![]() The lack of support at home suggests that she will need subacute rehabilitation at a nursing home and may have additional difficulties transitioning back to home. Her prior history of cerebrovascular events and carotid stenosis suggests that neurological causes of dizziness and syncope need to be considered and may necessitate additional evaluation and management. The fact that she required a walker premorbidly suggests that she has a residual deficit from her previous stroke, so one can safely assume this will have an impact on her recovery from her current injury. Anticoagulation must be carefully managed around surgery with consideration of the fact that she will require anticoagulation postoperatively, so that intramuscular or subcutaneous vitamin K should be avoided, as we do not want her to be warfarin resistant postoperatively intravenous or oral route of administration of vitamin K is generally preferred. First, why did she lose consciousness? Acute coronary syndrome? Arrhythmia? Stroke? Pulmonary embolism? Severe valvular disease? Second, what is her current level of anticoagulation? Third, what is the extent of her injuries? C-spine? Intracranial injury? Other injuries?ĭr Mendelson (Geriatric Medicine)-Her hearing difficulty is a major risk factor for delirium in the hospital. Nathan Clark, MD (Anesthesiology)-When I first hear about a patient, I am most concerned with things that will alter my usual anesthestic plan of care, or cause me to delay surgery in order to obtain further testing, information, or optimization. This is rather unlikely in this scenario, as there are no ischemic symptoms, that is chest pain or heart failure symptoms. Lastly and likely least importantly, she needs to be evaluated for ischemia or acute coronary syndrome as the cause of her syncope. Additionally, it is important to obtain her home medications, as they may provide further important information. Her initial blood pressure is not mentioned and provides additional important information. I suspect that in this case, tachyarrhythmia is the problem and the cause of her syncope. Patients with atrial fibrillation are prone to tachyarrhythmias from atrial fibrillation, as well as bradyarrhythmias due to intrinsic conduction disease or as a complication of medications. Jason Pacos, MD (Cardiology)-She has known atrial fibrillation and is appropriately anticoagulated with warfarin, given her risk factors. I am concerned she has had a cardiac event. She will need to be admitted to a monitored bed. This patient sounds too medically decompensated for immediate surgery due the rapid atrial fibrillation. The team will need to thoroughly discuss plans for management. It will be essential to medically comanage this patient with the geriatrician and cardiologist. Simple immobilization will not be a good long-term solution as she will be confined to bed. This patient is medically complex and a simpler procedure is desirable. Treatment options would include open reduction and fixation versus a hinged arthroplasty to allow immediate weight bearing. Initial immobilization in a splint is appropriate until the medical workup is completed. The fracture itself is reasonably simple, but the medical situation is not simple. Stephen Kates, MD (Orthopedic Surgery)-The X-rays demonstrate a displaced proximal tibia fracture. Additional consideration of β-blockade is also appropriate. The head contusion in the setting of anticoagulation necessitates careful neurological evaluation. Anticoagulation will need to be expertly managed with considerations to her cardiac status including atrial fibrillation, history of DVT, and prior cerebral vascular accident. This may be a medical patient that happens to have a fracture rather than the typical circumstance of a fracture patient who happens to have significant but stable medical conditions. The differential includes other causes of cardiac syncope, neurological syncope, and orthostasis or hypotension. In this instance, additional cardiac evaluation is completely appropriate even if it delays definitive care of the fracture. This may be one of the rare instances where the patient has an acute coronary event that leads to a fall and fracture. Comments on Emergency Department Presentationĭaniel Mendelson, MS, MD (Geriatric Medicine)-The differential diagnosis for her dizziness includes an acute episode of atrial fibrillation that could either cause or be caused by an acute coronary syndrome.
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