Special Operations Forces Medical Handbook

3-86

able to recall all three. Testing of retrieval ability is more difcult because the examiner may not know the
patient’s fund of knowledge. Testing can include standard information questions such as national leaders and
dramatic news events. Knowledge specic to his individual military unit can also be asked. If the patient is
able to successfully pass these memory tests, then his primary problem is unlikely to be with memory function.
Further assessment of other cognitive functions will need to be performed as indicated by the clinical situation
and his response to the MMSE.
Using Advanced Tools: Lab: WBC for infection; pulse oximetry for hypoxia. Papilledema should cause
immediate concern for intracranial hemorrhage, swelling, or mass.

Assessment:
Differential Diagnosis
Traumatic brain injury - memory problems following head trauma is common, so patient may not remember
the injury. Intracranial bleeding may lead to severe symptoms within minutes, but may also progress slowly
over hours to days, requiring close follow-up.
Infection - herpes simplex encephalitis is the most common infection causing predominantly memory
problems. There is usually associated behavioral deviations, disorientation, seizures, or weakness.
Stroke (ischemic from blocked vessel, or hemorrhagic from bleed) - uncommon in young individuals without
other neurologic signs or symptoms. Ask about stroke risk factors: hypertension, smoking, diabetes,
positive family history, hyperlipidemia, oral contraceptives, binge alcohol drinking, atrial brillation, and
coronary heart disease.
Seizure disorder - rarely manifested as isolated memory and cognitive problems. (See Neurology: Seizure
Disorders)
Hypoxia - can result in permanent damage to the memory systems of the brain. History may reveal a
recent hypoxic event.
Inammatory - consider multiple sclerosis or CNS sarcoidosis, although these rarely cause isolated
memory problems.
Transient global amnesia - uncommon in young adults; no associated symptoms, and the condition
resolves within 24 hours
Migraine - memory problems are transient (hours), and usually associated with a headache; prior history
of migraines.
Metabolic (such as thiamine deciency), toxic, degenerative, or neoplastic causes may also be considered
Psychiatric - causes can include sleep deprivation, stress, anxiety, and depression. Psychiatric etiologies
usually present as a retrograde amnesia. Other psychiatric symptoms are usually present. This category
should be strongly considered if the patient does not know his own name.
Decompression Sickness history of recent diving and/or ying; may have other associated neurological
ndings, including subtle (soft) signs

Plan:
Treatment

1. Secure all weapons.


2. Provide supportive treatment: rest, uids, reassurance, and observation will improve or stabilize many
   conditions.


3. Closely supervise military personnel who return to duty. If given signicant independent respons
   bilities, they can be a danger to themselves or others if memory problems remain.


4. Herpes simplex encephalitis has a high mortality and demands early and aggressive treatment with IV
   antiviral medication, such as acyclovir if available.


5. Intracranial bleeding, swelling, or mass requires neurosurgical intervention.

Patient Education
General: Signicant memory problems may be due to an organic or psychiatric etiology.
No Improvement/Deterioration: Return for evaluation daily initially, as symptoms may worsen rapidly in
some illnesses.