A 73-year-old man with hypertension is brought in by his family for having fallen earlier today.  He states that after urinating he “may have felt a little dizzy” briefly, and stumbled over the door jamb while walking out of the bathroom, falling to his knees on a carpeted floor.  He denies antecedent or subsequent chest pain, shortness of breath, or weakness; he has no current symptoms. In the ED, you find a pleasant, conversant elderly man in no distress.  His vital signs are normal; his physical exam shows no evidence of trauma, and is otherwise unremarkable.

Regarding his emergency department evaluation, which of the following is TRUE:

  1. The patient has no chief complaint, has normal vital signs, and an unremarkable exam; further testing would be of little benefit
  2. A hip fracture in this patient connotes a good outcome with early diagnosis
  3. Without recent history of head trauma, a subdural hematoma is unlikely
  4. A thorough medication history is warranted

In the meantime, a few quotes --   "One evil in old age is, that as your time is come, you think every little illness is the beginning of the end." 

"When a man expects to be arrested, every knock at the door is an alarm." -- Syndney Smith, British essayist (1771-1845)   "All diseases run into one, old age." -- Ralph Waldo Emerson, U.S. essayist (1803-82)


BIG Mike
08/13/2012 1:59pm

Answer is 4. Obtain medication history. This patient likely has micturition syncope which is basically a vasovagal response caused by stimulation of the vagus nerve during urinating resulting in a brief bradycardic and hypotensive episode. This response can be exaggerated by certain medications, in particular alpha blockers, which this elderly man is probably taking for BPH.

08/14/2012 11:48am

4. I agree with Mike on the likely etiology here, and I would add that a good fall risk assessment should be done on this gentleman which includes a comprehensive medication history, arguably the most important part because it is the most easily modifiable fall risk.

08/15/2012 5:55am


transcription services link
09/12/2012 1:09pm

Thanks for sharing, please keep an update about this info. love to read it more.


Leave a Reply