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MSGM Case Discussion May 2024

Prepared by: Dr Muhamad Danial Zulkifli

Supervisor: Prof Nor ‘Izzati Saedon

Location: Pusat Perubatan Universiti Malaya

Pre Admission Baseline

  • Patient is retired researcher in biological science and retired at age of 60.

  • Patient is single, staying alone in an apartment and independent (bADL& iADL) pre admission. He was walking without walking aids but has been having episodes of recurrent falls due to dizziness. However collateral history from his siter, 2 months prior to admission started asking sister for help to take care of him due to fear of fall with symptoms of dizziness.

  • Personality wise, according to patient’s sister patient is quite stubborn and get angry easily.

  • Medications prior to admission (as below), noted polypharmacy. He claimed that medications he was taking is for his general wellbeing which he has been taking 2-3 years. Denies underlying psychiatric illness or anxiety.


Investigations in Private Hospital (October 2023)

Blood Investigations

Tilt Table Test (Front Load Test)

Patient’s Progress

  • Patient was kept inpatient for physio and OT assessment and for tilt training.

  • Patient not able to fully accept the diagnosis and believe that the symptoms were due to other causes including cardiology perspective.

  • In view of patient was leaving alone prior to admission and concern by family on safety, patient was discharge to nursing home with fall prevention strategy, tilt training and education was done during inpatient stay.

  • Patient was due to continue follow up under gastro and cardiology in private hospital with memo on the update from this admission given.

  • Patient also for follow up in falls clinic in 3 months with options for outpatient OT and physiotherapy were given to patient.

Clinical Questions

  1. Based on the case above, what are the extrinsic and intrinsic fall risk factors for the patient?

  2. Based on the result of tilt table test above, what is the likely diagnosis?

  3. Would you consider fludrocortisone for the patient? If no, why?

  4. Other than tilt training, any other lifestyle modification you would advise for the patient?

  5. Patient is an educated person and unable to accept and understand the diagnosis hence not fully accepting conservative therapy and tilt training by therapist. How would you deal with this?

  6. What are the pathophysiology of Orthostatic Hypotension and how can you educate patient in this case on understanding of the condition?

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1.       Falls risk factors


-          Environmental hazard

-          Clutter


-          Postural hypotension and vasovagal syncope

-          FRIDs

-          BPH

-          Fear of fall

-          Mood disorder

-          Possible sarcopenia

2.       Postural hypotension and vasovagal syncope

3.       Would consider fludrocortisone—multiple hazardous falls leading to admissions, however may worsen hypertension

4.       ABC (a cup of water, baroreceptor training, calf compression exercises).

5.       The gravitational stress of suddenly standing causes blood (½ to 1 L) to pool in the veins of the legs and trunk. The subsequent transient decrease in venous return reduces cardiac output and thus BP

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