A new case study in which a 77 yo white female arrives to the emergency room by taxi with a suspected skull fracture. This topic was suggested by a reader – thank you so much for your ideas – keep them coming!
"I was working in the garden, and I tripped and fell and hit my head. It was so stupid of me to leave my rake lying on the grass. I'm sorry to bother you, but I couldn't get it to stop bleeding. I hope it's not too bad.”
General Appearance
Patient is thin and appears her stated age. She is wearing clothing with frayed edges and there is a stain on her shirt. Her socks are mismatched. She moves slowly and carefully. She holds a bloodstained washcloth to her right temple. She doesn't make eye contact and is restless – she fidgets and keeps folding and unfolding the sheet on the gurney.
Past Medical History
Occasional constipation
Arthritis in hands and feet
Depression
Family History
Both parents deceased, father died from CVA at age 77, Mother developed Alzheimer disease in late 70s and died when she was 83.
Brother died from heart disease at age 72
Social History
Lives with only daughter, age 53
Has been widowed for 15 years (husband died of cancer)
Does not smoke or drink alcohol
Medications
Ibuprofen 200 mg q 4h PRN
Docusate sodium 100 mg po BID
Citalopram 20 mg PO qday
Allergies
Co-tromoxazole = rash
Review of Systems: (only abnormal values presented)
Skin
Skin is pale and dry with senile lentigines, poor skin turgor
HEENT
Dentures present, small abrasion to right upper lip, patient states, "I can't find my glasses.”
Lungs/Thorax
Mildly increased chest AP diameter with mild kyphosis
Musculoskeletal
Healing bruise noted on left upper arm
Pain is rated at 7/10 in right temple and 5/10 in her hands and knees. "My arthritis is paining me today.” Upon examination, there appears to be a laceration to the right frontal lobe above the right eye, with a hairline fracture and a small amount of continuous bleeding.
Vital Signs
BP 141/93 sitting, RA 138/88 standing LA
HR 90 (60-90) seated, 95 standing
RR 20 (12-14)
T 98.9oF
HT 5' 2"
WT 95 lbs
BMI 17.4
Laboratory Test Results (normal values)
Na 146 meg/L (135-145)
K 4.8 meq/L (3.5-5)
Cl 111 (101-112)
Mg 2.8 mg/dL (1.8-3)
PO4 4.2 mg/dL (2.5-4.5)
BUN 21 mg/dL (8-20)
Cr 1.2 mg/dL (0.6-1.2)
Ca 9.0 mh/dL (8.5-10.5)
Hb 12.8 g/dL females (12-15.5)
Hct 36.2% females (35-45%)
Plt 290,000 cu/mm (150,000-450,000)
WBC 8,000 x 103/mm3 (4,800- 10,800)
Glu fasting 62 mg/dL (60-110)
Total Protein 6.0 g/dL (6-8.3)
Albumin 2.7 g/dL (3.4-4.7)
Prealbumin 10 mg/dL (15-36)
Urinalysis
pH 6.2 (5-6.5)
Specific gravity 1.035 (1.016-1.022)
Negative for white/red blood cells, proteins, ketones,bacteria or glucose
Urine is dark yellow with strong odor
What is going on with this patient besides a fracture?
Specializes in Education, Informatics, Patient Safety.
FINAL POST
After further questioning, the patient breaks down in tears and admits that her daughter pushed her into a wall, causing the fracture. The patient says, “please don’t do anything to her – she didn’t mean to. She does the best she can. I’m such a burden to her.” Eventually she admits that the bruise on her arm is from her daughter as well. She tells you that her daughter restricts what she can eat and that she isn't allowed to see a physician. A report is made to adult protective services and they begin the process of ensuring the safety of the patient.
According to the National Council on Aging, up to five million Americans are abused every year. “Elder abuse includes physical abuse, emotional abuse, sexual abuse, exploitation, neglect, and abandonment. Perpetrators include children, other family members, and spouses—as well as staff at nursing homes, assisted living, and other facilities.” Approximately 1/10 Americans over the age of 60 have experienced some form of elder abuse. It is estimated that only 1/24 cases are reported. In almost 60% of incidents the perpetrator is a family member and 2/3rds are adult children or spouses. Elders who have been abused have a 300% higher risk of death when compared to those who have not been mistreated.
Risk factors include mental impairment and social isolation. Interpersonal violence occurs at a higher rate among adults with disabilities.
Physical signs include
Dehydration or unusual weight loss
Missing daily living aids
Unexplained injuries, bruises, cuts or sores
Unsanitary living conditions and poor hygiene
Unattended medical needs
Emotional/Behavioral Signs of Elder Abuse include:
Increased fear or anxiety
Isolation from friends or family
Unusual changes in behavior or sleep
Withdrawal from normal activities
In a study of characteristics and comorbid diagnoses in older adults with fractures, the following characteristics were associated with elder abuse (Gironda, 2016):
Age 65-79
Female
White
No dementia diagnosis
ED
Only 1 visit to medical facility in past 3 years
Fracture at home
Fracture from fall
Head as location of fracture
The most common forensic markers from the Gironda study were laceration, abrasion, bruise, depression, anxiety or mood disorder, malnutrition, pressure ulcer and dehydration.
It is important that medical practitioners be aware of the signs and symptoms of elder abuse. It is crucial that we report suspected abuse to DSS so that elders can live out their lives with dignity and health.
The Council on Aging link has many resources where you can learn more.
The following are the guesses/diagnoses/rationales from members who came to the Help Desk during the "A Fracture from a Fall: What’s Going on Here?" Case Study.
Thank you, @SafetyNurse1968, for this excellent and very informative Case Study.
I think the woman in the case study is the victim of elder abuse and possibly neglect. She is vague on what caused her injuries, avoids eye contact, blames her own clumsiness, refuses to give contact information for her daughter, and verbalized that she wants to get home before her daughter gets home. I'm suspicious that her daughter has hit her in the face (lost glasses?), but I don't have enough evidence. It could be a boyfriend of either the daughter or the victim, or even someone else. This isn't for the RN to investigate, but we are required to put in a report with adult protective services. I would also get a SANE nurse in to make sure this woman wasn't also sexually assaulted, but they may be able to help in building rapport to aid investigation even if there is no sexual assault.
Neglect is also a major concern given her frayed, stained clothing and mismatched socks. Possibly financial abuse may be involved.
SafetyNurse1968, BSN, MSN, PhD
60 Articles; 529 Posts
FINAL POST
After further questioning, the patient breaks down in tears and admits that her daughter pushed her into a wall, causing the fracture. The patient says, “please don’t do anything to her – she didn’t mean to. She does the best she can. I’m such a burden to her.” Eventually she admits that the bruise on her arm is from her daughter as well. She tells you that her daughter restricts what she can eat and that she isn't allowed to see a physician. A report is made to adult protective services and they begin the process of ensuring the safety of the patient.
According to the National Council on Aging, up to five million Americans are abused every year. “Elder abuse includes physical abuse, emotional abuse, sexual abuse, exploitation, neglect, and abandonment. Perpetrators include children, other family members, and spouses—as well as staff at nursing homes, assisted living, and other facilities.” Approximately 1/10 Americans over the age of 60 have experienced some form of elder abuse. It is estimated that only 1/24 cases are reported. In almost 60% of incidents the perpetrator is a family member and 2/3rds are adult children or spouses. Elders who have been abused have a 300% higher risk of death when compared to those who have not been mistreated.
Risk factors include mental impairment and social isolation. Interpersonal violence occurs at a higher rate among adults with disabilities.
In a study of characteristics and comorbid diagnoses in older adults with fractures, the following characteristics were associated with elder abuse (Gironda, 2016):
The most common forensic markers from the Gironda study were laceration, abrasion, bruise, depression, anxiety or mood disorder, malnutrition, pressure ulcer and dehydration.
It is important that medical practitioners be aware of the signs and symptoms of elder abuse. It is crucial that we report suspected abuse to DSS so that elders can live out their lives with dignity and health.
The Council on Aging link has many resources where you can learn more.
References