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?