DEPARTMENT OF REHABILITATION AND AGE CARE UNIT

16 June
2023 Mrs Melva Salazar
DOB: 05/10/49
Dr Pramod 5 Media Crescent
Malik BANKSIA GROVE WA 6031
Wanneroo H: 0415 648 047
GP Super M: 0452 388 401
Clinic UR: 00750553 JHC
1 ECU
Health Centre
30 Dundebar Road
WANNEROO WA 6065

Dear Dr Malik,

Medical History:
1. Hypertension
2. Hypercholesterolaemia
3. Chronic headache, intermittent yearly
3.1. Seen by Dr Ghosh at SCGH Neurology
3.2. Impression of hemicrania continua
3.3. Trial of indomethacin suggested for next episode, not yet trialled
3.4. MRI brain (January 2023) did not reveal any established cortical infarction, small vessel ischaemic
disease or haemorrhagic microangiopathy. No lobar atrophy or specific neurodegenerative process
3.5. Occlusion of left vertebral artery at the level of C3 50%, occlusion of left ICA 50% on CT angiogram at
SCGH as part of workup of headaches
4. Mild coronary artery disease
4.1. CT coronary angiogram (August 2020) showed mild stenosis of coronary arteries and calcium scores
4.2. Echocardiogram (July 2022) showed normal left and right ventricular systolic function
4.3. 24-hour Holter monitor (27 July) showed sinus rhythm and no arrhythmias
4.4. Known to cardiologist Dr Yuli Ten, prescribed frusemide
5. Chronic back pain secondary to osteoarthritis
6. Right ankle pain and swelling
6.1. X-ray right ankle (January 2023) showed pes planus, moderate midfoot arthropathy, minor Achilles
enthesopathy and mild plantar calcaneal spur
7. Laparoscopic cholecystectomy
8. Haemorrhoidectomy
9. Hysterectomy

Medications:
Aspirin 100 mg daily
Candesartan/hydrochlorothiazide 16/12.5 mg
daily
Rosuvastatin 40 mg daily
Frusemide 20 mg daily

Observations:
HR 69, BP sitting 129/58, BP standing 141/63, spO2 96%, Weight 80 kg
MMSE 29/30

I had the pleasure of meeting with Melva accompanied by her daughter, whose name is also Melva, in the Falls
Clinic. She was first reviewed by my colleague in December 2022 after referral by a physiotherapist for concerns
over a fall she had last year. The fall involved her reaching up to pick a guava, becoming dizzy, and then landing
on the floor. She does not remember if she lost consciousness at this time. This event led to a multitude of
investigations both for the fall, dizziness, and chronic headaches. In summary, she had cardiovascular workup,
which included a normal echocardiogram, normal 24-hour Holter and a CT coronary angiogram showing mild
coronary artery disease only. She is known to cardiologist Dr Yuli Ten who saw her last year and prescribed
frusemide 40mg daily. Melva stopped this medication after a while as she did not believe she needed it and did
not develop any bilateral leg swelling. For some reason, she restarted frusemide again late last year. She tells
me however that her GP has spoken to Dr Yuli Ten approximately two weeks ago and they have reduced it to
Frusemide 20mg daily. She again has not had any lower limb swelling or other symptoms with this decreased
dose.

Melva Salazar / 2

Melva was also seen by Sir Charles Gairdner Hospital and had various tests including CT angiogram, which
showed 50% left vertebral artery and left internal carotid artery stenosis that was not associated with any
neurological deficits. She has also been seen by Dr Ghosh at SCGH Neurology in March 2023 when she was
referred for chronic headaches. All of these recent neurological and cardiovascular assessments were reviewed
again at this appointment. During this consultation however the focus was the intermittent severe headaches
Melva had been having for at least 10 years. They occur approximately once a year and consist of a unilateral
pain in the mastoid, which shoots up to top of the head. The impression from Dr Ghosh was that her symptoms
were consistent with hemicrania continua. He suggested trial of indomethacin. Melva has not however trialled
indomethacin because she has not the headache since then.

At last review, Melva was referred for an MRI brain, which was unremarkable. She also described to my
colleague chronic right ankle pain, which occasionally involved swelling, so she was sent for a right foot x-ray,
which revealed chronic degenerative arthropathy. Melva has also been seen by our physiotherapist at Day
Therapy Unit last year, who found her balance was reasonable with a Berg of 51/52. The physiotherapist thought
her problem list included decreased confidence and endurance, so gave her exercises to improve these and
discharged her from clinic. Since this time, Melva has not had any falls and mobilises well without a walking aid.
Melva was referred for a bone density scan from our clinic at last review, but did not proceed to have this done.

Aside from all of these investigations, Melva in herself has been well. She is independent with her activities of
daily living. She is a non-smoker and non-drinker. Her husband is under palliative care for prostate cancer and
had a recent hip surgery, but she is coping well at home with him. He still remains functional to some degree
managing all their finances. Her daughter Melva has been appointed EPA and EPG and is very supportive.
Melva maintains all domestic activities including cleaning and cooking. She sleeps well and does not have any
incontinence issues. They do not have an ACAT and do not want services at this point in time. There are no
concerns from Melva’s daughter regarding her cognition and there were no safety issues raised in review today.

Impression:
Melva is a 73-year-old woman who had one fall secondary to dizziness while picking a guava. She has had
appropriate cardiological and neurological investigations. She has not had any other falls. Melva has not had any
osteoporosis screening. She has been reviewed and discharged by physiotherapy.

Plan:
1. I have recommended Melva speak to her general practitioner about screening for osteoporosis should she
wish to proceed with that.
2. I have recommended that Melva continue discussing with her GP her frusemide as she is unsure if she
actually needs it. Given her normal echocardiogram and lack of clear peripheral oedema, it may be the case
this can be weaned and ceased with close monitoring afterwards. I have told her this is a decision between
herself, her GP, and her cardiologist.
3. As Melva has had no further falls and she has had appropriate workup, we will discharge her from Falls
Clinic.

Thank you for ongoing care of Melva.

Yours sincerely,

Sighted but not signed

Dr Julia McFarlane Dr Steven Jujnovich

Senior Registrar Consultant Physician
Dept. of Rehab & Aged Care PRACWA Associate
JM/ms
JHC File
DTU