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OSCE Acute > Approach to Collapse / Fall > Flashcards

Approach to Collapse / Fall Flashcards

1
Q

Differentials - neurological

A 
Generalised seizure
PD
TIA / Stroke
Vasovagal 
Situational syncope i.e. cough, micturition

Neuropathy - i.e. MS
Intracranial haemorrhages
Raised ICP

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2
Q

Generalised seizure

  • hx
  • exam
  • ix
  • mx
A

Hx

  • tonic clonic - sudden LOC, stiff then jerk, incontinence, tongue biting, myalgia, confusion after
  • absence (petit mal) - unresponsive, staring into space for a few seconds (typically in childhood)
  • atonic - all muscles relax drop to floor
  • tonic - all muscles rigid
  • myoclonic - involuntary flexion

Exam

  • may be post-octal
  • focal neurology may indicate cause

Ix

  • EEG if required
  • find cause - CTH, U&E, cap glucose, drug levels

Mx

  • treat cause
  • anti-epileptics if >2 episodes
  • IV lorazepam or PR diazepam to terminate acute seizure
  • driving restriction
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3
Q

PD

  • hx
  • exam
  • ix
  • mx
A

Hx
- rigidity, tremor, bradykinesia, postural instability

Exam

  • resting tremor
  • shuffling festinant gait with lack of arm swing
  • cogwheel rigidity
  • bradykinesia

Ix - clinical diagnosis
- functional neuroimaging / dopamine transporter imaging (DaTscan) if diagnostic uncertainty

Mx

  • Levodopa
  • Dopamine agonists
  • Monoamine oxidase inhibitors
  • Physiotherapy + home modifications
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4
Q

TIA / Stroke

  • hx
  • exam
  • ix
  • mx
A

Hx

  • Sudden onset neurological symptoms i.e. limb/face weakness, slurred speech, hemianopia
  • RF - age, HTN, smoking, DM, vascular disease, AF

Exam
- neuro deficits - hemiplegia, HH, dysphasia

Ix

  • CTH
  • ECG - AF
  • Coagulation screen
  • Carotid dopplers

Mx

  • Acute: anti platelet or thrombolysis if ischaemic stroke (+/- endovascular clot evacuation where available)
  • Long-term: clopidogrel + statin + BP control
  • Carotid endarterectomy - if stenosis >50% NASCET criteria /70% ECST criteria
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5
Q

Vasovagal

  • hx
  • exam
  • ix
  • mx
A

Hx

  • occurs in response to stimuli i.e. pain, emotion, standing
  • preceding pallor, sweating, nausea, closing visual fields then transient LOC

Exam - normal

Ix - clinical diagnosis

  • tilt table test - if syncope diagnosis unclear
  • consider ix to exclude other causes
  • ECG normal

Mx - reassurance, avoid triggers

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6
Q

Situation syncope

  • hx
  • exam
  • ix
  • mx
A

Hx
- transient syncope in specific circumstance

Exam normal

Ix

  • tilt table test if diagnosis unclear
  • consider ix to exclude other causes
  • ECG normal

Mx - reassurance

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7
Q

Differentials - cardiovascular

A

Postural hypotension
Aortic stenosis
Cardiac syncope

Structural - HOCM, arrhythmogenic RV dysplasia

Carotid sinus hypersensitivity - precipitated by head turning/shaving - dx by carotid sinus massage –> >3 second pauses

Vertebrobasilar insufficiency - vertigo precipitated by neck extension in elderly with OA

Subclavian steal syndrome - proximal subclavian artery stenosis causing retrograde flow in one vertebral arteries as they become involved in a collateral circuit to bypass the obstruction

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8
Q

Postural hypotension

  • hx
  • exam
  • ix
  • mx
A

Hx

  • dizziness +/- LOC when sit to stand
  • recently started anti-HTN

Exam
- postural BP of >20mmHg (systolic) or >10mmHg (diastolic) within 3 mins of standing

Ix

  • U&E - dehydration
  • CRP - infection
  • FBC - anaemia
  • Synacthen test - Addison’s
  • Fasting glucose - diabetic autonomic dysfunction

Mx

  • Treat cause - i.e. rehydrate, change anti-HTN
  • Elastic stockings
  • Sit to stand slowly
  • Fludrocortisone if refractory
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9
Q

Aortic stenosis

  • hx
  • exam
  • ix
  • mx
A

Hx
- SOB and collapse on exertion

Exam

  • ejection systolic murmur
  • may be signs of LVF
  • slow-rising pulse and narrow pulse pressure
  • heaving apex beat

Ix - ECHO

Mx

  • surgical valve replacement if severe or symptomatic
  • TAVI if not fit
  • ECHO f/u
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10
Q

Cardiac syncope (arrhythmia)

  • hx
  • exam
  • ix
  • mx
A

Hx

  • fall and sudden LOC after transient arrhythmia
  • may have palpitations or feel strange before collapse
  • cardiac hx or FH of sudden death
  • may occur during exercise or while supine

Exam - may be normal

Ix

  • ECG - usually normal between attacks but may reveal cause i.e. WPW syndrome, Brugada syndrome, long-QT
  • 24-hour tape
  • Implantable loop recorder if episodes less frequent
  • ECHO - look for structural heart disease

Mx

  • depends on arrhythmia
  • B-blockers or antiarrhythmics or ablation where appropriate
  • ICD if risk of VT/VF
  • Pacemaker if persistent symptomatic bradycardia, trifascicular block, Mobitz II, complete heart block or pauses >3 seconds
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11
Q

Other differentials (non neuro or CV)

A

Drug overdose / toxicity
Alcohol intoxication
Mechanical fall

Postural instability 
Polypharmacy 
Ectopic pregnancy 
Ruptured AAA
Delirium 
Vertigo 
Hypoglycaemia 
Hypercapnic acidosis
Sepsis
Eyesight problems 
Arthritis 
Leg weakness
Anxiety 
Factitious blackouts 
Heat syncope 
Multifactorial
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12
Q

Drug OD / toxicity

  • hx
  • exam
  • ix
  • mx
A

Hx
- hx of drug use or taking drug with narrow therapeutic index

Exam - depends on drug

Ix - drug levels and urine toxicology screen

Mx - depends on drug

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13
Q

Alcohol intoxication

  • hx
  • exam
  • ix
  • mx
A

Hx of alcohol use

Exam - odour of alcohol

Ix - ethanol level if required

Mx - observation

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14
Q

Mechanical fall

  • hx
  • exam
  • ix
  • mx
A

Hx - clear account of tripping, no LOC/syncope/sx

Exam - normal, check for injuries

Ix - consider ix to exclude other causes

Mx - reassurance and treat injuries

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OSCE Acute (21 decks)

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