With Age

Multisystem Processes & Disorders


{"ops":[{"insert":{"image":"\/storage\/case-images\/cs\/M53_F1.jpg"}},{"insert":"\n\n"},{"insert":"\u0022Well, alright then. See you later I guess,\u0022 says your patient\u0027s son, who is clearly not thrilled about your decision not to declare his father mentally incompetent.\n\nAs he wheels him out of the office, his father, a 93-year old man you\u0027ve known for years, gives you a wink.\n\nThis reminds you how much you love your work, and that after all, it is the kind and frail elderly that are your priority - not their occasionally ungrateful family members.\n"}]}


{"ops":[{"insert":{"image":"\/storage\/case-images\/cs\/M53_F2.jpg"}},{"insert":"\n\n"},{"insert":"You invite the next patient in. She is accompanied by her son.\n\nMary is an 85-year-old woman who walks very slowly and seems unsure of her steps as she clings onto her son\u0027s arms for balance.\n\n\u0022Hello Mary, hello Jeff, how have you been?\u0022 you greet them with a big smile on your face.\n"}]}


{"ops":[{"insert":"This is only the second time Mary has been to your office. Last week she came in with Jeff, complaining of recurrent falls over the last few months. She had been falling all over her apartment, which she shares with her cat.\n\nOne night, she fell over in her bathroom in the middle of the night and had no one to help her get up. Jeff, worried for her safety, decided to have his mum stay with him and his family after that fall.\n\nJeff also reported that Mary has trouble sleeping at night, that she wakes up during the night and reads her books, but naps during the afternoon. She also needs to pass urine frequently at night.\n\nYou couldn\u0027t find anything else unusual in her history and found no abnormalities on the physical examination except multiple bruises of different ages, which were compatible with the injuries she\u0027s been sustaining on a regular basis.\n\nFor completeness, you ordered several investigations that you are due to discuss today.\n"}]}


{"ops":[{"insert":{"image":"\/storage\/case-images\/cs\/M53_F5.jpg"}},{"insert":"\n\n"},{"insert":"Mary has a 20-year history of diabetes, dyslipidemia, and arterial hypertension. She was a heavy drinker and a smoker since adolescence but quit both 15 years ago, after suffering an acute myocardial infarction. This was treated with thrombolytic therapy and followed by aggressive lifestyle change management.\n\nMary currently receives a tablet per day of aspirin 75mg, furosemide 20mg, carvedilol 40mg and rosuvastatin 40mg. She also has metformin 850 mg with her morning and evening meals and takes paracetamol 500mg whenever her osteoarthritic pains worsen.\n\nMary used to work as a teacher. She has been living alone since after she was widowed 10 years ago. She has two sons: James who is 60 years old, and Jeff, who is 55 years old. Both of them are healthy and well. It is Jeff who accompanied her today.\n"}]}


{"ops":[{"insert":{"image":"\/storage\/case-images\/cs\/M53_F10.jpg"}},{"insert":"\n\n"},{"insert":"Mary has a body mass index of 24.3 kg\/m2. Her heart rate is 85 bpm and completely regular. Her blood pressure is 120\/60 mmHg lying down and 100\/50 mmHg standing up.\n\nThe general examination is normal, as are the cardiorespiratory, abdominal, and neurological examinations. She completes the mini-mental status examination with a near perfect score.\n\nYou perform a diabetic foot examination but note no ulcers, infections or deformities. Her pressure, vibration and proprioception sensation is preserved. Her random blood sugar is 155 mg\/dL.\n\nYou decide to perform a \u0022Timed Up and Go\u0022 test, and ask Mary to get up from her chair, walk ten feet, turn around, walk back to the chair, and sit down. She looks quite unsteady while doing so, and takes fifteen seconds to complete the task.\n"}]}


{"ops":[{"insert":{"image":"\/storage\/case-images\/cs\/M53_F11.jpg"}},{"insert":"\n\n"},{"insert":"Regarding the lab workup you ordered last week, Mary\u0027s results are all normal, except for an HbA1c of 7.5% and FBS of 118 mg\/dL.\n\nHer complete blood count, electrolyte levels, lipid profile, liver functions, kidney functions, thyroid function tests, and vitamin B12 levels are all normal. An ECG shows no abnormalities.\n\nThe echocardiogram report notes an ejection fraction of 45%, with functional mitral regurgitation, mild dilation of the left ventricle with normokinesia, mild biatrial enlargement with normal left atrial pressures, and moderate apical systolic dysfunction.\n\nA carotid ultrasound is negative for carotid stenosis.\n"}]}


{"ops":[{"insert":{"image":"\/storage\/case-images\/cs\/M53_F12.jpg"}},{"insert":"\n\n"},{"insert":"Given the lack of organic culprits, and the insistence of Mary and Jeff that her house is uncluttered with no problematic wires or furniture, it appears that Mary\u0027s medications are the reason for the falls.\n\nWhat will you do now?\n"}]}
1. Decrease carvedilol to 20mg
2. Stop carvedilol completely
3. Stop furosemide completely