Val Proate
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You are the FY1 working on your first rotation on the Acute Medical Unit at your local District General Hospital. Valerie Proate is a 74 year old lady who has presented following a fall at home. Inconveniently, your consultant has already seen this patient on the ward round, but did not document anything in the notes. The nurse has told you that Val has been diagnosed with a long term medical condition.
Please take a history from Val and undertake the most appropriate examination. Take into account her concerns and identify her long term medical condition.
You are Val Proate, a 74 year old who has always felt younger than her age. You remember fondly the days when you were one of Britain’s finest meringue makers. However, that feels like a long time ago now, and the last few months have been a bit difficult, culminating in this fall.
HPC: You remember the fall vividly. You had just got up from the sofa after watching an omnibus of your favourite soap, and were headed for the kitchen. As you went through into the kitchen, your feet got a bit muddled and you tripped and fell. You didn’t really hurt anything, but you have a nasty bruise on your hip.
This isn’t the first fall you have had. You had a similar episode last month, and the month before that. Each time, you can remember the fall well. You didn’t notice any dizziness beforehand, and your vision didn’t change. You haven’t felt confused at all during this time. You didn’t lose consciousness during any of the falls. You just think your legs are ageing faster than you are! None of the previous falls have resulted in any injuries. You didn’t hit your head.
Your daughter was there to pick you up after you fell, so you weren’t laid there for very long. She was quite anxious about your falls, so insisted you came in. You think it’s a lot of fuss over nothing!
Over the last few months, you must admit that you haven’t felt quite yourself. If pressed, you would say that you’ve been a lot slower than usual; stiffer. You don’t climb the stairs as quickly, and worst of all, your meringue making has been suffering! You can’t whisk one egg any more, let alone twenty… your hands just slow up after a while! You haven’t noticed any numbness, tingling or weakness in your arms or legs. You feel a bit restless sometimes, like you can’t sit still. Your sense of smell hasn’t been great either, but you think that’s because you haven’t been making any delicious meringues lately.
ICE: You’re a bit annoyed as your daughter keeps telling you that you look miserable, that you don’t smile as much as you used to. The cheek! You think that all of this is a fuss over nothing, that you haven’t broken anything so you should be able to go home quickly. You are a little distressed and low due to how your life has changed recently, however.
PMH: You take warfarin tablets, as you have a funny heartbeat. Your doctor tried to put you on a different tablet for the heartbeat when you were there last, but you weren’t too fussed: you don’t like change! Your joints ache now and again, but you generally think you’re quite well for your age – you’ve always led an active lifestyle.
SH: You live alone in a house with stairs. Your husband passed away 4 years ago. You had felt you were coping ok at home but you miss his company. Your daughter comes to visit you a lot nowadays, but you feel she frets too much. She needs to relax more! You don’t smoke, and you have the occasional glass of wine. You used to be a cook and a housewife, and are very proud of your desserts!
FH: Your mum had thyroid problems, and your dad died of an aneurysm. You don’t have any brothers or sisters.
The student should demonstrate a good falls history, and include questions specific to assessing for Parkinson’s disease, ideally assessing for a differential for the cause of this fall. In terms of examination, a Parkinson’s examination would be ideal, however a neurological or cardiac exam would be appropriate, depending on the student’s differential diagnosis.
The student’s differential diagnosis should sound something like:
My differential diagnosis would be a neurological problem: specifically Parkinson’s disease. This is due to Val’s history of bradykinesia, her rigidity and her pill-rolling tremor. I would also want to rule out other conditions, which can lead to falls. These would include: cognitive impairment, urinary tract infections and cardiac syncope.
Example questions for discussion may include:
- How would you investigate this patient?
- How would you manage this patient and her chronic condition?
- What is the pathognomonic triad for Parkinson’s Disease?
- What other symptoms may be typical of Parkinsonism?
- What are the long term complications of Parkinsonism?
- Do you know any tools for assessing cognitive function?
