Sorting Out the Complexities of an Elderly Woman's Fall

I enjoyed Dr Henry Schneiderman's "What's YourDiagnosis?" case of an elderly woman with severe facialecchymoses from a fall (CONSULTANT, April 1, 2004,page 619). Would Dr Schneiderman elaborate on severalpoints about that case? This woman did not trip orcomplain of dizziness before she fell. What caused her tofall?The patient's sclerae were icteric. Could this be explainedby hemorrhage into the subconjunctival areas? Shealso had subconjunctival hemorrhages on the right thatare not mentioned. Of what significance is this? The patientappears to have sustained most of her trauma to theleft side of her face, with abrasions and/or lacerations overthe left malar area and left supraorbital area. She alsohas a "raccoon-like" facial ecchymosis and abrasions overthe bridge of the nose, which would suggest a nasal fracture.Occasionally, nasal fractures are not seen on a radiographunless a view with nasal bones is ordered. Wasit? The pattern and color of the ecchymotic areas are compatiblewith dissection of the blood through the tissueplanes--and with the timing of the incident.Would Dr Schneiderman explainher slightly prolonged INR? Wasshe taking warfarin or a similaragent or did she have some kind ofliver malfunction or hepatic congestion(eg, from heart failure)?The patient's elevated white bloodcell count is also of interest. Can it beexplained simply by the trauma? Orcould it also be that she had somekind of infectious process, such as aurinary tract infection (UTI)? UTIsare quite common in the elderly andare sometimes found in those whohave had unexplained falls.Most important, this patient hasa vertical, midsternal, well-healedsurgical scar, which suggests that shehad a thoracic procedure--presumablycoronary artery bypass graft(CABG)--at some time. Moreover,her medications suggest that she hassome kind of cardiac/hypertensivehistory. She also had some chest discomfort.Did she have some kind ofcoronary event--in particular, an arrhythmia--that caused her to fall?Given these reasons to suspect acardiac history, it is notable that aspirinis not included on her medicationlist. I would expect her to be takingit if she had had CABG, as proposed.Did she have open heartsurgery, and was she taking aspirin?If so, this agent could decrease the effectiveness of the platelets' ability toclot and thus cause more ecchymosisthan anticipated.-- Robert A. Scalice, MD
   Gloucester, MassWe appreciateyour close andcareful readingof our case, andyour points areall well taken.We believe that this woman'sfall was multifactorial. Although sheherself denied tripping, the fall appearedto be at least partly environmental(even though she also hadseveral of the other risk factors for falls that we discussedin our article). We did not take the patient's negativereport at face value, in part because of the factor ofembarrassment that is universally present in adults whohave had a fall, and also because this woman had somedementia. Her answers were thus considered suspect,as mentioned in the case discussion.You are on target about her subconjunctival hemorrhages.Before she reached our nursing home, whereshe finished her recuperation and reconditioning, shewas studied thoroughly in the hospital for facial and intracranialtrauma, with appropriate CT imaging of thehead and the facial bones. No fracture was found, includingfracture of the nasal bones.Of course you are correct that she had had CABGin the past and carries the scars of it on her chest. However,she was not taking aspirin; the reason her priorphysician had not prescribed it for her remains obscure.She did not receive warfarin and had no medical indicationfor it. We interpreted the slight prolongation of theINR as related to mild nutritional compromise; she hashad no known hepatopathy and no hepatotoxic drugtherapy.As we wrote, the results of tests for myocardial infarctionas the precipitant of the fall were negative;so was in-hospital cardiac monitoring for arrhythmia.There was no 24-hour Holter monitor report in the medicalrecords we received with her transfer to our facility.We deliberately downplayed cardiac aspects of thecase so as to direct readers' attention to the broaderworkup of less glamorous but more likely causes offalls--and away from cardiac causes, which there is awidespread tendency to investigate for even in nonsyncopalfalls. In the absence of syncope, the yield of suchan investigation is very low. Although laboratory cardiacevaluation was performed before this woman cameunder our care, we strongly approve of its having beendone; one can never prove that there was no syncope inan unwitnessed fall, whether or not the patient's reportis reliable.UTI offers another key differential diagnosis, especiallyin a multifactorial fall. Your comments on leukocytosisare apt. Gait, like cognition, is a uniquely susceptiblelocus in an old person; thus, trouble any place in thebody may manifest in such misleadingly localized ornonspecific ways as falls or delirium.The patient has done very well in the year sinceher fall, and at age 93, that is no small thing.-- Henry Schneiderman, MD
   Physician-in-Chief
   Hebrew Health Care, West Hartford, Conn
   Professor of Medicine (Geriatrics)
   Associate Professor of Pathology
   University of Connecticut Health Center
   Farmington
-- Elizabeth Esstman, APRN
   Hebrew Health Care
   West Hartford, Conn
-- Dorothy Baker, PhD, RN
   Yale University
   Connecticut Collaboration for Fall Prevention
   New Haven
-- Margaret Gottschalk, RPT, MS
   Yale University
   Connecticut Collaboration for Fall Prevention
   New Haven