Return to Scenario ListShow Learning Points most relevant to Phase 1:

Falls and collapses

Clinical Discipline(s)/Organ System(s)
Emergency Medicine, Geriatric Medicine
Progress Test Topic(s)
General duties
A 77 year old NZ European woman presents to the Emergency Department. She lives at home, with a stressed family. She has mild cognitive impairment. There is a vague history from the ambulance officer of the patient falling earlier that day. She appears emaciated with fingerprint bruising on her inner arms. She has a bruised eye and smells of urine and faeces. As the medical student, you observe the emergency doctor assess the patient.
Progress Test-Type Questions:   Question 1 | Question 2
Applied Science for Medicine 
   - Anatomy of the musculoskeletal and autonomic nervous systems
   - Physiology of blood pressure control, including adaptation to standing
   - Central and peripheral neurological controls of posture, balance and gait
   - Pathophysiology of vasovagal syncope
Clinical and Communication Skills 
   - History from a patient post-fall and/or collateral history; include nutritional assessment
   - Information-gathering in a situation where a patient is vague about the history
   - Examination of cognition, neurological system, skin and a Gait-Arms-Legs-Spine (GALS) screen; recognise signs of abuse and neglect
   - Perform assessment of the level of consciousness using Glasgow Coma Scale (GCS) and Alert, Voice, Pain, Unresponsive (AVPU) Scale
   - Perform measurement of postural blood pressure
   - Perform ECG, capillary blood glucose test
   - Differential diagnosis and investigation of fall in older people
   - Indications for CT head, toxicology screen, Holter monitor, infection screen
   - Interpret ECG, blood glucose level, postural blood pressure
   - Management of fall and of abuse/neglect including documentation of injuries for medico-legal reasons
   - Role of the pharmacy; polypharmacy
   - Role of the geriatrician,geriatric psychiatrist, nurse, physiotherapist, occupational therapist, social worker, dietitian, Age Concern, including discharge planning with team and family/whānau
   - Explain types of care for adults including respite, rest home, private hospital
Personal and Professional Skills 
   - Competence and voluntariness, role of family/whānau
   - Manage your own professionalism and judgement about interacting with a patient who smells of urine and faeces
   - Time management of complicated history in ED setting
   - Complexity of establishing collateral information from several sources – family whanau, staff, management
   - Explore the possibility of abuse in a sensitive manner, including the issues around confidentiality
   - Conduct effective family/whānau meetings
   - Involve senior staff to ensure appropriate management and the safety of the patient
   - Protection of vulnerable adults
   - Role of the Accident Compensation Corporation
   - Role of Age Concern, DHB regulatory bodies for aged care, police; understand the Protection of Personal and Property Rights legislation regarding protection of patients
Hauora Māori 
   - Caring for kaumatua and kuia
   - Consideration of access to cultural/spiritual support for patient and whānau
   - Awareness of disproportionate impact of socioeconomic deprivation on Māori, and appropriate response
Population Health 
   - Epidemiology of abuse
   - Epidemiology of falls
   - Strategies for preventing falls in older people
Conditions to be considered relating to this scenario
fall, frailty, abuse, postural hypotension, drug induced, vasovagal syncope, stroke, hypoglycaemia, cardiac arrhythmias, seizures, substance abuse, Parkinson's disease
Less common but 'important not to miss'
subdural haemorrhage, meningitis, subarachnoid haemorrhage, cerebral tumour

Age Concern