Clinical Case Presentation March 2024

Name: Khoo Pei Jie

Supervisor: Dr Reena Nadarajah

Location: Hospital Selayang

Case Scenario

Mr OLK 75 year old Chinese gentleman

Comorbidities:

• Hypertension

• Dyslipidimia

• Ischemic heart disease

• History of motor vehicle accident with intracranial bleed requiring craniectomy more than 10 years ago

• History of admission Sept 2022 for unstable angina complicated with delirium but defaulted follow-up
  

Current Medication

• Tab Aspirin 150 mg OD

• Tab Clopidogrel 75 mg OD

• Tab Atorvastatin 40 mg ON

• Tab Pantoprazole 40 mg OD

1. He had defaulted Klinik Kesihatan follow-up due to logistic issues.

2. Son purchased medication from pharmacy.

Social History

He is an elderly gentleman who had been separated from his wife 6 years ago and was staying with his second son (who had issues with drug addiction) who is also the primary care taker. They were financially supported by the youngest son.

History of Presenting Illness

• Brought in for recurrent falls.

• Patient had 2 falls on the same day when he tried to go to kitchen multiple times to make coffee despite already drank his coffee earlier. He had difficulty to get up after the last fall. Did not sustain any injuries.

• Patient was referred to Geriatric team for management of his recurrent falls.

Premorbid

• He was ADL independent till 2020 when he developed slurred speech, followed by slowness in movement, stiffness over the bilateral lower limbs and forgetfulness.

• In 2020, patient started having repetitive questionings, misplacing items and forgetting recent events such as appointments.

• Cognition was progressively declining.

• By 2022, he stopped driving and using phone.

• By June 2023, BADL required assistance with functional urinary incontinence.

Mobility and Falls

• He experienced progressive slowing of movements and rigidity over the bilateral lower limbs for the past 4 years.

• While still ambulating without aid, he had recurrent falls. The frequency of falls had increased from 1-2 times per month to 2-3 times per week over the past 1 year (2023)

• In 2023, most falls occurred in the bed room while trying to get up from the bed. There was no giddiness, no loss of consciousness, no seizure, no palpitation nor chest pain prior to the falls. Never sustain major injuries.

• He had been housebound for the past 2 years due to the slowness in movement and frequent falls.

Mood and Behavior

• Over the past 1 year, patient’s judgement continue to worsen resulting in his continuous pacing despite safety issues and recurrent falls.

• No hallucination or delusion.

Physical Examination

• Calm, well kempt, good eyes contact, dysarthric, answer relevantly ,hypomimia, vision and hearing intact.

• BP: 137/72, P: 61, SpO2: 99 under room air, Temp: 37

• BP lying:130/74, pulse:70, BP standing 0min: 110/60mmHg, P: 90, 1min standing: 90/50mmHg, P: 95, 3min standing: 98/60mmHg, P: 96/min

• 4AT: 0/2/0/0=2

• Lungs: crepitation over the right lower zone

• CVS: S1+ S2 no murmur

Neurological Examination

• Gait – Difficult to initiate and very slow gait, magnetic gait, narrow base

• Rigidity bilateral lower limbs more than upper limbs

• Bradykinesia left more than right

• No resting tremor, no dysmetria or nystagmus

• Power: grade 4 bilaterally

• Reflexes: normal bilaterally

• Barbinski: equivocal bilaterally

• Sensation intact–proprioception and pinprick

• MMSE: 16/ 27 (orientation 5/10, registration 3/3 attention 2/5, recall 0/3 language: 6/8, construction 0/1)

Investigations

• Hb: 12.7 WBC: 8 Plt: 263

• Na: 142 K: 4.3 Urea: 4.9 Creat: 69

• Calcium: 2.42 Phos: 1.09 Mg: 0.83

• Albumin: 41 ALT: 17 Bilirubin: 13.9

• TFT: T4: 14.4, TSH: 1.6 (normal)

• B12: 105 (low)

• Folate 6.5 (normal)

CT Brain 12.09.2022

• Findings

• Evidence of left temporo-parietal craniectomy with air pockets within.

• Well defined hypodensities seen at the left corona radiata and right centrum semiovale.

• Encephalomalacic changes of the left frontal and left posterior parieto-occipital temporal regions with ex vacuo dilatation of the ipsilateral lateral ventricle.

• No acute intracranial haemorrhage.

• Prominent ventricles, sulci and basal cisterns in keeping with cerebral atrophy.

• Periventricular hypodensities in keeping with deep white matter ischemia.

• No midline shift.

• No suspicious skull vault lesion.

• The visualized paranasal sinuses and bilateral mastoid air cells are preserved. Impression 1) Multifocal chronic infarcts with encephalomalacic changes as described. 2) Background cerebral atrophy and small vessel disease.

Questions

1. What is the possible diagnosis ?

2. How would you manage this?