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Clinical Case Presentation October 2023

Prepared by: Nareshraja Janardanan

Supervisor: Dr Elizabeth Chong


Case Scenario

Mrs J is a 76 year old lady who has been under follow up in the general medical clinic for about 2 years. Below are her list of co-morbidities.


Hypertension - on antihypertensives

Atrial Fibrillation - CHADSVASC:6 - on DOAC

Ischaemic Stroke - occurred in 2017 - MRS:2


Hypothyroidism -TSH: 58, T4: 5.9 ( Nov2022) - on thyroxine

Nephrotic Syndrome - in remission for more than 10 years

Bilateral eye cataracts - under ophthalmology follow-up - planned for op in the future


Medications from general medicine clinic

  • T. Micardis plus 1/1 OD

  • T. Bisoprolol 2.5mg OD

  • T. Rivaroxaban 20mg OD

  • T. Thyroxine 75mcg OD

  • T. Simvastatin 40mg ON

  • T. Pantoprazole 40mg OD

Cognitive Impairment? During the recent medical clinic follow up, Mrs. J mentioned that she was frequently forgetting to take her meds, thus she was referred to the geriatric clinic for a possible diagnosis of dementia.


First visit to the Geriatric Clinic

She came to the geriatric clinic in July 2023. She was dropped of by her nephew at the HKL main entrance, and she found her way to the clinic. At the clinic, she was noticed to have a very high Blood Pressure of 210/100. She couldn’t remember if she had taken her antihypertensives that day. She was asymptomatic and was subsequently admitted urgently to the geriatric ward for BP control. Her BP was stabilized with oral antihypertensive.


Comprehensive Geriatric Assessment

After being admitted to the ward, a CGA was done to identify and address her issues in a wholistic manner.


Cognition

Family members started to notice the memory issues after her stroke in 2017






Activity of Daily Living



Social history

  • Madam J used to be a typist in the Istana Negara till about the age of 45 years old in which she took early retirement due to chronic back pain.

  • She is unmarried, and lives with her brother for many years. She claims to not be close to her siblings, but she prefers to spend time with her nephews and nieces.

  • She says she that does not have much friends, although in the ward she is able to befriend the patients who are next to her, and always seems to be quite chatty.

Clinical Examination


Geriatric Scores

Radiological Investigations (Aug 2023)


Blood Investigations

  • Full Blood Count Hb-14.3, TWC-4.6, Plt-151

  • Renal profile Na-139, K- 3.7, Urea- 9.2, Creat- 95

  • Electrolytes Ca-2.4, Mg- 1.04, Po4- 1.07

  • Liver function Alb-34, T. Bili-12, ALP-53

  • Vitamins Folate/ B12- within normal limits

  • Viral screen HIV serology- negative

  • Thyroid Function TSH -95, T4- 10.9

Questions for Discussion

  • What are some of the neurological deficits expected for someone with a Posterior Cerebral Artery (PCA) infarct?

  • What are the differences between vision problems caused by a PCA infarct and those caused by cataracts?

  • What could be the aetiology behind Mrs. J’s cognitive impairment?

  • What cognitive domains are usually affected by people with hypothyroidism?

  • How would you manage Mrs. J?

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4 Comments


Her cognitive impairment could be contributed by previous stroke, severe hypothyroidism and worsened by her visual impairment. Hypothyroidism should affect complex attention, memory, visuospatial function and sometimes executive function or expressive language.


I would optimise her treatment of hypothyroidism, ensure medication adherence (direct supervision/dosette box/pill box), engage her in CST group, correct her visual impairment.

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Catarcts may present as BOV, xanthopsia, difficulty seeing in the dark, glare sensitivity and seeing halo around lights.

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PCA infarcts: contralateral homonymous hemianopia (due to occipital infarction), hemisensory loss (due to thalamic infarction) and hemi-body pain (usually burning in nature and due to thalamic infarction). If bilateral, often there is reduced visual-motor coordination. Hemiparesis is generally absent

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For those who have viewed this case discussion, what are your thoughts?😄

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