Clinical Case Presentation February 2024
- Malaysian Society of Geriatric Medicine
- Feb 1, 2024
- 2 min read
Prepared by Dr Lee AV
Supervised by Dr Terence Ong (Universiti Malaya Medical Centre)
Background
Mrs FA, a 65-year-old woman, lost her balance and fell on her right hip. She presented to the emergency department 3 hours later, complaining of severe pain over her right hip and unable to ambulate.
There was no history of fever, nausea, vomiting, diarrhoea, or other symptoms indicating an infectious disease. She has no recent weight loss.
She has multiple comorbidities, which included Type 2 Diabetes Mellitus, diagnosed 8 years ago, dyslipidemia and bilateral knee osteoarthritis.
Social History
Married with 5 children
Lives with husband and eldest son
Ex-smoker
Worked as an executive at a business corporation
Education level: Degree
Background
Medications included gliclazide modified release(MR), dapagliflozin and metformin combination, with ezetimibe and atorvastatin combination. There was no history of steroids, traditional supplements or alcohol consumption.
Prior to the fall, she was living with mild frailty (clinical frailty scale 5) and was able to ambulate with a walking stick.
Clinical examination
On examination, her temperature was 36.4°C, blood pressure 173/88 mmHg, pulse 108 beats per minute, oxygen saturation 100% on room air and respiratory rate 20 breaths per minute. Clinically dry. Her DXT was 5.4 mmol/L.
She has a BMI of 23.37 kg/m2. Her Glasgow Coma Scale was 15/15. AMTS 9/10.
The right lower limb was shortened and externally rotated, with tenderness over the right hip. She was able to move her ankle dorsiflexors, plantar flexors, and extensor hallucis longus.
The sensation was intact to light touch over the medial, lateral, dorsal, plantar, and first dorsal web space. Dorsal is pedis pulse was palpable 2+.
Investigations
Her pelvic X-ray revealed a right pertrochanteric femur fracture.
Regular analgesic syrup morphine and tablet paracetamol were served.
She was planned for Right Trochanteric femoral nail.
Progress
The patient was fasting for 8 hours for the operation. However, it was noted she had sinus tachycardia (pulse 111 beats per minute), was clinically dry, BP 131/73mmHg, temperature was 36.6°C, oxygen saturation 100% on room air and respiratory rate 20 breaths per minute. Repeated DXT was 5.4 mm ol/L.
Her chest was clear to auscultation bilaterally. Heart sounds were at a regular rate and rhythm. The abdomen was benign.
ECG showed sinus tachycardia with no acute ischemic changes.
The chest radiograph was normal.
Blood investigations
FBC: WCC 10, Hb 14, Plt 178
Renal profile: Na 135, K 3.2, Ur 2.5, Cr 37, chloride 105
Electrolytes: Ca 2.25 (corrected), Phos 0.85, Mg 0.7
Liver function: Bil 16, ALP 84, ALT 17, Albumin 32
HbA1c 8.2%
VBG : pH 7.32, HCO3 15.7, BE -13.4, lactate 0.7
UFEME Glucose 3+, ketone 2+
serum ketone 5.6
Discussion
What would be the provisional diagnosis?
What would be the provisional diagnosis?
How will you manage this patient?
What are the challenges in managing diabetic emergencies in older adults?