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You are an FY1 working at a local rehabilitation hospital in your region. An 81 year old patient has just been transferred from the acute medical site after a brief inpatient stay. The patient, Stephanie O’Scope, has presented with a fall. She has a number of chronic medical conditions.

Please take a history from Steph and perform an appropriate examination. Ensure that you undertake a relevant social history from this patient. You will be asked about this patient’s potential for rehabilitation.

You are Steph O’Scope, an 81 year old lady who lives with her husband on a farm. You’ve lived there for 50 years in peace, and you have been getting a little bit stressed recently. This is because you don’t like change, but life seems to be very different than it appeared 5 years ago. Your main problem is that you are the carer for your husband, Dermot. Dermot suffers from dementia, and he depends on you to look after him. You need to be with him 24/7, which you admit has become a little bit overwhelming recently. However, you love him dearly and he has always been therefore you, through thick and thin.

HPC: Things have been thrown into chaos in the last 2 weeks since you had a fall at home, on the farm. You don’t remember much from the fall. You had a vague experience of light-headedness, and then you must have tripped over your own feet. You’ve been doing that a lot recently, and feel quite silly about it. You don’t think you hit your head when you fell, but you did fall onto your left side, where you hurt yourself quite badly.

The pain was one of the worst you have ever experienced, and you think it shot down your left leg towards your knee. You weren’t able to get up after that, and you reckon you were lying on the floor for around 1 hour. Luckily, your daughter was stopping by that afternoon to bring in the shopping, and she found you on the floor and brought you to hospital. In hospital, they told you that you had broken your hip, and you had an operation. That bit of your memory is really hazy and you can’t quite recall what happened in hospital: it was all a blur of worry and pain. You just remember being devastated that you couldn’t go home straight from hospital, and that the doctors insisted that you come to this rehabilitation ward instead. At the moment, you feel well again. You were a little confused for a time at hospital, but now you can think clearly. Your pain is well controlled, though you haven’t opened your bowels in about a week. You suspect that this is down to the painkillers, but aren’t quite sure. These doctors don’t tell you anything!

ICE: Your main concern is obviously for Dermot, who is at home being cared for by your daughter. You were loathe to leave him, however, and apparently you did try to self-discharge from the acute hospital when you weren’t quite well. However your daughter tells you that you that the doctors wouldn’t let you as you weren’t yourself. You’re still desperate to get home to care for Dermot, however.

Your daughter tells you that you fell because you took on too much in caring for Dermot and that he should be cared for by a ‘qualified nursing home’. Not a chance!

PMH: You think this is the sixth time you have fallen in the last two years. You have a heart murmur, apparently, and a funny heartbeat. You smoked for 20 years, recently giving up (too expensive!), and subsequently have a ‘bad chest’.

SH: You live in a farm house with your husband, Dermot. Your daughter comes to visit every week, but this seems to have become more frequent recently. The house has stairs so you and Dermot have had to move everything downstairs this year, since he can’t manage to climb stairs. Your doctor has previously recommended moving, however you don’t want to leave the home you have lived in for so long: somewhere where you have so many happy memories. You used to drive, up until one month ago, but haven’t really felt confident enough to do so recently.

FH: Your mother had emphysema and your father died of a stroke. Your mother had brittle bones.

The student should demonstrate a succinct falls history, accompanied by identifying the appropriate risk factors for a fall in this elderly patient. In terms of examination, a hip exam would be appropriate, however a cardiovascular exam would also be acceptable.

The student’s differential diagnosis should sound something like:

This patient has had a fall which has resulted in orthopaedic pathology, likely a fractured left neck of femur, for which she is currently receiving rehabilitation. In terms of a cause for her fall, my differential diagnosis would include a mechanical fall or a fall of cardiovascular origin. She also describes a period of delirium during her inpatient stay. Example for discussion may include:

  • How would you investigate the causes of this lady’s fall?
  • What aspects of this lady’s social history may impact negatively on her potential for rehabilitation?
  • This lady experienced likely delirium as an inpatient. What is delirium? How is it different to dementia?
  • This lady attempted self-discharge when experiencing delirium. What legal framework allowed the medical staff to detain her in hospital?
  • How do you manage a fractured neck of femur?