. The doctor did a “mini mental status exam” (MMSE), a 30-point questionnaire that is a very important baseline check to screen for dementia. The doctor asked Carol to repeat words, remember three objects, and count by serial 7’s, among other tasks. The test revealed mild impairment. Carol’s score was 20. Over 24 is normal.

At this point, the doctor had begun to suspect what the diagnosis would be but being certain is critical. That’s why the doctor ordered blood tests, and either an MRI or CT scan depending on what Carol’s insurance would cover.

The doctor referred Carol to a neurologist who specializes in mild dementia and also asked Carol to come back in a week or two after all the test results would be available.

To be continued . . .

Come back to ThirdAge.com next Thursday to learn how the doctor continued the quest for a correct diagnosis of Carol’s condition . . .

Marie Savard, M.D., a former Medical Contributor for ABC News and a frequent keynote speaker around the world, is one of the most trusted voices on women’s health, wellness, and patient empowerment. She is the author of four books, including one that made the Wall Street Journal list of the best health books of 2009: “Ask Dr. Marie: What Women Need to Know about Hormones, Libido, and the Medical Problems No One Talks About.” Dr. Marie earned a B.S. in Nursing and an M.D. degree at the University of Pennsylvania. She has served as Director of the Center for Women’s Health at the Medical College of Pennsylvania, technical advisor to the United Nations’ Fourth World Conference on Women in Beijing, advisor to the American Board of Internal Medicine Subcommittee on Clinical Competency in Women’s Health, health columnist for Woman’s Day magazine, and senior medical consultant to Lifetime Television’s Strong Medicine. Please visit DrSavard.com.