FINAL PROJECT – LRPD

CLINICAL CASE
CASE DISCUSSION

PRESENTED BY

BASURTO YSLA, ANDREA

HERNANDEZ JIMENEZ, CAMILA
CASE DESCRIPTION
 AFFILIATION DATA

Name and Last Name: D. M. S

Age: 64 years
Date of Birth: October 25, 1958
Place of Birth: Aija, Ancash
Number of siblings: 4° - 1 brother and 3 sisters
Grade of Education: 2nd Grade Primary
Laterality: Right
Ocupation: Housewif
Place of Residence: Chorrillos
Marital Status: Single
 REASON FOR CONSULTATION

Neuropsychological evaluation of a
patient who has been experiencing
frequent memory loss in recent
months. She refers that "she no longer
remembers some things very clearly,
sometimes she forgets where she left
the key or even where she lives
 GENERAL OBSERVATIONS

PHYSICAL DESCRIPTION

The woman evaluated, is of fair complexion, slim

build, thin face, short and frizzy hair, white with gray
tones, and brown eyes.

Her clothing was a pair of brown wool pants, a blue

polo shirt and a thin black sweater, and she was
wearing a knitted cap. She wore no earrings or jewelry
 GENERAL OBSERVATIONS

BEHAVIORAL DESCRIPTION

the examinee showed a willingness to cooperate

She was nervous, but maintained a friendly, smiling expression

His oral expression is accelerated and he even stutters in some questions

His expression changed from smiling to hesitant when he did not remember some
facts of his life
 BACKGROUND
From the initial interview, an anamnesis was applied in which the following data were obtained
FAMILY BACKGROUND
Dad: Leandro Mallqui, according to the evaluated, has not
had any illness, worked as a farmer and died naturally in
Paramonga when Mrs. Daría was 18 years old.
Mom: Maxima Solorzano, was a good person and stricter
than the father, worked spinning and weaving, did not
suffer diseases ,but in his stage of menopause it affected
him a lot being the reason for his death at age 48.
The assessee met her paternal grandparents and has 3
siblings and she is the third, she has a very good
relationship with them.
PERSONAL BACKGROUND
Her education began at the age of 7 to the 10.
At school she did not have many friends.
She played volleyball, her favorite subject was
mathematics because it helped her to do the math.
She would have liked to be a knitting teacher because she
could teach others how to make clothes or accessories.
Lived in Switzerland for a year taking care of a neighbor's
daughter who was a doctor.
TECHNIQUES AND APPLIED TESTS

Based on the information

obtained, the following
Mini Mental Test
tests are applied

PSYCHOLOGICAL
INTERVIEW

Memory Impairment Test

 INTERPRETATION OF RESULTS

IN THE MINI-MENTAL TEST

He patient obtained a score of the
patient obtained a score of 13 points in
the overall test, which would mean that
she is below normal and would be in the in the subareas of
orientation,
range of moderate cognitive impairment
attention and
calculation and
memory, he had
greater difficulty
 INTERPRETATION OF RESULTS

IN THE MEMORY ALTERATION TEST

The immediate memory section
He patient obtained a score of the has 2 points.
patient obtained a score of 8 points, The time orientation memory has
5 points, but failed to score.
This test is divided into immediate Semantic remote memory has 3 Result: cognitive
memory, time orientation, free points
impairment of
The free evocation memory has 1
evocation and evocation with tracks. point. the amnestic
The free evocation memory has type, to a
1 point.
moderate
The memory of evocation with
obtain 2 points. degree.
 DIAGNOSTIC CONCLUSION

MAJOR OR MILD NEUROCOGNITIVE DISORDER DUE TO ALZHEIMER'S DISEASE

Under code 331.0 (G30.9) Alzheimer's disease 294.10 (F02.80) without
behavioral disturbance, because she meets the following criteria:
A. Criteria for a major neurocognitive disorder are met.
B.Presence of insidious onset and gradual progression of the disorder
in one or more cognitive domains.
C. Criteria for possible Alzheimer's disease are met, such as:
2. The following three appear:
1. Clear evidence of a decline in memory, learning, and memory
impairment.
2. Progressive, gradual and steady decline in cognitive ability
without prolonged plateaus.
3. No evidence of a mixed etiology
DIAGNOSTIC CONCLUSION
DIAGNOSTIC CRITERIA FOR MAJOR NEUROCOGNITIVE DISORDER
A. Evidence of significant cognitive decline compared to previous level of
performance in one or more cognitive domains (complex attention,
learning and memory, language) based on:
1. Concern in the individual him/herself, an informant who knows
him/her, or the clinician that there has been a significant decline in a
cognitive function.
2. Substantial impairment of cognitive performance, preferably
documented by a neuropsychological test.
B. Cognitive deficits interfere with the individual's autonomy in daily
activities.
C. Cognitive deficits do not occur exclusively in the context of delirium.
 RECOMMENDATIONS

Have an evaluation by a neurologist

Perform occupational therapy

Perform physical exercises

Perform music therapy

Keep autobiographical diary

CONCLUSIONS
 CONCLUSIONS

In conclusion, Alzheimer's disease is

a progressive disease or described
as a disease that slowly destroys
memory, the ability to think and
language, as the patient loses his
or her own identity, the memories
of his or her entire life.
1
 CONCLUSIONS

In short, Her declarative memory is mainly

reflected in what was taught by his mother;
episodic memory, is one of the most
remembered (autobiographical); semantic
memory is low and may be affected by having
received a very poor school education and at
home it was not so good; implicit memory, it

2
maintains it with the theme of spinning and
weaving and with explicit memory, it is
currently below normal.
 CONCLUSIONS

In sum, Memory is our trunk of

memories that we live throughout
our lives, besides being the
storehouse of all the information
we receive based on our
experiences, but when it begins to
break into fragments, memories
are distorted 3
 CONCLUSIONS

In particular, immediate memory,

that is, in the short term, with
respect to the tests shown, it can
be said to show that it does not
have information retention and if it
does, it is somewhat minimal, in

4 addition it is not located in time

and space.
 CONCLUSIONS

In summary, The patient has a

severe deterioration that we can
say that her mental capacity
already interferes in her daily life,
we talk about her Alzheimer's
dementia progressively advancing
and affecting her short-term
memory 5
APPENDIX
INFORMED
CONSENT
ANAMNESIS
ANAMNESIS
PSYCHOLOGICAL TESTS

MINI MENTAL TEST MEMORY IMPAIRMENT TEST

 THANK YOU FOR
YOUR ATTENTION!