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    lalitrajindolia
    An 82-year-old woman presents with recurrent falls. She has a history of arthritis, heart failure, poor vision, and hip replacement. On examination, she has cognitive impairment, limited vision, an abnormal spine, brisk reflexes, leg swelling, irregular heart rate and mitral valve problems. Differential diagnoses include poor vision, low blood pressure when standing, multiple medications, neurological issues, bone/joint problems and irregular heart rhythms. Further history and tests are needed to determine the cause and appropriate treatment options such as medication review, supplements, pacemaker or home safety assessment.

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    Tasks:: For Student

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    lalitrajindolia
    32 views3 pages
    An 82-year-old woman presents with recurrent falls. She has a history of arthritis, heart failure, poor vision, and hip replacement. On examination, she has cognitive impairment, limited vision, an abnormal spine, brisk reflexes, leg swelling, irregular heart rate and mitral valve problems. Differential diagnoses include poor vision, low blood pressure when standing, multiple medications, neurological issues, bone/joint problems and irregular heart rhythms. Further history and tests are needed to determine the cause and appropriate treatment options such as medication review, supplements, pacemaker or home safety assessment.

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    An 82-year-old woman presents with recurrent falls. She has a history of arthritis, heart failure, poor vision, and hip replacement. On examination, she has cognitive impairment, limited vision, an abnormal spine, brisk reflexes, leg swelling, irregular heart rate and mitral valve problems. Differential diagnoses include poor vision, low blood pressure when standing, multiple medications, neurological issues, bone/joint problems and irregular heart rhythms. Further history and tests are needed to determine the cause and appropriate treatment options such as medication review, supplements, pacemaker or home safety assessment.

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    © All Rights Reserved
    Download as DOCX, PDF, TXT or read online from Scribd
    Download as docx, pdf, or txt
    32 views3 pages

    Tasks:: For Student

    Uploaded by

    lalitrajindolia
    An 82-year-old woman presents with recurrent falls. She has a history of arthritis, heart failure, poor vision, and hip replacement. On examination, she has cognitive impairment, limited vision, an abnormal spine, brisk reflexes, leg swelling, irregular heart rate and mitral valve problems. Differential diagnoses include poor vision, low blood pressure when standing, multiple medications, neurological issues, bone/joint problems and irregular heart rhythms. Further history and tests are needed to determine the cause and appropriate treatment options such as medication review, supplements, pacemaker or home safety assessment.

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    © All Rights Reserved
    Download as DOCX, PDF, TXT or read online from Scribd
    Download as docx, pdf, or txt
    of 3

    For Student

    An 82-year-old woman presents with recurrent falls.


    The patient is housebound. Her most recent fall occurred while getting up to go to the toilet at
    night. She has arthritis, heart failure and poor vision as a result of macular degeneration, and she
    has had a previous hip replacement. She receives treatment with furosemide, ramipril, co-codamol,
    amitriptyline and temazepam. She is very frail. The main findings on examination are: abbreviated
    mental test 6/10, vision – large print only, kyphotic spine, brisk reflexes bilaterally, peripheral
    oedema, clear lung fields and normal jugular venous pressure (JVP), heart rate 112/min, atrial
    fibrillation (AF), blood pressure sitting 114/62 mmHg, mitral regurgitation.

    Tasks:
    1. What is the differential diagnosis?
    2. What features in the history support the diagnosis?
    3. What additional features in the history would you seek to support the potential diagnoses?
    4. What other features would you look for on clinical examination?
    5. What investigations would you perform?
    6. What treatment options are available?
    Student’s name
    For examiner

    An 82-year-old woman presents with recurrent falls.


    The patient is housebound. Her most recent fall occurred while getting up to go to the toilet at
    night. She has arthritis, heart failure and poor vision as a result of macular degeneration, and she
    has had a previous hip replacement. She receives treatment with furosemide, ramipril, co-codamol,
    amitriptyline and temazepam. She is very frail. The main findings on examination are: abbreviated
    mental test 6/10, vision – large print only, kyphotic spine, brisk reflexes bilaterally, peripheral
    oedema, clear lung fields and normal jugular venous pressure (JVP), heart rate 112/min, atrial
    fibrillation (AF), blood pressure sitting 114/62 mmHg, mitral regurgitation.
    Task 1 (2.0) - There are multiple causes, including: poor vision postural hypotension
    polypharmacy neurological dysfunction – previous stroke, cervical myelopathy, vitamin B12
    deficiency arthritis/osteomalacia arrhythmia – AF.
    Task 2 (2.0) - Poor vision: the fall occurred at night when environmental hazards are more difficult
    to see and avoid. Postural hypotension: the fall occurred as the patient was getting out of bed to
    go to the toilet. She is on a lot of medications that can impair postural blood pressure control – a
    diuretic, an angiotensinconverting enzyme (ACE) inhibitor and amitriptyline (a tricyclic
    antidepressant with anticholinergic properties). Polypharmacy: postural hypotension: impaired
    balance and cognition caused by temazepam, opiate analgesic and tricyclic antidepressant muscle
    weakness; diuretic-induced hypokalaemia. Neurological dysfunction: brisk reflexes are suggestive
    of upper motor neuron dysfunction. Common causes at this age include stroke disease, cervical
    myelopathy and occasionally vitamin B12 deficiency. Falls 145 As a result of the history of falls
    and the finding of cognitive impairment, a chronic subdural haematoma should also be considered.
    Atrial fibrillation: poorly controlled (rapid) ventricular rate on exertion causing syncope. AF might
    also be a manifestation of sick sinus syndrome, predisposing to supraventricular tachycardia or
    bradycardia.
    Task 3 (1.0) Poor vision: access to spectacles, ability to read or identify objects, adequacy of
    lighting in the home. Postural hypotension: dizziness or falls when upright, with associated
    symptoms of faintness or syncope, and rapid recovery when recumbent. Polypharmacy:
    concordance with medication regimen and any potential to exceed the intended dosing schedule.
    Neurological dysfunction: history suggestive of previous stroke or TIA. Neck arthritis: giddiness
    on head movement and pain radiating to shoulders and upper limbs (cervical spondylitic
    radiculopathy) suggest cervical myelopathy as a potential cause of falling. Enquire about diet,
    previous gastric surgery, bowel (terminal ileal) disease or resection, anaemia and symptoms of
    sensory neuropathy in suspected vitamin B12 deficiency. Fluctuating alertness: confusion or
    consciousness with a history of falls and head injuries (even trivial) should highlight the possibility
    of subdural intracranial bleeding. Bone pains and muscle weakness: in a housebound patient with
    poor diet, these point to osteomalacia. Cardiac arrhythmia: recurrent episodes of dizziness or
    syncope unrelated to posture or activity with prompt recovery suggest an intermittent cardiac
    rhythm disturbance.
    Task 4 (1.0) Poor vision: Snellen chart to assess visual acuity, examination of eyes for common
    causes of visual loss in older people (i.e. refractive disorder), cataracts, glaucoma, macular
    degeneration, diabetic retinopathy. Postural hypotension: lying and standing blood pressure.
    Neurological disorders: thorough central nervous system (CNS) examination essential. Focal
    upper motor neuron signs suggestive of stroke or subdural haematoma. Up-going plantar
    responses, consistent with cervical myelopathy; peripheral neuropathy and posterior column
    dysfunction (joint position/vibration sense) suggest vitamin B12 deficiency.
    Arthritis/osteomalacia: joint examination, back pain, muscle weakness.
    Task 5 (2.0) The following tests are necessary: lying and standing blood pressure ECG plasma
    urea, creatinine and electrolytes (U&Es) and glucose full blood count (FBC) (and vitamin
    B12/folate levels if macrocytic anaemia present) radiograph of painful bones and significantly
    arthritic joints vitamin D, calcium, albumin and alkaline phosphatase (ALP; for osteomalacia).
    Other tests might be indicated after preliminary assessment and investigation, including: cervical
    spine radiograph with option to proceed to magnetic resonance imaging (MRI) cervical spine if
    cervical myelopathy is probable and surgery is a realistic option computed tomography (CT) of
    the brain thyroid function.
    Task 6 (2.0) Vision: occupational therapist home visit to remove environmental hazards and
    improve lighting. Assess for spectacles and ophthalmic referral as needed. Postural hypotension
    and polypharmacy: review the need for and doses of all medications. Neurological dysfunction:
    beyond the scope of this case scenario. Osteomalacia: calcium and vitamin D supplements. Atrial
    fibrillation: discuss the need for rhythm or rate control – options include cardioversion, digoxin,
    beta-blockers and amiodarone. If the patient has a bradyarrhythmia, they will require assessment
    for cardiac pacemaker. Owing to the risk of further falls, anticoagulation with warfarin is often not
    appropriate without very careful assessment of the ongoing risks. Always involve the patient,
    family and general practitioner (GP) in such discussions.

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