Mrs Audrey Bennett is a 78 year old lady who has been referred to the Community Falls Clinic by her GP after complaining of 4 falls in the last 3 months.
Mrs Audrey Bennet tells you she has never fallen before but had her first fall 3 months ago and has had 2 falls in the last 2 weeks which prompted her to see her GP.
Her first fall was when she waiting for the bus. She was feeling well and after boarding the bus felt ‘giddy’ and the next thing she remembers is being helped up by fellow passengers. She sustained a small laceration to her forehead but did not seek medical attention as she felt well (though a bit shaken up).
Her second fall was while she walking to the shops. She thinks she probably tripped on a loose paving stone but says she can’t quite remember how she fell and again she sustained a facial injury.
She began to lose confidence after her 2 falls and would only go out if accompanied.
Her more recent 2 falls were within her own home. On both occasions she had been standing up and remembers feeling ‘dizzy’ and having palpitations before collapsing and waking up on the floor. She did not sustain any injuries.
She has a past medical history of treated hypertension, hypercholesteraemia and osteoarthritis of both knees.
She is currently taking amlodipine 10mg, bisoprolol 2.5mg, losartan 50mg, bendroflumethiazide 2.5mg and simvastatin 20mg. The bendroflumethiazide was started 4 months ago and her bisoprolol had recently been increased from 1.25mg. She takes paracetamol PRN.
She lives alone in a ground floor flat and is independent for all activities of daily living. A friend is helping with shopping since she is reluctant to go out alone. She does not require a mobility aid. She is an ex-smoker and does not drink any alcohol.
There is no significant family history of note.
Question 1: What further information would you obtain from history and examination in order to refine your differential diagnosis?
On review of systems, the only things of note are that she does not have any exertional chest pain or breathlessness but she does complain of feeling lightheaded when she stands up and since her falls, feels ‘off balance’ when walking.
She looks well hydrated. Her lying BP is 110/70mmHg and after 1 min standing drops to 90/50mmHg. Her pulse rate is 60bpm regular and normal in character and volume. Oxygen saturations are 98% on air. Her heart sounds are normal but she has an ESM heard loudest in aortic area which is non radiating. She has no peripheral oedema and her chest is clear. Her abdominal and neurological examination are normal.
Her routine blood tests are all within normal limits. Her ECG shows sinus bradycardia with first degree heart block. Her chest x-ray shows normal heart size and clear lung fields with a healed rib fracture on the right hand side.
Question setter & Expert: Dr Sana Mufti, ST5 Geriatrics and General Medicine, Newham University Hospital.
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