Step 2 CS Case:
Doorway information:
Mrs. Rogers, an 80 year-old female brought to see you because of a fall at home. Husband
found her outside the bathroom.
Blood pressure =120/60 RR = 11 T = 98.6 F HR = 58
At the age of 75, one would like to tease out to the cause of the fall. Was it that the patient just tripped over something mechanical, or does she not know the cause of the fall. In the latter scenario, one must consider cardiac and neurological causes. If the patient lost consciousness, it must be treated as a case of syncope. If the patient did not lose consciousness, it is important to assess in this patient falls frequently. If she does, then the patient needs to be assessed further.
My approach to the patient would be as follows.
Enter the room and say
"hello, My name is Dr. (your name here). What is yours?" (even though I know the patient's name, I want to know if the patient is oriented or not).
How are you feeling now Ma'am?
Different answers could be
I'm having headache - there may be an injury which could either be superficial or could involve the skull.I'm feeling light headed - this might mean vertigo or just feeding slightly off balance
I'm having chest pain - this could signify a cardiac event as the precipitating factor or just chest trauma
Where am I - the patient either passed out or is disoriented now
Who are you - introduce yourself and then test the patient for orientation to time place and person.
Patient's disoriented - find out if this is the patient's usual baseline or is it a new change in mental status. If it is new, evaluate the patient for causes of delirium and head injury.
I am bleeding through my nose - suspect fracture of the anterior fossa of the skull - particularly if there is blood mixed with thin clear fluid.
I am short of breath - think about a cardiac event.
Tease out the HPI properly and then take ROS.
Take the PMH,Medication history S/H and F/H. There might be strong clues in the above as a patient may have a PMH of AS or PE or MI or VT or have a PPM or Sz or recently started a drug that could cause bradycardic.
Keeping in mind that each of the above responses needs to be a different type of evaluation, I am now going to go down a path of one of the commonest scenarios.
Next, ask the patient if there is any pain she is having:
"Do you have any pain anywhere?"
No
Did you have any palpitations?
No
Ever had a seizure?
No
Ever passed out before?
No
When do you remember waking up?
Immediately after I fell.
If the answer signifies a period of loss of consciousness, patient will need to be admitted to telemetry floor even if nothing wrong is found on History & Physical. Serial EKGs, cardiac enzymes and periodic neurological evaluation needs to be done.
If on the other hand, the patient just tripped over something obvious, an out patient evaluation with his Primary care doctor should be advised UNLESS the scenario is not clear-cut and the patient has a previous cardiac history.
A sudden fall and head injury/tongue bite strongly signifies neurological problems and thus should be evaluated by EEG +/- CT brain too. Admit in this scenario too and on the orders put "seizure precautions".
Do a complete physical exam that must include and mention the following pertinent negatives/positives:
looking for slow or irregular pulse, head injury, tongue bite, goiter, carotid stenosis/bruit, Cardiac murmur, Generalized palpation to look for any broken or bruised areas, power and reflexes.
| 5 differential diagnoses that are suitable in this scenario could be one
of the following 1. Micturition syncope: Patient was found outside bathroom. 2. Cardiac syncope/arrhythmia: This is the most acute problem of them all and always needs hospitalization. Consider Sick sinus syndrome, Ventricular tachycardia, occasionally SVT. 3. Aortic stenosis (especially if the patient has an Ejection systolic murmur) 4. Seizure: if witnessed, must be thoroughly investigated - CT/MRI brain, EEG. Sometimes seizure can occur with cardiac syncope too. 5. Vasovagal syncope: common - associated with queezy feeling in stomach, sweatiness and bradycardia and syncope. 6. Basilar CVA 7. Carotid hypersensitivity 8. PE |
5 Investigations will depend on where the SP leads you but important ones
are 1. 12 Lead EKG 2. Telemetry monitoring 3. CPK (As it will give you an idea about cardiac syncope if MB fraction is positive but if the MM fraction is high, a seizure becomes important on the differential) 4. CT brain - particularly if seizure is on the differential at this age. (check for Tumor) 5. Routine blood tests like CBC and BMP 6. ABG if PE enters the differential (Patient would be SOB) 7. After listening to the carotid, do a carotid massage if there is no bruit - this must be done with the patient on a cardiac monitor and the technician/yourself should be recording the events. |