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 64 year old man with incoordination

sheena briefly presented the case of a man who fell over at the bus stop

we focused on examining his cerebellar system

we could only examine his left arm

he had:
- no rebound of the outstretched arm
- no dysmetria
- mild dysdiadochokinesis at the forearm
- moderate dysdiadochokinesis at the fingers
- unconvincing horizontal nystagmus in the direction of gaze
- a reasonable gait
- normal heel-toe walking

we did not test his speech
we did test his power (why would we want to do this?)
_ _ _

unfortunately we had to rush his story & did not look at his scans

sheena: could you update us (anonymously) please?
_ _ _

we talked about learning resources

i mentioned the book by geraint fuller which i think is excellent

this site from the university of utah is also excellent & demonstrates many of the signs we were discussing
_ _ _

Salaam


sabih

new year

welcome to this site: a space to record & review shared experiences


do leave comments / questions
_ _ _
half of you have heard me rant on SNP-ignorance


i would point you to the first post in this blog for more on the issue
_ _ _

yesterday 3 out of 5 of you clerked patients with some form of 'collapse'


sheena then went on to present the case of a 64 year old man who 'collapsed' at the bus stop


the first important point was: the terminology is confused & task 1 is to work out which type of collapse the patient is talking about


namely:


- loss of consciousness
- limb weakness
- loss of balance
- vertigo
- light-headedness on standing


see below for half an algorithm from Davidsons

_ _ _

we mostly talked about loss of consciousness & were tentatively dividing causes into cardiovascular, neurological & other

we did not get round to organising our diagnostic lists properly

we moved on to examining the cerebellar system (see next post)

_ _ _

25 year old diabetic with a grand mal seizure

after starting late ...

joel presented the case of a 25 year old Caucasian man with type I diabetes who had a witnessed seizures

there was some discussion of terminology (what is a funny turn?)

loss of consciousness was a key issue to establish

important categories of causes were neurological, cardiovascular and meto-toxic

features differentiating cardiogenic from neurogenic syncope are important - here is a bit table 18.21 from Davidson's - it's OK, but can you do better? neuro-cardiogenic is a fancy name for a faint

18.21 Typical features of cardiac syncope, vasovagal syncope and seizures

	Cardiac syncope	Neuro-cardiogenic syncope	Seizures
Premonitory symptoms	Often none	Nausea	Confusion
	Lightheadedness	Lightheadedness	Hyperexcitability
	Palpitation	Sweating	Olfactory hallucinations
	Chest pain		'Aura'
	Breathlessness
Unconscious period	Extreme 'death-like' pallor	Pallor	Prolonged (> 1 min) unconsciousness
			Motor seizure activity*
			Tongue-biting
			Urinary incontinence
Recovery	Rapid recovery (< 1 min)	Slow	Prolonged confusion (> 5 mins)
	Flushing	Nausea	Headache
		Lightheadedness	Focal neurological signs

*N.B. Cardiac syncope can also cause convulsions by inducing cerebral anoxia.

in this chap the alcohol intake is important - it will decrease seizure threshold & also causes hypoglycaemia [why?]

if this is a recurrent phenomenon it would be nice/critical to find out why? - this issue may kill him soon - is he bothered? is it an education problem? is it insulin regimen related?
_ _ _

we then digressed into what would you do if this fitting person was in front of you in resus

we demonstrated the gaping hole between book/rote learning "I would assess ABCDE" and learning by doing "I would look, listen & feel for signs of respiratory effort" [of course easier to say than do often]

we talked about diazepam PR, lorazepam IV and the need for general anaesthesia

BM stands for Boehringer Mannheim, not Bayer

50mL of 50% glucose (or x) is around 25g glucose (or x)
one regular UK Mars bar weighs 58g
_ _ _

lessons/memories were:

- key questions around funny turns
- double check the timetable
- blood bottle colours x2
- the importance of starting on time
- DR ABCDE

homework generated was

- acute management of hypoglycaemia (including which blood tests to do)
- emergency pages cheese & onion fitting
- fitting look at local fitting guidelines
- emergency pages cheese & onion electrolytes Na & K
- read illustrated colour text of endo
- long term follow up epilepsy in cheese & onion
- read management of DM in taught course & K&C
_ _ _

my view on things to learn from the case:

- managing hypoglycaemia
- managing acute seizures
- managing alcohol withdrawal
- types of insulin & how to use them
- unusual, but important causes of LOC in young people (eg HCM, brain tumours eg astrocytoma)
_ _ _

we also touched on how governments kill people, focusing on the USA

interestingly some states are now switching from a 3-drug protocol, to a 1-drug protocol (5g of sodium thiopental)

here is how the state of Florida executes (3-drugs: barbiturate, ACh antagonist, KCl 120mmol)

here is a video of a discussion at NEJM


Salaam