2 elderly women with falls

fayth presented the case of an 86-year-old woman with a 'mechanical' fall


we remembered dr hayman's assertion that there is no such thing as a mechanical fall!


rory also mentioned an 85-year-old woman with a more dramatic fall
_ _ _


we reviewed possible causes of loss of consciousness (which she did not have? but the 85-year-old woman rory saw did)


- cardiac (rhythm, valve)
- stroke (anterior, posterior, limb weakness)
- epilepsy (new onset in elderly space occupying lesion till proven otherwise)
- vaso-vagal
- postural hypotension
- anaemia
- infection
[drugs]
_ _ _


we talked about the critical nature of the history which needs to be taken in great detail


eg when, where, what next etc


specific questions are also important, eg palpitations? post-event sleepiness? position?


there is a bit more on this subject in the case from 5-7-10

_ _ _

rory nicely presented his patient's social history

she was cooking for herself, shopping for herself and going out to visit friends

an excellent level of function

_ _ _


fayth's lady also had type II diabetes and aortic stenosis, both important things to consider


eg oral hypoglycaemic OD [what was the BM], critical aortic stenosis


unfortunately we were not able to examine her
_ _ _ 


we did look at her ECG


she had LAD & LBBB

we concluded it was essential to find out if this was new, which could be due to an MI


we also enacted the 6 ECG limbs leads and thought of a quick method to determine raxis (one of the 3 Rs of ECg analysis!)

_ _ _

comments welcome

Salaam

sabih

a 52-year-old woman with tiredness and visual disturbance

yesterday rory presented an interesting case of a middle-aged woman, previously pretty well, who has become increasingly tired over recent weeks


she has also had some blurriness of vision


TIRED ALL THE TIME (TATT)


this is a common complaint but can sometimes be very difficult to diagnose


(also a common OSCE scenario)
_ _ _


i could not find a specific chapter in davidsons, harrisons or my favourite symptom book tutorials in differential diagnosis (written by eric beck who invented the MRCP exam & is still involved in PDS teaching at he whitt - i was his house officer many years ago; robert souhami was dean of UCL medical school)


in my library the best i could do was a case from an excellent MRCP book (case 2.50 in PACES for MRCP by tim hall)

however, i did find a BBC radio program all about TATT, part of the very good case notes series (with a full transcript available)
_ _ _


we discussed various causes:


- major organ failures (heart, kidneys, liver, lungs)
- endocrine disorders (thyroid, diabetes, also addisons, hypopit)
- cancer
- depression
- anaemia
- auto-immune type disorders (rheumatoid, lupus, GCA, polymyalgia)
- drugs, eg beta-blockers


our patient did not have any features pointing to the specific causes above?
_ _ _


we did not really go through investigations in detail
_ _ _


while we did not examine her, you did go through her pupillary reactions with gordon


she had an afferent pupillary defect [like this one?]

these data point to the possibility of multiple sclerosis

_ _ _

we briefly talked about this mostly relapsing-remitting condition

the diagnosis requires more than one 'attack' in more than one place

the criteria i learnt have now been replaced the the mcdonald criteria which incorporate the advances MRI has brought

rory was going to update us about MS [perhaps as a comment?]

we need to review her investigations, including MR imaging & LP

[tangentially, josiah bartlett, the fictional US president in the west wing, had MS & hid it from the electorate during his first election]

_ _ _

we finished by considering what we would do to learn more

reading a textbook & wikipeding were mentioned

find another patient with MS (soon) is a particularly good strategy

Salaam

sabih