MSGM Clinical Case Discussion January 2026

Title: Beyond the Bedside: A Comprehensive Approach to Geriatric

Multimorbidity and Carer Well-Being

Prepared by: Dr. Ng Tyng Sam

Supervised by: Dr. Ng Chai Chen

Madam LYK, 75 years old Chinese lady with multiple comorbidities and complex

medical needs.

Comorbidities

1. Hypertension

2. Chronic kidney disease stage 3B

3. Ischemic heart disease with atrial fibrillation and HFpEF

4. Chronic polyarthropathy –related musculoskeletal pain

• History of treatment for presumed gouty arthritis at a Singapore polyclinic

with chronic steroid consumption

5. Osteoporosis with multi-level spinal fractures likely secondary to (4)

6. Left lacunar infarct with right sided minimal residual weakness in March 2025

7. Iron deficiency anemia with resolved upper gastrointestinal bleed

Home meds

T Prednisolone 5mg OD

T Bisoprolol 1.25mg OD

T Gabapentin 150mg BD

T Hydroxychloroquine 200mg EOD

T Pantoprazole 40mg OD

T Calcium Carbonate 500mg OD

T Calcitriol 0.25mg OD

T Paracetamol 1000mg TDS

T Edoxaban 30mg OD

SC Prolia 60mg 6 monthly

Presenting illness

The patient came for her first follow-up in July 2025 at the Geriatric Clinic, Hospital

Sultan Ismail, after her initial admission in March 2025 for left lacunar stroke. She

complained of intermittent swelling and pain involving the right shoulder and right knee joints, associated with intermittent episodes of fever.

During the clinic review, she was noted to be disoriented, spoke incoherently, and

was unable to recognize family members. In addition, she displayed emotional

lability with marked fluctuations in mood. There were no reports of hallucinations,

delusions, or other perceptual disturbances. She was admitted for further evaluation.

Compressive Geriatric Assessment

Admission	March 2025	July 2025
CFS	5	6
bADL	-        Feeding independent using spoon and fork (due to her hand deformities) -        Bathing, Dressing, Grooming - independent	·       Able to feed herself independently. ·       Grooming and dressing require assistance from the caregiver. ·       She is urinary catheterized, while bowel function remains intact, with the patient able to use the toilet and no reported bowel incontinence.
Mobility	Prior to her stroke in March 2025, she was able to ambulate short distances with a walking frame and used a wheelchair for longer distances.	Following the stroke, she became dependent in mobility and now requires one-person moderate assistance for transfers from bed to wheelchair.
Fall	More than two falls over the year, attributed to a combination of intrinsic (e.g., weakness, poor balance) and extrinsic (e.g., environmental) factors.	Fall primarily during transfers from bed to wheelchair.
iADL	-        Cooking: No longer cooking. -        Grocery shopping: Done by family. -        Watching TV: unable to navigate the channels due to hands deformities -        Medication intake: Independent.	Fully dependent due to deformities affecting both hands and toes.
Sleep	Poor quality sleep. No REM disorder	Having segmental sleep. No REM sleep disorder.
Appetite	Poor Appetite. But not notice reduction of weight	Poor oral intake. Picky eater. Weight loss has been noted.
Cognition	Memory: Occasionally forgetful (Short term memory) Language: Intact Attention: Intact Social functioning: Intact Executive function: Not much involvement Perceptual-Motor function: No issues	Memory: Forgetfulness noted since her stroke in March 2025, with frequent misplacement of items and occasional repetition of speech. Language: Occasional word-finding difficulties and miswording during communication with family members. Attention: Easily distractible. Social Functioning: Still able to participate in family gatherings and festive celebrations; family members did not initially perceive significant cognitive changes. Executive Function: No longer involved in planning or organizing activities. Perceptual-Motor Function: Unable to assess accurately, as the patient no longer goes out unaccompanied.
Mood and behaviour	·       No psychotic symptoms	·No psychotic symptoms were reported. ·The patient demonstrates a persistently low mood but does not meet criteria for dysthymia or anhedonia. ·There are no suicidal thoughts or ideations.
Family genogram	The patient lives with her husband and eldest son in a double-storey house. She has four children. Her main caregiver is her second daughter, has resigned two years ago to provide full-time care for her mother.

On examination

Otoscope Examination:

• Right ear: External auditory canal with dried wax, no erythema or discharge. Tympanic membrane not visualized.

• Left ear: Presence of pus collection within the external auditory canal.

Musculoskeletal Examination:

• Hands: Bilateral proximal interphalangeal and metacarpophalangeal joints tender with ulnar deviation noted.

• Knees: Bilateral knee effusion with associated pain; left knee warm to touch. Pain elicited on passive movement of both knees.

• DAS28-CRP: High disease activity

Vital signs during admission

Blood pressure: 178/96 mmHg

Pulse rate: 121 bpm

Respiratory rate: 31 bpm

SPO2: 96 % under room air

Temperature: 38.1 ‘c

Glucose monitoring: 5.0 - 7.2 mmol/L

Respiratory examination: right midzone fine crepitations   

Cardiovascular examination: dual rhythm and no murmur

Abdominal examination: bowel soft and non tender

Rectal examination: bleeding anal fissure

Blood investigations during hospitalisation in July 2025 (Table 1)

Blood	Admission	Hospitalization (Desaturation)
Full Blood count	Hb 6.2 g/L (MCHC picture) WCC 8.35 109/L Platelet 528 109/L	9.9 g/L (post transfusion) 15.7 109/L 320 109/L
PBF	Severe anemia. Hypochromic cells. RBC Occasional cigar cells seen. No spherocytes/ schistocytes seen. No increase in polychromasia. Adequate count with eosinophilia. Occasional hypersegmented neutrophils and reactive lymphocytes seen. No blast/ abnormal mononuclear cell seen. Platelet plentiful. IMPRESSION: 1) Anemia to rule out iron deficiency. Blood loss cannot be excluded. To correlate with iron study and clinically. 2) Eosinophilia to rule out secondary causes i.e. skin disease, allergic reaction, parasitic infection, etc. 3) Thrombocytosis to rule out reactive causes.	-
Renal Function Test	Na 138 mmol/L K 3.9, post correction: 3.4 mmol/L Urea 19.8 mmol/L Creat 124 mmol/L Calcium 2.3 mmol/L Phosphate 1.4 mmol/L Magnesium 0.8 mmol/L	134 mmol/L 3.9 mmol/L 15.6 mmol/L 118 mmol/L 2.4 mmol/L 0.9 mmol/L 0.8 mmol/L
Liver Function Test	Total protein 77 g/L Albumin 25 g/L Bilirubin 3.8 µmol/L AST 22 U/L ALP 151 U/L ALT 22 U/L	75 g/L 23 g/L 4.5 µmol/L 33 U/L 165 U/L 24 U/L
C-Reactive Protein	231 mg/dL	225 mg/dL
Tumor markers (PSA, AFP, Ca 19-9, CEA)	Normal value	-
TFT	T4 16.4 pmol/L TSH 1.55 mIU/L	-
Anemia work up	Iron 3.4 TIBC 24.5 TSAT 13.8	-
Blood cultures Sputum culture QuantiFERON-TB Gold	No growth No growth -	No growth Acinetobacter Baumanii (MRO) Indeterminate

Image 1: Chest xray during admission

Image 2: Right shoulder Xray

Image 3: Bilateral Knees Xray

Ultrasound Shoulder (17/7/25)

Findings: The previously seen heterogeneous lesion at the right sub deltoid region predominantly at the anterior aspect extending to the posterior shoulder, measuring approximately 2.0 x 8.9 cm (AP x W). Presence of cystic areas within with mobile echogenic debris. There is extension of this lesion into the right glenohumeral joint. No internal vascularity.

Impression: Features are suggestive of right sub-deltoid collection/abscess with intra-articular extension.

Ultrasound right shoulder and left knee (12/8/25)

Findings: Hypoechoic collection with mobile echoes seen at the deltoid region just adjacent to the proximal humeral bone, measuring 2.3 x 3.1 x 3.8cm (ap x w x cc) with the suspicion of joint involvement. The surrounding subcutaneous tissue is oedematous. There is left suprapatellar collection with thick septations within measuring 2.1 x 5.0 x 7.9cm (ap x w x cc), no obvious joint involvement.

Impression: Right deltoid region collection with suspicion of joint involvement. Left suprapatellar complex collection.

Impression given during the hospitalisation

1.     Right shoulder and left knee septic arthritis

2.     Mixed delirium secondary to multi-factorial precipitating factor with predisposing of ischemic stroke

3.     Acute on chronic kidney disease secondary to sepsis/ poor nutrition

4.     Functional anaemia secondary to chronic illness and bleeding anal fissure

5.     Hypereosinophilia likely secondary to helminthic infestation  

6.     Left otitis media

7.     Physical deconditioning, undernutrition and sarcopenia

Case was then referred to orthopaedics team

The patient underwent incision, drainage, and arthrotomy washout of the right shoulder for septic arthritis.

Operative Findings:

Intraoperatively, a seropurulent collection was noted in the subdeltoid region, extending into the glenohumeral joint capsule. The joint space contained extensive slough and necrotic debris. The coracohumeral ligament and coracopectoral fascia were absent, consistent with chronic inflammatory tissue destruction.

Microbiological Results:

• Joint fluid culture: No organism seen.

• Tissue culture and sensitivity: No bacterial growth.

• Pus aspirate C&S: No pus cells observed; no growth on culture.

The absence of microbial growth on culture, together with intraoperative findings of chronic synovial inflammation and tissue destruction, was initially more suggestive of a rheumatoid arthritis flare involving the right shoulder. Despite surgical intervention, the patient continued to experience intermittent fever. However, a diagnostic dilemma remained, with differential considerations including rheumatoid arthritis flare, acute gouty arthritis, osteoarthritis, and septic arthritis. A repeat right shoulder aspiration was performed by rheumatologist; microscopy revealed no crystals. Correlation of clinical features, laboratory parameters, and ultrasonographic evidence of a subdeltoid collection/abscess supported a working diagnosis of septic arthritis. The patient was therefore managed with intravenous antibiotics and surgical drainage.

During hospitalization, the patient developed a productive cough and desaturation requiring high-flow oxygen. Investigations (blood tests, cultures (Table 1), and radiological imaging; Image 4) confirmed hospital-acquired pneumonia. Despite adequate antimicrobial and surgical management, her progress was suboptimal, and a fall during admission further worsened her functional status and deconditioning.

Image 4: Chest Xray (During patient desaturation)

Patient’s primary caregiver is her daughter, who had resigned from her job in Singapore two years prior to provide full-time care. The caregiver was noted to be highly anxious and having Grave’s disease eye sign. However, the carer declined the offer for further assessment of her condition. She would frequently question medical decisions and express distrust towards the healthcare team. She became irritable when explanations were delayed, occasionally being rude to the patient, and at times displayed verbal aggression towards allied health staff. The caregiver expressed strong hope that her mother would regain mobility and return to her premorbid functional status prior to May 2025. A family discussion was held; however, family conflict was observed during the meeting.

The patient was eventually discharged after completion of antibiotic therapy and once caregiver training and education had been successfully provided.

Questions:

1. How does her comorbidities and functional trajectory help in managing this patient?

2. How would you prioritize her problems using a geriatric approach (acute, subacute, chronic)?

3. How do we manage the diagnostic uncertainty when differentiating between an acute rheumatoid arthritis flare, osteoarthritis flare, and septic arthritis?

4. What are your short term and long term management goals?

5. What is the role of the Geriatric Team in providing holistic and coordinated management for an older adult with complex multimorbidity and functional dependency in this case?

6. What factors may contribute to poor recovery in such cases, and how can multidisciplinary interventions optimize functional outcomes in frail elderly patients?

7. How can the healthcare team maintain a therapeutic relationship despite conflict?

8. How would you assess and manage caregiver stress or burnout in this situation?

9. What communication strategies can the healthcare team use to manage a distressed or difficult caregiver?

10. What ethical issues may arise when the caregiver’s behaviour/beliefs/understanding affects patient care?