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Journal of Postgraduate Medicine, Vol. 48, Issue 4, 2002 pp. 328-329 Letter to the Editor Hidden Diseases Detected After a Fall Vadivelu R, Mathew EJ, Hadid N. Hospital of St. Cross, Rugby and University Hospital of Coventry and Warwickshire NHS Trust, Coventry, CV2 2NE, UK. E-mail: rvadivelu@yahoo.com Code Number: jp02110 Sir, When patients present to the Accident and Emergency Department after a considerable time gap following injury, detailed history taking and thorough clinical examination can help diagnose the presence of systemic diseases that have eluded detection. We present two such instances. A 46-years-old white Caucasian lady, previously fit and well, presented with a painless right ring finger deformity and back pain following a fall a week earlier. On enquiry, she admitted that the fall in fact, exaggerated her back pain that has been there previously. On clinical examination, the right ring finger was deviated to the radial side and was overriding the middle finger. The lower back, sacro-coccygeal region and pelvis exhibited tenderness. Only limited movements of the back were possible. There was no neurological deficit. Plain radiographs showed a secondary deposit in the middle phalanx of the right index finger and osteolytic lesions in the lumbo-sacral spine, pelvis and rib. A detailed enquiry revealed that she was suffering from loss of appetite and loss of weight for the last 3 months. A mammogram revealed a completely asymptomatic highly aggressive primary tumour in the breast. Biopsy confirmed it to be a highly aggressive ductal carcinoma. A 37-years-old lady of Asian origin tripped at home, falling sideways and landing heavily on her right hip. Two days later, she presented with history of severe pain in her right hip and unable to bear weight. On examination, there were no signs of external injuries. However, the movements of the right hip were slightly restricted at the terminal stages because of pain. Plain radiograph of the pelvis showed bilateral pseudo- fractures or Looser zones in the upper femoral shafts suggesting the diagnosis of osteomalacia. The diagnosis was confirmed on the basis of low levels of serum calcium and phosphorus with normal levels of serum alkaline phosphatase. In these cases there was telltale evidence of systemic disorders in the form of complaints preceding the fall, history of loss of appetite and weight loss and presence of signs such as tenderness, limitation of movements and that were disproportionate to the degree of injury. Several other disorders are notorious to present in this manner. Patients with blood disorders can present with haemarthrosis following trivial injury and their coagulopathy can be diagnosed using information from history and by undertaking appropriate investigations. Delayed presentation to the accident and emergency department after a fall is a very common scenario. Persisting pain and deformity are the usual reasons for which these patients seek help after overcoming the acute phase following a fall. The treating physicians, in such a situation, should pay great attention to detailed history and clinical findings to see if there is any other systemic disease. The fall, in fact, induces the patient to seek medical attention for the manifestations that he may have got accustomed to. The emergency physicians should use this opportunity to detect these hitherto undiagnosed conditions.
Vadivelu R, Mathew EJ, Hadid N. Hospital of St. Cross, Rugby and University Hospital of Coventry and Warwickshire NHS Trust, This article is also available in full-text from http://www.jpgmonline.com/ © Copyright 2002 - Journal of Postgraduate Medicine |
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