Clinical case:- A woman was found lying on the pavement outside her house by a passerby

[bashar]

An 80-year-old woman was found lying on the pavement outside her house by a passerby. She was difficult to rouse. An ambulance was summoned and she was taken to hospital. On arrival she was verbally abusive to staff, started to wander about, and had two falls. On examination there were knee abrasions in various stages of healing and numerous bruises, including a head injury. Her GCS was 13/15. She was afebrile. Examination of the cardiovascular system, chest, abdomen, and skin was otherwise unremarkable. Nervous system examination showed unsteadiness of gait with globally poor co-ordination and sustained nystagmus in both extremes of lateral gaze. There was no smell of alcohol on her breath. Her son said that his mother was a heavy drinker of gin and tonic (since being widowed 3 years earlier) but had recently had an attack of the flu and had not been able to go shopping for several days. He also mentioned that she had not been eating properly for the last year and had lost some weight.

INVESTIGATIONS



Serum salicylates, alcohol, and paracetamol were not detected. Oxygen saturation was 98% on air. Routine urinalysis was negative. An urgent CT head scan showed mild atrophy.

1 In addition to general care, the most appropriate next step in her management is:

A Intravenous infusion of 5% dextrose.
B Intramuscular injection of 5 mg haloperidol.
C Nurse with cot sides on the bed.
D Intravenous infusion of B group vitamins.
E Low-dose subcutaneous morphine

2 What other therapeutic measures are likely to be needed?

3 Discuss the likelihood of the patient being able to stop or moderate her drinking

4 If the patient had a sustained convulsion on day 2 of the admission, the best choice of treatment would be:

A Intravenous diazepam.
B Intravenous fosphenytoin.
C Intravenous phenobarbitone.
D Rectal diazepam.
E Rectal paraldehyde.


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[garryjoey]

d, a....nutrition, special cares for behavior, mmse