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 40-year-old African-Caribbean man with chest pain

lukas presented in interesting (?!) case of a man with a short history of chest pain going through to his back

we discussed likely culprits in this age group

we came up with:

- IHD
- aortic dissection
- PE (large & sma
- GORD
- musculo-skeletal

the full list is longer [how many does the C&O list?]

we said this is a common presenting complaint - so it should be known intimately
_ _ _

this gentleman was actually pretty fit with not much atherosclerotic risk

it would have been good to get a better description of the pain from him

& also to know whether he has any illicit (cocaine) drug use [why?]
_ _ _

there was not much to the history

we thought about questions to be answered on examination

we considered:

- does he have signs of aortic dissection?
- is he in heart failure?
- does he have evidence of high cholesterol or diabetes?
- might he have a DVT?

we would like to take the blood pressure in both arms
_ _ _

the diagnostic probabilities had not shifted too much, although PE was less likely

we thought about tests that might help, both in casualty & on monday morning

the ECG is key [we mentioned dissection causing inferior MI]

a CXR might help, although a normal CXR does not rule out dissection

a CT aortogram or trans-oesphageal echo would be needed

Dr Donna D'Souza: radpod.org

we also considered blood tests (FBC - to look for anaemia, creatinine - to check out his kidneys before we give him nephrotoxic contrast, TFTs as hyperthtyroidism might trigger ischaemia)
_ _ _

it turns out that his initial ECGs showed complete heart block with a rate of 30

this was treated with atropine (back to sinus??)

he had a wenkebach-type of heart block



[this is a second degree block - because some p waves are not conducted]

[wenkebach is type 1 second degree, also called Mobitz 1]

[wenkebach is not usually dangerous, compared to second degree type 2 (Mobitz II) which is]

he had a normal echo (apparently) & was discharged with a view to a 24-hour tape & cardiology follow up
_ _ _

we very briefly thought about why a 40-year-old man might have complete heart block (IHD or ...)
_ _ _

things to learn:

- the assessment of people with chest pain
- stuff about aortic dissection
- stuff about complete heart block (CHB)
- echo features of imminent cardiac tamponade
- CT anatomy of the thorax


Salaam


sabih

64 year old man with 5 days of breathlessness

adam presented an interesting case of a man with a 90 pack-year history of smoking and a short history of breathlessness


we discussed the most likely causes, namely LVF [secondary to something], COPD and pneumonia


as there was little evidence for these conditions, we pursued other diagnoses, eg PE, anaemia [secondary to something] and cancer


we discussed the distinction between massive and peripheral PE, including examination & ECG features of right heart strain


here is the classical SI QIII TIII, taken from ABC of clinical electrocardiography, which is a useful resource [we should have mentioned AF as a common ECG presentation of PE]

he also briefly mentioned hypercoaguability, something worth knowing about

adam it would be good if you could upload an anonymous image of his acute ECG & the most relevant CTPA image [with arrows if possible]


homework generated included:


- causes of breathlessness [kumar & clark, harrisons, cecils, cheese & onion, medicine at a glance and beck et al were mentioned as things to read - paul dilworth's lecture is also a possibility - eric beck is a PDS tutor at the whitt & basically invented the MRCP - very good clinician, co-author diana holdright is one of your cardiology consultants]
- causes of metabolic acidosis
- wells score (or geneva score) for DVT/PE


most important, it is vital to follow this chap up to see what happens to him - this is the only way to get a full picture of what is going on