History From the patient-

faithfulparsleySoftware and s/w Development

Nov 2, 2013 (3 years and 11 months ago)

72 views

MODULE 1
-

ASSIGNMENT
-

ASSESSMENT

AND THE ELDERLY


ID
-
1318.



OUTLINE YOUR APPROACH TO THIS PATIENT.


History

From the patient
-

The fall itself
-

What was she doing at the time?

Did the fall occur while she was standing straight or was she bending over?

D
id she trip over something?

Did she lose consciousness?

Were the lights on?


Did the fall occur during the day or at night?

Had she been to the toilet
shortly

beforehand?


Was she
able to

see clearly where she was going?


What time did the fall occu
r?

Did she feel unsteady on her feet before the fall?

Could she have been moving her neck at the time of the fall?

When had she last had food?

Did she notice any symptoms before the fall such as a sensation of movement, light
-
headedness, palpitations, ch
est pain, loss of power, paraesthesia?

Had she been I pain before the fall?

Had she taken her medication that day? If so, at what times?

Could she have taken an
extra tablet especially either Isosorbide mononitrate or bendrofluazide.? Had she
noticed

any light
-
headedness especially on changing position since starting
bendrofluazide?

Had she taken any OTC medicine? Could she have taken a hypnotic which she might
have obtained elsewhere?

Was she wearing footwear at the time of the fall? If so, what typ
e?

Does she remember banging her head? If so, what did she bang it off?

Does she
remember

putting out her hands to protect herself/


How was she feeling in the days beforehand? Any symptoms to suggest an evolving
illness
such

as pneumonia, urinary tract
infection?


Immediately after the fall
, what

was stopping her from getting up? Was she trapped
by an environmental hazard? Was pain stopping her from getting up? Was
weakness/loss of power stopping her from getting up? Was
she

able to see where she
was

going?

When she was not able to get up, did she try to reach for the phone
? (If

present).

Was she frightened?

Was she aware of any pain anywhere especially wrists, hips/

Did she feel cold?

Did she develop any symptoms such as cough?

Did she develop and ne
w pain
when

the carer helped her up?

How was she feeling now?

Does she feel nervous about further falls?


Has she fallen before especially in the last six months? If so, were the previous
fall/falls similar in nature? Has she injured herself before?

How

has she been feeling in the previous few days?


Had she alcohol taken on the day of the fall? How much? How much does she drink
on a

weekly basis?


Has she noticed any

disimprovement in her eyesight recently?


H
as she had a lot of symptoms fro
m her oste
oarthritis recently? Which joints?


From the carer
-

What did she notice on arrival? Was patient alert? Was she coherent? Did she notice
any localised weakness? Was there any evidence of damage to the environment?

Was there a lot
of
blood

evident on the

floor?

Had she noticed any
changes

in her gait
or unsteadiness recently? Had she been eating well?


From the family
-

The question does not specify if there are family supports. However, if there are
, I

would contact them to inform them, to clarify any
recent history and to involve them
in the immediate and long tem
management
.



Examination.

Patient
-

Level of alertness
-
Glasgow Coma Scale.

Signs of shock
-
Pallor, sweating.
-
She may have bled significantly.

Assess level of
hydration.

Is speech slurred?

Is
there a smell of alcohol?

Look at level of spontaneous activity? Is there evidence of loss of function?

Any signs of tremor?


Measure temperature to outrule pyrexia and hypothermia. Important to have a low
-
reading thermometer.


Examine musculoskeletal sy
stem.

Look for obvious signs of injury and look for muscle wasting.


Especially examine wrists, lower limbs, hips to outrule the possibility of fracture.
Palpate spine to asses the possibility of osteoporotic fracture.
This lady has a past
history of ost
eoporosis and is therefore at risk of fracture.

Examine the feet. Look for signs of osteoarthritis, corns, ulcers, all of which can
affect balance.


Examine the head wound. Look at depth. Any signs clinically of
underlying

skull
fracture.


Any signs of
lacerations/ Bruising/haematoma formation elsewhere?


Examine pulse to assess
rate, rhythm and strength. Look for signs of heart block,
arrhythmia.


Examine blood pressure supine. If patient can stand measure the blood pressure after
one minute and five
minutes of standing. To look for signs of postural hypotension.
This is especially important in that
she

has had a fall within two weeks of starting
bendrofluazide which is a recognised potential cause of postural hypotension.


Examine cardiovascular syst
em. Look for new murmurs. Look for carotid bruits.


Examine respiratory system. Looks for signs of pneumonia.


Examine the ears. Look for signs of infection, Bloody
discharge (? fracture

base of
skull). Look for wax which may affect hearing.


Examine
the eyes
-

How

significant are the cataracts?

Check visual acuity if possible.


Abbreviated mini
-
mental test score to look for signs of confusion.


Central Nervous system examination.
-

Any localizing signs on examination of cranial
nerves.

Assess power and

reflexes in upper and lower limbs to detect underlying CVA.

Assess co
-
ordination,nystagmus thing about underlying vestibular or cerebellar
problems.

Assess position and vibration sense.


If possible stand the patient out. Perform Romberg’s test.


Assess
balance and gait.

Do one
-
leg balance test.

Do “get up and go” test.

It
may

not be possible to do these in the acute phase. However, it would be very
helpful to do them
at some


near stage in the future.


Environment.

This is especially important if I am h
appy there is no obvious cardiac
/CNS cause for
the fall.

What is the floor surface
like?

Linoleum? Carpet? Are there any hazards on the floor
surface?

Are there any stray cables?

Are there any sharp edges?

Is there any evidence of damage to contents in th
e room such as glasses, furniture?
This may raise suspicions regarding an underlying sinister cause for the fall.

What is the lighting like? Is the room warm?

Is there alcohol in the room?

Is the room cluttered?

What is the bed like? Is it low down? Co
uld
this

increase the chances of postural
drops

in
BP
?


Evaluate social supports.


Family supports?

Carer supports?

Does she have friends? Does she go to Day Care? Are there enough supports to keep
this lady at home if it is felt that she can be managed i
n the home setting?


MANAGEMENT
.


Initial.


This will depend on the initial assessment.


I would refer to hospital in the following circumstances
-


Acute confusion
-

to assess head injury. Outrule fracture skull, acute subdural
haematoma.

Also need to outr
ule underlying acute infection/
metabolic

disturbance.

Signs of pneumonia.

Signs of acute LVF.

History suggestive of myocardial infarction/acute arrhythmia.


Signs of shock. Could this be due to blood loss?

Signs of fracture especially wrist, pelvis, hip.

Signs suggestive of complete heart block.


If there is a history of syncope, loss of consciousness
, Palpitations, and if the patient is
clinically stable
, I

would arrange urgent geriatric assessment.



If the patient is not confused, is haemodynamically st
able and mobile
, I

would arrange
to have the scalp laceration sutured either in the house if lighting was satisfactory and
I could access suturing equipment or in the surgery if she could be transferred.


If there are signs of hypothermia, I would encourag
e gradual rewarming in the bed

with encouragement of warm fluid intake.


I would encourage gentle mobilisation within 24 hours to try and get confidence back
and to minimise complications
of prolonged

bed rest.


If the history is suggestive of postural hyp
otension, it may be necessary to stop the
bendrofluazide
. I would encourage the patient to avoid sudden movements, to sit on
the side of the bed and flex her ankles especially in the am and at night before getting
up. I would consider elastic support st
ockings.



If she is in pain secondary to head injury and any other injuries, I would prescribe
paracetamol to be taken regularly.


I would arrange follow up, involve the gamily, public health nurse.
Consider

referral
for

geriatric assessment and falls ri
sk assessment.


Blood testes would be helpful to outrule anaemia, electrolyte disturbances,
e.g.

hypokalaemia, hyponatraemia secondary to recent diuretic use.




Question 2.


List (
in order of importance) the principle factors, which you consider may have
contributed to the fall.


Demography
-

Older age.

Living by herself.


Medication
-

She is on five medications. Elderly people on four or more drugs are at a greater risk
of falling.

She is on cardiac medication which increases her risk of falling. She has
recently
started bendrofluazide which is associated with postural hypotension and risk of
falling.


Chronic conditions.

She
has generalised osteoarthritis. This will reduce mobility, affect balance, and slow
one’s responses to losing balance. It will als
o increase her chances of sustaining
fractures and interfere with her ability to get up after falling.


She ha
s bilateral cataracts. These will affect her vision which is important for
proprioception and would therefore increase her risk of falling.


Sick

Sinus syndrome.

This is very strongly associated with falls. She had a pacemaker inserted 7 years ago.
Is it working correctly?








Question 3.


List 6 measures, which in your view will reduce patients risk of a further fall.


1.

Medication review.
? N
eed

for bendrofluazide. Review blood pressure.
Consider 24 hour blood pressure monitor.
Balance

risks of stroke against risks
of harm secondary to medication. Consider referral for tilt testing.
Should

consideration be given to
midodrine?


2.

Consider ref
erral for cataract surgery. Improvement in visual acuity will
significantly reduce the risks of further falls.


3.



Home safety check. Involve community occupational therapy and public health
nurse. Try to eliminate environmental hazards. Consider safer f
urniture, using
hand rails in bathroom and stairs.


4.



Consider referral for community physiotherapy. This will help improve mobility
through muscle strengthening exercises. The physiotherapist will also be able to
assist with the provision of the most

appropriate walking aids. They may also be able
to assist with balance training.


5.


Involve the family. Get their assistance with modification of hazards in the
home
place
. Get their assistance with the provision of an alarm system which the
patient
can carry herself. Get the name of a family member with whom the
primary care team can liaise with.


6.

Follow up and education re falls. An information leaflet on prevention of falls
would be helpful.



_______________________________________________
______________________
_____________________________________________________________________