MODULES 9 &10 - GERAIATRICS
Old But Not Forgotten
TRIGGER 1
A 70 year old male diabetic, hypertensive, post CVD consulted at the out-patient department
because of dizziness.
TRIGGER 2
He had been feeling lightheaded the past 2 weeks especially when getting up from bed or
when rising from a chair. It was worse this morning when hurrying to get up as he woke up
much later than usual. He felt dizzy and nearly lost consciousness. He fell back on his bed
and laid down for 30 minutes after which he felt much better. He got up slowly after that
without further episodes of dizziness but still lightheaded. He decided to seek consult. He
does not have fever nor weakness. He had been having difficulty initiating sleep for the past
year and sleep has been disturbed by having to get up 3-4x at night to urinate.
He was diagnosed to have diabetes as well as hypertension 10 years ago. He was admitted
two years ago for a lacunar infarct and now has slight residual weakness on the left lower
extremity. Current medications being taken include the following: Metformin 500 mg 2x a day,
Gliclazide 80mg daily, Amlodipine 10 mg OD, Metoprolol 50 mg BID, ASA 80 mg OD,
Atorvastatin 80 mg OD. He is also taking Doxazosin (extended release) 4 mg OD titrated from
1mg OD since a month ago for BPH. He also self medicates with Diclofenac 50 mg taken 3x a
day occasionally for severe knee and low back pain as well as Diphenhydramine 25 mg 1 tab
at bedtime when it is really very difficult for him to initiate sleep.
His last consult with a doctor was a year ago with an FBS of 140 mgs/dL. His BP ranges from
120/70 mmHg to 130/90 mmHg. He uses reading glasses which he purchased from a street
stall and cannot see clearly far objects especially when the lighting is low or poor. He is a
widower with no children and lives alone. He has a nephew who lives closeby whom he calls
for errands and to accompany him when he goes to places.
He denies tinnitus, palpitation and headache. He has early morning cough productive of
minimal think expectorate often whitish to yellow but sometimes greenish in color for the past 6
months. He was a smoker (20 pack years) but stopped 2 years ago and is not an alcoholic
beverage drinker.
TRIGGER 3
Examined awake, coherent, afebrile, not in respiratory distress with the following vital signs:
BP = 120/70 mmHg supine, 90/50 mmHg sitting
HR = 92/min, regular; RR = 18/min; O2 saturation @Room air = 98%
SHEENT: slightly pale palpebral conjunctivae, anicteric sclerae, + opacity of the lens OD, VA:
light perception OD, 20/100 OS; minimal aural discharge, intact tympanic membrane; neck
veins non-distended, no masses/lymphadenopathies
C/L: occasional rhonchi in both lungs
CVS: adynamic precordium, tachycardic, regular rhythm, G3 systolic murmur on the upper
right sternal border, no heaves nor thrills, PMI at the 6th ICS left anterior axillary line
Abdomen: flat, normoactive bowel sounds, soft, non-tender, no masses
Extremeties: no edema, loss of muscle bulk left > right, hypertrophic knees with crepitations
but no tenderness, no swelling, equal pulses,
GUT: + prostatic enlargement, no tenderness, no blood on examining finger
Neurologic Exam: motor strength: 5/5 on all except for the left lower extremity which is 4/5. The
rest of the findings are unremarkable.
TRIGGER 4
CBC WBC = 8,700
Segmenters = 67%
Lymphocytes = 26%
Monocytes = 4 %
Eosinophils = 3%
Platelets = 140,000
FBS – 132
Serum crea – 1.13
Hg = 10.0 g/dl
Hct = 30 vol %
MCV = 63.9 fL
MCH = 25 pg
HbA1c – 8.0
SGPT - 45
CXR atheromatous aorta, cardiomegaly, prominent bronchovascular markings
ECG – sinus rhythm, normal axis, LVH