MSGM Clinical Case Discussion September 2025

Prepared by: Dr Muhamad Danial Zulkifli

Supervisor: Dr Ungku Ahmad Ameen Ungku Mohd Zam

Patient’s Background:

-Mr. AS, 72 years old male.

Medical Background History:

Medications Pre Admission:

Presenting & History of Presenting Complaint:

Patient has been having 1 week history of intermittent exertional central chest pain, non radiating, mostly persistent, pressing in nature, requiring daily GTN for 1-3 times per day for 1 week prior to admission. Baseline NYHA was class I progressing to class II  for past 1 week. Otherwise has no failure symptoms including PND, orthopnoea or lower limb oedema.  

Other associated symptoms include lethargy, generalized weakness resulting in not being able to get up and  manage himself. Patient had one episode of fall 1 month prior to admission. The mechanism of fall involved him trying to get up from sitting position, felt dizzy and fell to the floor. Patient reported persistent intermittent postural dizziness. Following the fall, no obvious injury sustained and was able to ambulate as usual.

Other History:

Overall, patient has baseline CFS of 5

Physical Examinations:

-General: Alert, lethargic looking, cachexia

-Vital signs: BP: 104/82, HR: 80, T: 37, RR: 22,  SpO2: 97% (under RA)

-DXT: 5.6

-CVS: S1+S2, no audible murmur, no pedal oedema

-Lungs: clear on auscultation

-Abdomen: Soft, non tender

-Neurological exam:

No cerebellar signs

Tone: no rigidity

Power:

-Lower Limb: 4/5 bilaterally (proximal / hip); 5/5 (knee flexion, extension)

-Upper Limb: 5/5 bilaterally

-Standing & Lying BP:

Investigations:

-Bloods:

FBC: WCC: 7.4, Hb: 9.7 (Baseline: 9-10), Platelet: 265

RP: Urea: 18.1 (baseline: 9) Cr: 199 (baseline: 110), Na: 137, K: 4.7

LFT: ALT: 19, ALP: 51, TB: 7

TP: 78, albumin: 37

Trop T: 35-> 34

Vit B12: 383, folate: 7.4

Iron studies: Serum iron: 14.3, Tsat: 35%, ferritin 500

HbA1c: 5.5%

AM Cortisol: 191

-ECG:

1) SR, Flattened TW in lead I, TWI in aVL

2) SR, new TWI in V2-V3

3) SR, TWI in AVL, V2-V4

-CXR: No focal consolidation, normal heart border

Summary of Medical Issues:

Clinical Questions:

1. With the complexity of falls risks and the co morbidities, how would you prioritize the management of the co morbidities?

2. Based on the case above, what are the extrinsic and intrinsic falls risk factors for this patient?

3. Collectively, what are the aetiologies and other possible risk factors for postural hypotension in this case?

4. What is the principal of management for Postural Hypotension?

5. How would you balance management of IHD with Postural Hypotension in this case?

6. What would be your management of polypharmacy and appropriate medication adjustment for this patient?

   
   

Clinical Issues & Management Dilemma :

1. Management of Angina in IHD vs Postural Hypotension:

• Vasodilator and risk of worsening of postural hypotension

2. Excessive hydration with risk of hypervolemic state in the setting of Heart Failure with Reduced Ejection Fraction (HFrEF)  & Postural Hypotension

3. Limitation of rehabilitation in the setting of IHD and Postural Hypotension where realistic rehab goal is needed

4. Clinical diagnosis of Parkinson Disease: Given patient has no clinical signs of Parkinsonism, probably worth the trial to stop madopar and observe as madopar can also worsen postural hypotension

5. Discharge issues: Given patient is living alone with high risk of falls, there is a need to assess home environment, safety and limitation of cardiac endurance in the setting of cardiac disease.

Discussion & Management while Inpatient:

Diagram below shows identified falls risks & factors contributing to and worsening of postural hypotension:

Considerations in patient management include managing both cardiac and postural hypotension aspects.

Management Strategies:

Medication Changes upon discharge:

Progression prior to discharge:

From symptoms perspective:

•        Patient reported less episodes of postural dizziness

•        No chest pain upon ambulation

•        Able to walk with 2m + 2m (break in between)

•        No worsening of urinary symptoms

•        Whilst on trial of withholding madopar, no clinical signs of Parkinson noted

Objectively, prior to discharge, had repeated standing and lying BP post intervention / changes of medications:

Summary of input by MDT:

• SALT: Oral phase dysphagia secondary to dentition issues (only 2 tooth)

• Dietician: Glucerna 4 scoops 200mls x 3

• Dental: No need tooth extraction, suggest for denture (patient keen to go under private), no contraindication for Fosamax/ Denosumab should there be plans to initiate in future

• Physio progress:

• Sit at edge of bed, postural dizziness limiting rehab however overall improving with tilt training and medical measures.

• Progress after intervention, able to ambulate with rollator 4m distance

• OT:

• OT: training of daily function, toilet training

• Moderate dependency level, independent with Personal Hygiene Activity, MBI: 74

Prior to discharge, done family meeting update:

• Discharge Planning

• Son plan to get half day private Helper for a short term and plan to sort out Nursing Home placement as his long term plan

• Patient and carer education on Postural Hypotension

•  Education on medication changes

Follow up plan:

• Memo to Hospital Serdang (cardio) regarding current admission

• Ideally for home visit, however long term plan is for Nursing Home, hence no home visit arranged

• Geriatric clinic review in 5 months

•  BMD outpatient