Mrs since past 3 years, however there was

Mrs S
presents to the clinic, complaining of palpitation for 1 month.


History of presenting complaint

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Mrs S,
a 60 years old elderly Indian woman with background history Chronic
Hypertension (HPT), Type 2 Diabetes Mellitus (T2DM), dyslipidemia and
Parkinson’s disease presents to the clinic for her routine follow-up
complaining of palpitation since the past 1 month. The palpitation was on and
off, not aggravated by any activities. Each episodes lasted about 1 to 2
minutes. It was associated with dizziness and sweating. Patient thought it was
related to stress since she frequently worried about her 2nd
daughter since she is the one who is not getting married yet. She did not took
coffee or tea prior to palpitation. However, there was no chest pain, history
of syncopal attack. She also complaint of reduce appetite since past 3 years,
however there was no lose of weight. Her weight remained to be 37kg since the
past 3 years.


Past Medical History

was diagnosed with HPT, T2DM and dyslipidemia for the past 15 years. She is
currently on oral medications and compliant to the medication. She never missed
to take her medications. Her blood sugar and blood pressure is controlled based
on the serial reading during her regular follow up and also monitoring at home.
Her latest HbA1c
is …. . No history of hypoglycemia episode. Her blood pressure ranging from
110-130/70-80mmHg. She is under ophthalmology follow up in Hospital Kuala
Lumpur, annually. Until now, based on the yearly follow up, she do not develops
eyes complications such as retinopathy or maculopathy that can be cause by her
chronic DM and HPT. There are no symptoms of 
cardiovascular disease such as chest pain or discomfort and no shortness
of breath. Since she is a postmenopausal woman and doing less physical
activity, she is having risk to develop coronary artery disease. However, she
is not obese and non smoker.

             She was diagnosed with Parkinson’s Disease for
the past 10 years. Since then, she had to take medications to control her symptoms
especially tremors. After 7 years been diagnosed with Parkinson’s disease, she developed
side effect from those antiparkinsonian agents which was dystonia. Her daughter
described it as excessive involuntary movements and over twisting of the upper
and lower limbs. Mrs S had to be treated in Intensive Care Unit (ICU) for 2
days and a month in Neurological ward.





Metformin (Dimethyl Diguanide) HCL 0.5g BD


Perindopril 8mg OD


Simvastatin 40mg ON

Parkinson’s disease

Madopar 125/62.5/125/62.5/62.5mg  5x/day

Madopar 2mg BD

Amantadine 100mg BD


1. T. Ferous Fumarate 200 mg







Past Surgical History



Allergy history

No allergy history


Diet history

She takes very minimal amount of food everyday because of
lack of appetite and often worries about her tremor. She afraid to eat because
she afraid she might get the tremors during she eats. Her meals are prepared by
her daughter in-law who lives together in the same house.


Family History























Social History

Mrs S
is a housewife and a single mother since her husband passed away at the age of
46 years old due to motor vehicle accident. She is currently living with her 1st
son with his family and also with her unmarried 2nd daughter in a
double storey house, in Cheras.. Both her son and daughter are working, thus
her daughter-in-law is the one who taking care of her while at home. She is
also living with her 3 grandchildren. She is taken care very well since she
never skipped her medications and always take it on time and only has one
history of fall despite of her having instability in walking. She is non ADL
dependent. She can manage herself well. However, she sometimes needs help in walking
since she feels unstable. Fortunately, her children provides her a wheelchair
and walking aid to aid her in walking. Besides that, her daughter-in-law is
always there at home to look after her mother-in-law just in case anything
happen. At home, Mrs S does minimal work and do not really exercise due to her
condition . She do not have the guts to do something heavy and risky and her
children also prohibit her to do risky chores such as cooking because it might
put her into danger especially when her Parkinson’s attack comes, such as
tremors at both upper and lower limbs.


Physical Examination


General Examination

general examination,  Mrs A was an
elderly lady, underweight with a well kempt appearance. She was comfortable and
alert. She not pale, not jaundiced and did not have any xanthelasma.  Upon gait assessment, she appeared unstable
and need to hold his daughter while walking.

Pulse               : 86 beats minute, regular rhythm,
good volume.

BP                   : 117/80mmHg (normotensive)

Temperature   : 37.2

Weight : 37 kg

Height             : 164 cm

BMI                : 13.76 kg/m2 (Underweight)





Cardiovascular Examination

No murmur. S1 and S2 were heard.


Other systemic examination




Progress and Management

the patient was complaining of palpitation for that past 1 month, a few tests
were carried out to further investigate the cause of palpitation. Full Blood
Count (FBC) test was done to mainly check Haemoglobin (Hb) since anemia can
sometime cause palpitation and the result showed patient’s Hb) level was low
which was 10.4g/dL, mild anaemia. Besides that, Electrocardiogram (ECG) also
carried out, however patient was having tremor while doing the test and the
result was not accurate. She had to repeat the ECG in the next visit, in
another 2 weeks time. Due to her mild anaemia, she was prescribed with T.
Ferous Fumerate 200 mg OD.


Impact of Illness to the

impact of illness especially Parkinson’s Disease gives a few significant impact
on this patient. She has instability in walking and needs someone or walking
aid to help her in walking without falling. Even though she is on
antiparkinsonian medications, she will still having tremors after 2 hours
medication taken. This symptom scared her the most because she is afraid to
even eat because tremors can cause her difficulty to eat even though she is not
using eating utensils and only using hand to eat. She also have to limit her
physical activity and not encouraged to do house chores especially cooking
because this can put the patient in danger especially when she have the
tremors. She also had difficulty to sleep and need to eat sleeping pill to help
her to sleep since the past 6 years. Besides that, since she was anemic, she
will have symptoms of palpitations and also dizziness. This will increase the
patient’s risk of fall.




Impact of Illness to the

though patient is still non ADL dependent, it is somehow affects the family
especially her caretakers. She needs extra observation since she has
instability in walking because she is at risk of fall anytime and anywhere. Her
care takers also have to make sure all the medications are taken correctly at
the correct time. Currently, with extra risk factor of fall, which is anemia
that can cause dizziness, patient need more observation. Plus, her daughter
also complains that her mother currently quite sensitive and often worries
about her who is not getting married yet. She said that her mom always talk
about this issue and get mad at her, however, it will resolves eventually after
1 to 2 days. Luckily, her daughter is very understanding. Mrs A is worried
because she afraid no one will take care her daughter if she died later.



Impact of Illness to the

Patient spend most of her time at home because of her multiple
problems. So, they have limitations to give any contribution the
community.  Community must




with history of fall or have balance problem is at higher risk to have a
subsequent fall.  Those who had suffered
at 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 to
experience 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. Besides
that, her bedroom is located upstairs, she sleeps with her daughter. Even
though there is only one history of fall at the staircase, making patient climb
the stairs everyday is quite risky especially due to her instability.  It is more appropriate to change her bedroom
to downstairs, so she do not have to take risk everyday by climbing the
staircase. This is somehow reduce the risk of fall. She is fortunate to have
walking aid, wheelchair and also a companion that can aid her in walking
whenever she wanted to go. There is lack of safety measure at home especially
in the toilet where there is no railing for the patient to hold on. Patient
might said it is all alright for her because until now she never fall in the
toilet, but we cannot predict the future. It is better if the children can
provide that as safety measure before anything happens. In addition, study
shows that falls rate is higher in elderly with diabetes. This might be due to
diabetic neuropathy. (1)



have to take multiple medications due to her underlying diseases and also a new
medication was added on to treat her anemia. Being an elderly, suffering from
multiple illnesses, have to take multiple medications at different time, it
might cause confusion to them. Fortunately, she has very caring caregivers.
They provides her with medication dosette and explained to her the details of
each medications. What medication it is, when and how frequent patient have to
take it. Listening to patient herself explaining to me what she knew about each
medications clearly showed that she really know how to take care of herself and
her insight about her diseases also good. Since there is polypharmacy issue,
patient or her caregiver must know the name of medication well especially when
she experienced new symptoms because that might be due to side effect of
medications. (1)



to the digestive system, hormonal changes, disease, pain, changes to the sense
of smell, taste and vision and decreased need of energy are the physiological
changes that occur with ageing that can impair appetite.  (2 NIBC) Presence of chronic diseases such as
cardiac failure, chronic obstructive pulmonary disease, renal failure, chronic
liver disease, Parkinson’s disease and cancer can worsen patient’s appetite. This
condition can contribute to weight loss and nutritional deficiency. As in this
patient, she had been having low appetite since 3-4 years ago. Eventhough, her
weight maintains but it is still in underweight category. This nutritional
deficiencies and weight loss can increased risk of frailty, falls,
osteoporosis, hip fracture, muscle weakness and also mortality. It will
definitely impaired the quality of life and immune function. It is important
for the caregiver to provide nutritional food for the patient eventhough in
least amount and reassure her that there is someone who can observe her in case
she is worried about the tremors attacking during she is eating.




with multiple chronic diseases will develop various problems and this can
impaired their quality of life. It is important to have a good care and support
especially from the family members and community to ensure patient is having
the best life they can have despite of suffering from multiple illnesses.