Overcoming Inertia: an Exercise in Clinical Reasoning
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Division of Aging, Department of Medicine, Brigham and Women’s Hospital, Boston, MA, USA; 2Harvard Medical School, Boston, MA, USA; 3Division of Geriatrics and Palliative Care and New England Geriatrics Research Education and Clinical Center, Veterans Affairs Boston HealthCare System New England, Boston, MA, USA.
KEY WORDS: deprescribing; inappropriate prescribing; geriatrics; clinical reasoning; hospital medicine; medical education. J Gen Intern Med DOI: 10.1007/s11606-020-05928-6 © Society of General Internal Medicine 2020
this series, a clinician extemporaneously discusses the I ndiagnostic approach (regular text) to sequentially presented clinical information (bold). Additional commentary on the diagnostic reasoning process (italics) is integrated throughout the discussion. A 91-year-old woman presented to the emergency department after a fall. The morning prior to presentation, she was ambulating in her kitchen and felt dizzy. She fell, landing on her back and hitting her head on the floor. Her granddaughter helped her off the ground and brought her to the emergency department, where the patient reported ongoing dizziness. When an older adult reports “dizziness,” the differential is broad, including orthostatic hypotension, vertigo, cardiac arrhythmia, or central nervous system (CNS) hypoperfusion. The key to this patient’s presentation is that her fall is more than “tripping over something,” often referred to as a “mechanical” fall, but rather could be precipitated by a presyncopal event. Additional history regarding the fall would be helpful—what time of day was it? What type of activity was she doing prior to the fall? Had there been any recent changes to her medications or health status? The presentation of illness in an older person is often due to a multifactorial process rather than a single disease entity. Understanding context is of particular importance—clinical information needs to be grounded in detailed understanding of function and cognition, as well as the patient’s baseline. In older adults, possible diagnoses expand to include geriatric syndromes, which can be conceptualized as common endpoints of different physiologic perturbations.
Received September 18, 2019 Accepted May 18, 2020
A useful framework for falls is considering predisposing vs. precipitating factors.1 Predisposing factors include diseases or impairments that increase risk of falling, such as osteoarthritis, low vision, arrhythmia, cognitive impairment, gait impairment, and functional dependence. Precipitating factors include acute stressors directly leading to a fall, such as a tripping over an object in a cluttered home, alcohol intoxication, or new or adjusted medications. The patient reported daily episodes of dizziness occurring in the morning for the past few weeks, describing it as a “wooziness” rather than room spinning. The patient lived alone with family next door. At baseline, she reported independence with grooming, cooking, and medication management. She was dependent on family members for transportation and fina
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