Characteristics and outcomes of older patients presenting to the emergency department after a fall: a retrospective analysis.

OBJECTIVES: To study older patients presenting to the emergency department after a fall--factors associated with the fall, injuries sustained and outcome. DESIGN: A retrospective analysis using the Emergency Department Information System (EDIS), the Trauma Registry and the patient information database (CCIS), in addition to the patient's emergency and inpatient medical records. SETTING: Emergency department of a major inner city teaching hospital, 1 June-30 November 1997. PATIENTS: All patients over 65 years presenting to the emergency department (ED) after a fall, for whom complete medical records were available. RESULTS: Of 803 patients over 65 years presenting to the ED after a fall, complete records were available for 733 (91.3%) (283 men and 450 women). Extrinsic (accidental) causes were implicated in more than a third of falls (313 patients [42.7%]). A high proportion of the patients were living at home (520; 70.9%) and walking unaided (389; 53.1%). Although absolute numbers of women increased with age, men were as likely as women to present after a fall. Many patients had fallen before--39% of the men (111/283) and 24% of the women (110/450). In 78 patients (10.6%), alcohol misuse may have been a direct cause of the fall. The overall injury rate was 70.5% (517/733 patients), the most common injury being an isolated fracture (269/517 patients; 52.0%). In all, 419 patients (57.2%) were admitted to hospital, 48% (200/419) with a fracture and 52% (219/419) for investigation of the medical cause of the fall. The median length of hospital stay was 6 days (mean, 10.4 days; range, 1-129 days); 35% (146/419) of patients were in hospital for more than 10 days. CONCLUSION: Older patients presenting to the ED after a fall had high injury rates, high admission rates and often prolonged hospitalisation. About a third had fallen before. Patients at risk can be identified in the ED and referred to falls prevention programs.

Psychiatric manifestations of systemic illness.

Many behavioral manifestations of systemic disease exist, including delirium, psychosis, mania, catatonia, depression, and anxiety. The features and medical causes of each of those manifestations are described. The indications from history and physical examination that suggest underlying medical illness are reviewed. The psychiatric presentations of several specific conditions are discussed in detail.

Cutaneous lesions due to Pleurophoma (Phoma) complex.

We report a case of striking and disfiguring facial mycosis due to an organism belonging to the Pleurophoma complex of Coelomycetes. This condition was likely acquired through repeated contact with infected soil and exacerbated by prolonged applications of topical corticosteroid preparations. Antifungal drug susceptibility testing was used to direct a therapeutic choice in this unusual infection.

Gastrointestinal bleeding.

A systemic approach must be taken with both upper and lower gastrointestinal bleeding. The first priority is stabilization. Once this has been achieved, and in patients who present with stable vital signs, a systematic approach to diagnosis and management must be followed. The urgency with which this is performed will be dictated by such aspects as risk factors and the clinical presentation. Some patients may need immediate diagnostic studies in the emergency department, some in the intensive care unit, some on a regular floor, and others may even be able to receive medical treatment followed by investigation on an outpatient basis.

Evaluation of the traveler. An introduction to emporiatrics for the emergency physician.

Travel medicine, or emporiatrics, presents an additional challenge to the practicing emergency physician. In this time of increased travel for business and pleasure, travel history should become a routine part of patient evaluation. While the emergency physician may not need to become facile with specific details concerning immunizations and prophylaxis, he or she should have a good working knowledge of these in order to provide the potential traveler with some basic information and to be able to adequately evaluate the returned traveler who becomes ill and seeks care. Air travel allows many travelers to arrive back in the United States before manifesting symptoms and signs of illness acquired abroad. Many of these illnesses are not usually found in the United States. Late diagnosis of certain illnesses, such as falciparum malaria, may increase the morbidity and mortality. As such, travel history should become a routine part of patient evaluation, and the physician should have a good working knowledge of illnesses that may be acquired abroad.

Pityriasis folliculorum revisited.

Six cases of facial erythema with follicular plugging are described. These cases correspond with characteristics of the disorder pityriasis folliculorum, a presumed demodicidosis. Treatment modalities included topical tretinoin, gamma benzene hexachloride (lindane) lotion, and 1% permethrin cream rinse.

Corneal changes, hyperkeratosis, short stature, brachydactyly, and premature birth: a new autosomal dominant syndrome.

We report on an autosomal dominant syndrome consisting of unique corneal epithelial changes, diffuse palmoplantar hyperkeratosis, distal onycholysis, brachydactyly, short stature, premature birth, and dental problems. This condition has been present in seven persons in three generations of one family. Corneal biopsies demonstrate mild dysplastic changes in the epithelium. Skin biopsies show hyperkeratosis and acanthosis. In both eye and skin specimens, results of stains for polysaccharides, amyloid, and tyrosine were unremarkable. Roentgenograms of the hands show short distal phalanges, short 4th metacarpals, and constriction of the heads of some of the metacarpals. In three of four affected relatives, a variable medullary narrowness is seen. In mode of inheritance, clinical appearance, and/or associated defects. This syndrome appears to differ from previously reported conditions that include palmoplantar hyperkeratosis and/or corneal changes.

Benign neonatal hemangiomatosis.

Diffuse neonatal hemangiomatosis is a serious multisystem syndrome of multiple cutaneous hemangiomas, visceral hemangiomatosis with arteriovenous shunts, high output congestive heart failure, thrombocytopenia with hemorrhage and central nervous system involvement. Some neonates with multiple cutaneous hemangiomas, however, may follow a benign course of spontaneous resolution without symptomatic visceral involvement. Such cases may be called benign neonatal hemangiomatosis.

Balanitis plasmacellularis circumscripta (Zoon's balanitis plasmacellularis).

A patient with clinical and histologic features typical of Zoon's balanitis plasmacellularis is presented herein. This entity has been infrequently reported in the English literature, perhaps due to a lack of familiarity with the disease.

Radionuclide scanning in pseudo-Kaposi's sarcoma.

Sodium pertechnetate Tc 99m radionuclide scanning is considered to be a sensitive indicator in detecting lesions of Kaposi's sarcoma, including occult infiltrations. This report describes a "false-positive" scan in a patient with acroanglodermatitis (pseudo-Kaposi's sarcoma); therefore, this technique may not be useful in the differential diagnosis of these two clinically and histologically similar diseases. We suggest, instead that the technetium scan may be helpful in deciding on the course of therapy in acroangiodermatitis by demonstrating the nature of the underlying vascular anomalies.