Question

ou are allocated to also care for Lucy. She is 51 years old and admitted with a diagnosis of fracture neck of femur.

History:

Hypertension diagnosed since in hospital

Diabetes Mellitus since 2012 diet controlled.

BMI 36

Smokes 20 – 30 cigarettes a day.

She has a very demanding job, and is office bound all day. She travels far every day and does not have time for exercise.

She is known to be misusing medication and it is possible that her fall was related to an overdose of prescription drugs.

Medication:

What are the indications and side effects for the medication?

Enoxaparin 80 IU BD

Targin 20/10 BD

atenolol 50 mg daily

She had a fall two weeks ago and had been bed ridden after a neck of femur fracture. Explain what this is?

For the past few days, she had been complaining of fatigue and headaches. This is making her very sleepy with a lack of appetite. Why do you think this is happening?

You have helped her to have a wash in bed and her breathing seems to be rapid and very shallow. You also noticed her skin is looking yellow. She becomes very agitated while you are washing her. She is becoming incoherent and appears to be disorientated and confused. Her hands are shaking, and she has muscles twitching. She started vomiting. Why is this happening and why?

Suddenly, she is not responding.

What is the possible cause of her collapse? What should you do?

Answer 1

The patient presented with fracture neck of femur. she is diabetic, hypertensive and smoker.

ENOXAPARIN 80mg IU BD.

-Mode of action: keeps the smooth flow of blood by lowering clotting factors and thus preventing clot formation.
-Indication: mainly in unstable angina.
The reason it is prescribed here is because its usually after some hip/knee surgeries as bridging therapy. (given BD for the same.)
side effects.
-side-effects: mainly because of increased bleeding such as epistaxis, increased vaginal bleeding, bleeding gums, heamoptysis and in rare cases red tarry stools.

TARGIN (Oxycodone hydrochloride and naloxone hydrochloride)

-Mode of action- contains two different components naloxone and oxycodone.
oxycodone is an opiate analgesic and to counter the constipation naloxone (opiate antagonist) is added to it.
-Indication- is a strong analgesic.
-side-effects- constipation, fatigue, headache decreased interest in sexual activity, decreased sexual ability, diarrhoea, dizziness or light-headedness, ,nausea,sweating,vomiting.

ATENOLOL (beta-blocker)

-Mode of action- is a second generation beta blocker. It selectively blocks  beta 1  receptors. (cardio-selective)
-Indications- used mainly as a anti-hyperstensive. also used in the treatment of angina.
-side-effects- light headedness, dizziness, tiredness and nausea are common. It can also reduce blood flow to extremities and cause cold feet and hands.

The patient is described to be bedridden, as usually after the surgery for a fracture neck of femur, the patient needs to get a bed rest for 3-4 months.
The fracture is also associated mostly with hip dislocations, which need to be also aligned during surgery.
Fracture neck of femur is associated with posterior dislocation of hip mostly.
The main complication of fracture of head of femur is avascular necrosis of the proximal small head fragment which is because of the peculiar blood supply.

Blood supply
•medial femoral circumflex artery (MFCA)
-main blood supply to the weightbearing portion of the femoral head
-MFCA originates from the profunda femoris
•artery to the ligamentum teres
-lesser blood supply (10-15%)
-from the obturator artery or MFCA
-supplies perifoveal area

The patient is complaining of fatigue and headache because she is prescribed on Targin.
The headache is due to a phenomenon known as ‘medication-overuse headaches’. As each dose of medication gives pain relief, but as it wears off, the pain returns. This leads to a need of a higher dose to ease the pain. This can then lead on to a condition where the medication does nothing to the pain but instead causes headaches.

the sudden unresponsiveness maybe because of a haemorrhagic shock. She is under anti coagulants and the symptoms all match that of a stroke. Furthur investigation by an mri can give an absolute diagnosis.
The diffrential diagnosis maybe of opiod withdrawal. The patient maybe expiriencing withdrawal upon admission. Another possible complication is a fat emboli reaching upto thr lungs and causing pulmonary embolism. Which can explain ther symptoms similar to.