Mrs since past 3 years, however there was

Mrs Spresents to the clinic, complaining of palpitation for 1 month. History of presenting complaintMrs S,a 60 years old elderly Indian woman with background history ChronicHypertension (HPT), Type 2 Diabetes Mellitus (T2DM), dyslipidemia andParkinson’s disease presents to the clinic for her routine follow-upcomplaining of palpitation since the past 1 month. The palpitation was on andoff, not aggravated by any activities.

Each episodes lasted about 1 to 2minutes. It was associated with dizziness and sweating. Patient thought it wasrelated to stress since she frequently worried about her 2nddaughter since she is the one who is not getting married yet. She did not tookcoffee or tea prior to palpitation. However, there was no chest pain, historyof syncopal attack. She also complaint of reduce appetite since past 3 years,however there was no lose of weight.

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Her weight remained to be 37kg since thepast 3 years. Past Medical HistoryShewas diagnosed with HPT, T2DM and dyslipidemia for the past 15 years. She iscurrently on oral medications and compliant to the medication. She never missedto take her medications. Her blood sugar and blood pressure is controlled basedon the serial reading during her regular follow up and also monitoring at home.Her latest HbA1cis …. .

No history of hypoglycemia episode. Her blood pressure ranging from110-130/70-80mmHg. She is under ophthalmology follow up in Hospital KualaLumpur, annually. Until now, based on the yearly follow up, she do not developseyes complications such as retinopathy or maculopathy that can be cause by herchronic DM and HPT. There are no symptoms of cardiovascular disease such as chest pain or discomfort and no shortnessof breath.

Since she is a postmenopausal woman and doing less physicalactivity, she is having risk to develop coronary artery disease. However, sheis not obese and non smoker.             She was diagnosed with Parkinson’s Disease forthe past 10 years.

Since then, she had to take medications to control her symptomsespecially tremors. After 7 years been diagnosed with Parkinson’s disease, she developedside effect from those antiparkinsonian agents which was dystonia. Her daughterdescribed it as excessive involuntary movements and over twisting of the upperand lower limbs. Mrs S had to be treated in Intensive Care Unit (ICU) for 2days and a month in Neurological ward.   MedicationsT2DM1.    T.

Metformin (Dimethyl Diguanide) HCL 0.5g BDHPT1.    T.Perindopril 8mg ODDyslipidemia1.    T.Simvastatin 40mg ONParkinson’s disease1.    T.

Madopar 125/62.5/125/62.5/62.5mg  5x/day2.    T.Madopar 2mg BD3.    T.Amantadine 100mg BDAnemia1.

T. Ferous Fumarate 200 mgOD      Past Surgical HistoryNil Allergy historyNo allergy history Diet historyShe takes very minimal amount of food everyday because oflack of appetite and often worries about her tremor. She afraid to eat becauseshe afraid she might get the tremors during she eats. Her meals are prepared byher daughter in-law who lives together in the same house.  Family History                                                                                                                                                  Social HistoryMrs Sis a housewife and a single mother since her husband passed away at the age of46 years old due to motor vehicle accident. She is currently living with her 1stson with his family and also with her unmarried 2nd daughter in adouble storey house, in Cheras..

Both her son and daughter are working, thusher daughter-in-law is the one who taking care of her while at home. She isalso living with her 3 grandchildren. She is taken care very well since shenever skipped her medications and always take it on time and only has onehistory of fall despite of her having instability in walking. She is non ADLdependent. She can manage herself well.

However, she sometimes needs help in walkingsince she feels unstable. Fortunately, her children provides her a wheelchairand walking aid to aid her in walking. Besides that, her daughter-in-law isalways there at home to look after her mother-in-law just in case anythinghappen. At home, Mrs S does minimal work and do not really exercise due to hercondition . She do not have the guts to do something heavy and risky and herchildren also prohibit her to do risky chores such as cooking because it mightput her into danger especially when her Parkinson’s attack comes, such astremors at both upper and lower limbs.  Physical Examination General ExaminationOngeneral examination,  Mrs A was anelderly lady, underweight with a well kempt appearance.

She was comfortable andalert. She not pale, not jaundiced and did not have any xanthelasma.  Upon gait assessment, she appeared unstableand need to hold his daughter while walking. Pulse               : 86 beats minute, regular rhythm,good volume.BP                   : 117/80mmHg (normotensive)Temperature   : 37.2 Weight : 37 kgHeight             : 164 cmBMI                : 13.

76 kg/m2 (Underweight)   SystemicExaminationCardiovascular ExaminationUnremarkable.No murmur. S1 and S2 were heard. Other systemic examinationUnremarkable  Patient’sProgress and ManagementSincethe patient was complaining of palpitation for that past 1 month, a few testswere carried out to further investigate the cause of palpitation. Full BloodCount (FBC) test was done to mainly check Haemoglobin (Hb) since anemia cansometime cause palpitation and the result showed patient’s Hb) level was lowwhich was 10.4g/dL, mild anaemia. Besides that, Electrocardiogram (ECG) alsocarried out, however patient was having tremor while doing the test and theresult was not accurate.

She had to repeat the ECG in the next visit, inanother 2 weeks time. Due to her mild anaemia, she was prescribed with T.Ferous Fumerate 200 mg OD.

 Impact of Illness to thePatientTheimpact of illness especially Parkinson’s Disease gives a few significant impacton this patient. She has instability in walking and needs someone or walkingaid to help her in walking without falling. Even though she is onantiparkinsonian medications, she will still having tremors after 2 hoursmedication taken.

This symptom scared her the most because she is afraid toeven eat because tremors can cause her difficulty to eat even though she is notusing eating utensils and only using hand to eat. She also have to limit herphysical activity and not encouraged to do house chores especially cookingbecause this can put the patient in danger especially when she have thetremors. She also had difficulty to sleep and need to eat sleeping pill to helpher to sleep since the past 6 years. Besides that, since she was anemic, shewill have symptoms of palpitations and also dizziness. This will increase thepatient’s risk of fall.   Impact of Illness to theFamilyEventhough patient is still non ADL dependent, it is somehow affects the familyespecially her caretakers. She needs extra observation since she hasinstability in walking because she is at risk of fall anytime and anywhere.

Hercare takers also have to make sure all the medications are taken correctly atthe correct time. Currently, with extra risk factor of fall, which is anemiathat can cause dizziness, patient need more observation. Plus, her daughteralso complains that her mother currently quite sensitive and often worriesabout her who is not getting married yet. She said that her mom always talkabout this issue and get mad at her, however, it will resolves eventually after1 to 2 days.

Luckily, her daughter is very understanding. Mrs A is worriedbecause she afraid no one will take care her daughter if she died later.   Impact of Illness to theCommunityPatient spend most of her time at home because of her multipleproblems. So, they have limitations to give any contribution thecommunity.

  Community must Discussion1.    FallriskPatientwith history of fall or have balance problem is at higher risk to have asubsequent fall.  Those who had sufferedat least one fall experienced a decline in basic and activities of daily living(1). As for this patient, she had multiple risk factors that make her prone toexperience another episode of fall which are previous history of fall, old age,balance problems due to her Parkinson’s Disease and her acute problem, anemia. Besidesthat, her bedroom is located upstairs, she sleeps with her daughter. Eventhough there is only one history of fall at the staircase, making patient climbthe stairs everyday is quite risky especially due to her instability.  It is more appropriate to change her bedroomto downstairs, so she do not have to take risk everyday by climbing thestaircase.

This is somehow reduce the risk of fall. She is fortunate to havewalking aid, wheelchair and also a companion that can aid her in walkingwhenever she wanted to go. There is lack of safety measure at home especiallyin the toilet where there is no railing for the patient to hold on. Patientmight said it is all alright for her because until now she never fall in thetoilet, but we cannot predict the future.

It is better if the children canprovide that as safety measure before anything happens. In addition, studyshows that falls rate is higher in elderly with diabetes. This might be due todiabetic neuropathy. (1) 2.    PolypharmacyPatienthave to take multiple medications due to her underlying diseases and also a newmedication was added on to treat her anemia. Being an elderly, suffering frommultiple illnesses, have to take multiple medications at different time, itmight cause confusion to them. Fortunately, she has very caring caregivers.They provides her with medication dosette and explained to her the details ofeach medications.

What medication it is, when and how frequent patient have totake it. Listening to patient herself explaining to me what she knew about eachmedications clearly showed that she really know how to take care of herself andher insight about her diseases also good. Since there is polypharmacy issue,patient or her caregiver must know the name of medication well especially whenshe experienced new symptoms because that might be due to side effect ofmedications. (1) 3.    ImpairedappetiteChangesto the digestive system, hormonal changes, disease, pain, changes to the senseof smell, taste and vision and decreased need of energy are the physiologicalchanges that occur with ageing that can impair appetite.  (2 NIBC) Presence of chronic diseases such ascardiac failure, chronic obstructive pulmonary disease, renal failure, chronicliver disease, Parkinson’s disease and cancer can worsen patient’s appetite. Thiscondition can contribute to weight loss and nutritional deficiency.

As in thispatient, she had been having low appetite since 3-4 years ago. Eventhough, herweight maintains but it is still in underweight category. This nutritionaldeficiencies and weight loss can increased risk of frailty, falls,osteoporosis, hip fracture, muscle weakness and also mortality. It willdefinitely impaired the quality of life and immune function. It is importantfor the caregiver to provide nutritional food for the patient eventhough inleast amount and reassure her that there is someone who can observe her in caseshe is worried about the tremors attacking during she is eating.

  ConclusionPatientwith multiple chronic diseases will develop various problems and this canimpaired their quality of life. It is important to have a good care and supportespecially from the family members and community to ensure patient is havingthe best life they can have despite of suffering from multiple illnesses.