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Group B7
Tutor: dr Ramli

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G ^risca Ayu Utami 54071001042
G Zikrina Istifarani 54071001060
G Magista Febra N 54071001062
G Annisa Mulyandini 54071001079
G Rendi ^R Pratama 54071001081
G Tinton Ardiyan 54071001092
G Febi Stevi A 54071001093
G Mohammad Shahir 54071001104
G Rashidah bt M Jalil 54071001113
G Azri M F 54071001116
G Nor Azlan 54071001117

Feb 5th 2010 B7 tutorial 4 2

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Mr No 53 years old was brought by his wife to a clinic with the main complaint
that her husband always repeating certain work unawarely. Whenever someone
remind him, he always answered that he did it just once. For example, locking
the house door,. In every night he always locked the same door for several
times. This condition had already been happened around 7 months ago and
becoming proggresively worse week by week.
Mr No is a senior official of a private company for 4 years and he was
graduated from a famous National University. Although this condition has
already happened with him but in activity of daily living such as leading the
meeting, managing family financial, he was still normal except sometimes he
could not express some words orally. This condition happened in the last 1
month.
Physical examination was normal. GCS was 15. Neurological examination
showed no deficit in hard neurological function. Mental health was normal. CT
scanning of the head was normal. MMS^ score was 22.
Additional information: 4 years ago he got traffic accident and hospitalized for
3 days.

Feb 5th 2010 B7 tutorial 4 3

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G Repeating certain work unawarely
G Proggresively worse
G Could not express some words orally
G GCS
G Hard neurological function
G MMS^

Feb 5th 2010 B7 tutorial 4 4




 
1. Mr No 53 years old was brought by his wife to a clinic with the
main complain that her husband always repeating certain work
unawarely.
2. This condition had aready been happened around 7 month ago
and progressively worse.
3. His activity of daily living is normal but sometime he could not
express some word orally in the last 1 month.
4. His GSC was 15
5. Neurological examination showed no deficit in hard
neurological function
6. His MMS^ score was 22
7. He got traffic accident 4 years ago and hospitalized for 3 days

Feb 5th 2010 B7 tutorial 4 5





1. What are cause and mechanisme of repeating certain work unwarily?
2. What are the correlation, between age and gender with his condition?
3. How his condition become progressively worse?
4. What is the correlation between his activity and his condition?
5. What is the correlation between normal activities and his condition?
6. What is the cause and mechanisme of could not express word orally?
7. What is interpretation of examination
8. What is correlation of abnormal result with his condition?
9. What is correlation between he got trafict accident 4 years ago with his
condition now?
10. Differential diagnosis in this case?
11. How to diagnose?
12. Management?
13. Prognosis?
14. Complication?
15. GP competency.

Feb 5th 2010 B7 tutorial 4 6

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Mr No, 53 years old man, suffered from minimal
cognitive impairment & proggresively became a
mild dementia

Feb 5th 2010 B7 tutorial 4 7

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Feb 5th 2010 B7 tutorial 4 8






G 4 kinds of memory: G 2 forms of memory:
‡ £
   

‡ ^
 
  


Few seconds ‡ correlates with knowledge of

people, places, and things
‡ 
   

‡ involves evaluation,
Seconds to minutes; limited comparison, and interference.
storage capacity ‡ £
 





‡ £ 
   

‡ correlates with ´howµ to do
It describe the memories that things
overlap short-term and long- ‡ acquired slowly through
term memory. multiple repetitions.
‡ 
  

G Both of explicit & implicit memories
Days, weeks, or a lifetime; have short-term forms & long-term
requires transfer (consolidation) forms.
from short-term; rapid recall.

Feb 5th 2010 B7 tutorial 4 9

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Feb 5th 2010 B7 tutorial 4 10

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G Anatomic areas that correlate with memory:

‡ ^

‡ Immediate: prefrontal cortex & dorsal medial thalamus or
primary & secondary sensory cortex.
‡ Short-term: hippocampus ad temporal lobe, mammilary bodies,
midline diencephalic structures.
‡ Long-term: diffuse throughout the cerebrum.
‡ £

‡ Motor: cerebellum, basal ganglia, secondary motor cortex.
‡ ^motion-associated: amygdala.

Feb 5th 2010 B7 tutorial 4 11

 
 
 



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‡ Disturbance in the neuron  at the first time, there was a bit damage in the
neuron (not really make his conditions become worse)  followed by other
neuron  damage itself spread  progressively worse

Feb 5th 2010 B7 tutorial 4 12

 



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G It is caused by the accumulation of plaque beta amyloid protein,

tangles (tau protein)  the accumulation will spread  communication
between cells disturb  sometime forget few words
G Happening in the last 1 month means the proggresivity of the disease.

Feb 5th 2010 B7 tutorial 4 13




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G Graduated from famous national university might show
probability of lack of sleep
G His job as senior officer might be really busy (stressor).
G Lack of sleep & really busy  easily forget & contribute to
progressively worsen the damaging of nerve.

Feb 5th 2010 B7 tutorial 4 14

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G No physical abnormality that play role in this case

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G No hard neurological disorder that play role in this case

Feb 5th 2010 B7 tutorial 4 15

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G Is a scale to assess level of consciousness

G 3 things to be assessed:
‡ ^yes opening reaction
‡ Verbal response
‡ Motoric response
G The highest value is 15 (^4V5M6); the lowest value is 3
(^1V1M1)

Feb 5th 2010 B7 tutorial 4 16

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G No psychosis is happened
G What things must be examined:
‡ Common appearance
‡ Mood & affect
‡ Speech
‡ Perception
‡ Thinking
‡ Sensorium & cognitive
‡ Impulse control
‡ Judgement & insight
‡ Realibility

Feb 5th 2010 B7 tutorial 4 18

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G No hard abnormal appearance.

G CT scan and MRI are used to "see" the brain and
surrounding organs. They don·t give a definitive diagnosis of
MCI.
G They may show abnormalities in the brain that are
consistent with Alzheimer-like dementia. They also are used
to rule out potentially reversible causes of MCI.

Feb 5th 2010 B7 tutorial 4 19

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G It is to indicate the presence of cognitive impairment

G It is an 11-question measure that tests   

   
:
‡ Orientation (sekarang?, di mana?)
‡ Registration (sebut 3 buah benda)
‡ Attention & calculation (Kurangi 100 dengan 7 sebanyak 5x)
‡ Recall (sebut 3 buah benda tadi)
‡ Language (sebut nama benda, ulang kata, lakukan perintah, baca &
lakukan perintah, menulis spontan, menggambar bentuk)

Feb 5th 2010 B7 tutorial 4 20

Feb 5th 2010 B7 tutorial 4 21

  
 
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G

 (Latin: to shake violently ) is the most common type
of traumatic brain injury
G Concussion may be caused by:
‡ blow to the head, or
‡ acceleration forces without a direct impact.
G It causes a variety of physical, cognitive, and emotional symptoms

Feb 5th 2010 B7 tutorial 4 22





G è
 
‡ mild degree of forgetfulness
‡ it doesn·t disturb daily activities
G î £
‡ turunnya penampilan kognitif (hendaya daya ingat, daya belajar, sulit
berkonsentrasi)
‡ 
 sampai memenuhi kriteria diagnosis demensia, sindrom
amnestik organik, atau delirium
‡ dapat mendahului/menyertai/mengikuti berbagai macam gangguan
infeksi, fisik baik serebral maupun sistemik.
G ÷  
‡ penurunan kemampuan daya ingat & daya pikir, mengganggu
kegiatan harian
‡ clear consciousness
‡ gejala sudah nyata • 6 bulan
Feb 5th 2010 B7 tutorial 4 23
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‡ penurunan daya ingat jangka pendek
‡ amnesia retrograde anterograde
‡ riwayat cedera otak atau penyakit otak lainnya (terutama di
diensefalon & temporal medial)
‡ tidak kurang daya ingat segera atau immediate recall
‡ tidak ada gangguan kesadaran dan gangguan perhatian
G ÷ 
‡ ganguan kesadaran dan perhatian
‡ gangguan kognitif secara umum, gangguan psikomotor, gangguan
siklus tidur bangun, gangguan emosional
‡ Onset cepat
‡ perjalanan penyakit hilang timbul setiap hari, keadaan ” 6 bulan

Feb 5th 2010 B7 tutorial 4 24

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G Multiaxial diagnosis
‡ Axis I : F06.7 gangguan kognitif ringan
‡ Axis II : Z03.2 tidak ada diagnosis axis II
‡ Axis III : -
‡ Axis IV : -
‡ Axis V : 70 ² 61

Feb 5th 2010 B7 tutorial 4 25

 
G ÷
: Minimal Cognitive Impairment
G ÷  
: Gangguan memori (ingatan) nyata, bahasa, tetapi tidak
mempengaruhi aktifitas atau kegiatan sehari-hari penderitanya. MCI
merupakan fase degenerasi otak ( otak mengalami kemunduran).
G ^ 


:
‡ Process of brain degeneration
‡ Abnormality of metabolism
‡ Vitamin deficiency
‡ Plaque
‡ Hippocampus atrophy
‡ Parkinson disease
G ^





Average age of patient is more than 75 years old

Feb 5th 2010 B7 tutorial 4 26

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G Stage of brain deterioration:
1. S^N^SC^NC^ (physiological)
‡ Ditandai dengan mudah lupa (forgetfulness)
‡ Merupakan proses fisiologis (normal) pada usia lanjut
‡ Prevalensi:
‡ 35% di usia > 65 tahun
‡ 39% kelompok usia 59-60 tahun
‡ 85% usia > 80 tahun
2. S^N^LITY (in between group)
‡ Ditandai dengan memori dan language nyata tanpa demensia
‡ Pada Mild cognitive impairment (MCI) merupakan fase
transisi ke demensia

Feb 5th 2010 B7 tutorial 4 27

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3. D^M^NSIA (pathological)
‡ Minimal adanya 3 gangguan fungsi luhur
‡ Gangguan memori yang paling menonjol: pikun
‡ Merupakan medical illness

Feb 5th 2010 B7 tutorial 4 28

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G ^xamination that is required:

1. Anamnesis ‡ Blood Test
‡ Alloanamnesis full blood count
‡ Autoanamnesis thyroid function test
2. Physical examination B12 and folat
3. ^xamination ‡ Biochemical (beta amyloid)
‡ Neurologic examination ‡ ^^G : to know the function of brain
‡ Mental status ‡ P^T(positron emission tomography)
-> untuk mengidentifikasi adanya
4. Additional test amiloid atau tangles
‡ Additional anamnesis ‡ CT scan dan MRI untuk
membedakan MCI dan alzeimer
history of disease dengan derajat atropi hipokampus
history of ‡ KI^(komunikasi, informasi, edukasi )
medication yang ditujukan untuk keluarga.
history of alcohol ‡ GLO : gerak dan latih otak atau brain
gym.

Feb 5th 2010 B7 tutorial 4 29




 2
 to prevent or slow up the worsening proggresivity of Alzheimer·s
dementia

G Pharmacologic therapy:
‡ Cholinetrase Inhibitor
‡ Antioksidan
‡ NSAID
G Nonpharmacologic therapy:
‡ Physical exercise
‡ Brain exercise
‡ Widen the social network
‡ Vitamin consumption

Feb 5th 2010 B7 tutorial 4 30


 
G The next level of brain deterioration: Alzheimer·s dementia

Feb 5th 2010 B7 tutorial 4 31


G Uuo ad vitam  bonam
Tidak mengancam jiwa
G Uuo ad functionam  malam
Progresif menjadi demensia

Feb 5th 2010 B7 tutorial 4 32

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MCI (Mild Cognitive Impairment) 1  3A 3B 4

‡ Level 2
Be able to established diagnosis based on physical examination &
additional examinations
Refer to relevant specialist
Be able to follow up this patient

Feb 5th 2010 B7 tutorial 4 33

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