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CASE STUDY 1
Patient Presentation
Beatrice is a 68-year-old, retired librarian who volunteers
at the local hospital. She lives at home with her husband
and is active in her church community. Her medical
history includes hyperlipidemia, osteoporosis, and basal
cell carcinoma that was successfully excised last year.
She has come in for a routine visit.
1. What action would you recommend, given that
Beatrice is in the age range where dementia
prevalence begins to increase?
A, Screen her with a cognitive screen, such as the
clock-drawing test, to test her cognitive abilities
B. Ask if she experiences problems with memory or
calculations
C. Question her as to any health concerns that she
has
D. Discretely probe her cognition and memory
E. All of the above
F. None of the above
Current Medication Regimen
Simvastatin 20 mg once daily
Alendronate 70 mg once weekly
Multivitamin
Ginkgo biloba
Examination
While you begin your initial examination, you make small
talk with her about her favorite pastime – gardening.
During this conversation, she mentions that she
frequently misplaces her gardening tools and has to ask
her husband, Harry, to help her find them. Harry says the
garden gnomes are playing tricks on her, but she finds it
frustrating. She attributes it to “just part of getting old”.
She had discussed this problem with several of her
friends, who agreed that their memories are “not what
they used to be”. One friend suggested that she begin to
take ginkgo biloba because she had heard that it
improves memory. The friend had been taking ginkgo
regularly for 2 years.
2. Following this conversation, what action, if any,
would you recommend?
A. Question her regarding other memory-type issues
B. Administer quick cognitive and memory screens,
like the clock-drawing test and 3-word/3-minute recall test
C. Schedule a full diagnostic workup
D. Note the concern in her files and probe her
cognitive function further during a subsequent routine visit
E. A and B
F. A, B, and C
The tests you perform do not suggest dementia and
laboratory results show that her hyperlipidemia is well
controlled with her current medication and other
parameters are within normal limits. You document all
test results and schedule another office visit in 6 months.
In 3 months, Beatrice is back in your office complaining
that in addition to misplacing garden tools, she now can
almost never find her keys when she is leaving the
house. You decide to administer the MMSE and Beatrice
scores 25/30.
3. Given that you have identified potential cognitive and
memory problems, what next step(s) would you take in
the clinical care of this patient?
A. Start her on a sample pack of cholinesterase
inhibitors and readminister the MMSE in 3 months
B. Schedule a full diagnostic workup
C. Refer her to a neurology practice for further
assessment
D. Increase her ginkgo biloba intake and
readminister the MMSE in 3 months
E. A and B
F. A and D
After this intervention, diagnosis, and formulation of a
management plan that includes treatment with a
cholinesterase inhibitor, Beatrice is back in your office in
4 months. This visit is prior to her next-scheduled office
visit and occurs at the insistence of her husband. Harry
complains that Beatrice is often irritable and has had two
minor traffic accidents after a near-perfect, lifelong driving
record. You administer the MMSE and Beatrice scores
20/30.
4. Given that Beatrice has lost five or more points on
the MMSE in 7 months, what would be your next step(s)
in the clinical care of this patient?
A. Add memantine to her medication regimen
B. Schedule another full diagnostic workup to try to
identify confounding causes of cognitive decline
C. Refer to a neurology practice for further
assessment
D. Refer for neurobehavioral status examination
E. A and B
F. C and D
5. What does self-treatment with Ginkgo biloba
suggest about this patient?
A. She is easily influenced by her friend
B. She has noticed a decline in her memory and is
trying to combat it
C. She has a tendency to try unproven remedies,
especially herbal supplements
D. She is health conscious and following “healthy
brain” guidelines for Medicare-aged people
E. A and C
F. B and D
CASE STUDY 2
Patient Presentation
Thomas is a 76-year-old retiree who has come to the
clinic at the prodding of his wife, who accompanies him.
She feels he has become “irritable and depressed”,
although he refutes this characterization. She further tells
you that Thomas no longer tracks their investments,
which was an activity he enjoyed every morning. Thomas
refuses to acknowledge any problems and insists that
his wife “needs someone to pick on”. He has a history of
obesity, diabetes, and hypertension, and had cataract
surgery 2 years ago. On further questioning, you find that
Thomas has difficulty verbally expressing himself.
Current Medication Regimen
Metformin 1000 mg twice daily
Glipizide 10 mg twice daily
Lisinopril/Hydrochlorothiazide 20/25 mg once daily
Examination
Based on his verbal difficulty, you give Thomas a 3-
word/3-minute screen. He repeats two of the three words
without prompting.
6. What action would you recommend for Thomas,
given the results from this quick screen?
A. Order blood tests to exclude some causes of
cognitive problems
B. Administer the MOCA or MMSE to verify findings
from the screen
C. Schedule a visit for a diagnostic workup for
dementia
D. Screen for depression
E. A and D
F. All of the above
Blood tests reveal that Thomas is well nourished and
has no thyroid abnormality. However, his A1C was 8.5%
and his blood pressure was 151/95 mmHg, after a
history of good control for both conditions.
7. What next step do you recommend, given these A1C
and blood pressure values?
A. Consider adding insulin to his medication regimen
B. Increase the dose of lisinopril/HTCZ and increase
the dose of glipizide
C. Ensure compliance with current medications
since he may have a memory problem
D. Add a DPP-IV inhibitor and a beta blocker to his
medication regimen
E. A and B
F. A and D
8. What evaluation would you recommend, given that
Thomas has the behavioral symptoms of irritability and
depression?
A. Refer for neurobehavioral status examination
B. Wait to see if better metabolic control resolves the
issues
C. Start a trial of amitriptyline
D. Start a trial of cholinesterase inhibitor
E. B and C
F. C and D
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Case Study 2 continued
The intervention you chose decreased Thomas’s A1C
and blood pressure to well-controlled levels. However,
his wife reports that he is still irritable and depressed.
You have administered the MMSE twice over the past 4
months and Thomas has scored 27/30 and 28/30.
9. What intervention would you recommend,
knowing that his behavioral symptoms have
persisted despite prior intervention?
A. Refer for neurobehavioral status examination
B. Refer to a psychiatry practice
C. Start a trial of SSRI and re-evaluate in 3–6
months
D. Start a trial of low-dose, atypical antipsychotic
and re-evaluate in 3 months
E. B and C
10. Given Thomas’s clinical course and your choices
of intervention, what diagnosis would you suggest?
A. Early dementia
B. White matter disease
C. Major depression
D. Potential alcoholism
E. C and D
CASE STUDY 3
Patient Presentation
Janet is an 80-year-old businesswoman who remains
active in the flower shop she opened 30 years ago.
Her son has performed many of the daily operations
for the last 10 years, but she has always paid the
invoices to “keep her young”. In recent months, he
noticed that she paid the same bill twice and, on one
occasion, she paid the same invoice three times.
When he questioned her about these payments, she
became defensive and irritable.
Janet has a history of hypothyroidism, hyperlipidemia,
and she had a mild stroke 7 years ago, but has
recovered fully.
Current Medication Regimen
Levothyroxine 0.1 mg once daily
Policosanol 10 mg once daily
Atorvastatin 40 mg once daily
Aspirin 81 mg once daily
Multivitamin
Examination
11. How many risk factors does Janet have for
developing dementia?
A. Two
B. Three
C. Four
D. Five
During the physical exam, you ask Janet to describe a
typical day at the flower shop. She has difficulty telling
a linear narrative and seems to have a jumbled notion
of time. That is, she described having “lunch” before
going to work, although you know from her social
history that she likes to get to the flower shop before
7 AM.
12. What evaluation or intervention would you
recommend for Janet at this point?
A. Trial of low-dose, atypical antipsychotic to
combat her irritability
B. Refer to neurologist for further assessment
C. Schedule a comprehensive, single-system,
psychiatric exam
D. Document the presence of abnormal findings
and order comprehensive blood work
E. B and D
F. C and D
On follow-up, you find that Janet’s lab test values are
all within normal limits except for an elevated
homocysteine level of 15 µmol/L. She also scored
23/30 on the MMSE.
13. How would you code Janet’s initial office visit?
A. ICD-9-CM code reflecting a memory problem
during CPT level 3 exam
B. ICD-9-CM code reflecting a cognitive problem
during CPT level 5 exam
C. ICD-9-CM code reflecting routine follow-up for
thyroid and lipid management during CPT level 2 exam
D. ICD-9-CM code reflecting a mood disorder
during CPT level 2 exam
Question 14. How would you code Janet’s follow-up
office visit?
A. ICD-9-CM code reflecting a memory problem
during CPT level 3 exam
B. ICD-9-CM code reflecting a cognitive problem
during CPT level 4 exam
C. ICD-9-CM code reflecting routine follow-up for
thyroid and lipid management during CPT level 2 exam
D. ICD-9-CM code reflecting a comprehensive,
single-system, psychiatric workup during CPT level 5
exam
15. Assume that you have gathered enough
information from your examinations to diagnose
Janet’s condition confidently. How would you code
the visit in which you reveal the diagnosis if half of
the visit was spent in counseling?
A. ICD-9-CM code reflecting a memory problem
during CPT level 3 exam
B. ICD-9-CM code reflecting a cognitive problem
during CPT level 4 exam
C. ICD-9-CM code reflecting routine follow-up for
thyroid and lipid management during CPT level 2 exam
D. ICD-9-CM code reflecting a specific diagnosis
during CPT prolonged service visit
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