Can a 75-year-old male with intermittent sharp right hip pain radiating to his right leg and groin, history of recent fall, episodes of dizziness and headaches, and normal imaging and lab results, including electrocardiogram (EKG), computed tomography (CT) scans of head, spine, and hip, complete blood count (CBC), comprehensive metabolic panel (CMP), troponin, brain natriuretic peptide (BNP), creatine phosphokinase (CPK), and urinalysis, be safely discharged from the emergency room (ER)?

Safe Discharge Assessment for an Elderly Patient with Fall, Dizziness, and Hip Pain

This 75-year-old male patient with normal imaging and laboratory studies can be safely discharged from the emergency room as long as proper discharge instructions and follow-up are arranged, since he has a normal neurologic examination, can walk without falling, and has social support at home. 1

Clinical Assessment and Risk Stratification

Traumatic Brain Injury Evaluation

• The patient presents with a history of fall with head strike, dizziness, and headaches
• According to the American College of Emergency Physicians guidelines, patients with mild traumatic brain injury (GCS 14-15) and normal neurological examination can be safely discharged if:
  • CT head shows no evidence of intracranial injury
  • Patient has normal neurologic examination
  • Patient has adequate social support 1

Cardiac Evaluation

• The patient's normal ECG and troponin levels effectively rule out acute coronary syndrome
• The American Heart Association recommends considering ACS in elderly patients with atypical presentations, but this patient's normal cardiac workup is reassuring 1, 2

Musculoskeletal Pain Assessment

• The patient's hip pain is likely musculoskeletal in nature given:
  • Normal CT of the hip
  • Ability to walk without falling
  • Normal CPK levels (ruling out significant muscle injury)

Discharge Safety Algorithm

1. Confirm normal diagnostic studies:

   • CT head, spine, and hip: Normal
   • Laboratory studies (CBC, CMP, troponin, BNP, CPK, UA): Normal
   • ECG: Normal

2. Assess neurological status:

   • Patient has GCS of 15 (implied by ability to give history)
   • No focal neurological deficits (implied by ability to walk)
   • Multiple studies have shown that patients with normal neurological examination and normal CT findings have a very low risk of deterioration 1

3. Evaluate mobility and fall risk:

   • Patient can walk without falling
   • Intermittent pain suggests non-acute pathology

4. Assess social support:

   • Patient lives with son and daughter-in-law who can monitor him

Important Discharge Considerations

Red Flags to Monitor

Instruct the patient and family to return to the ED if any of the following develop:

• Worsening headache
• Persistent or worsening dizziness
• Vomiting
• Confusion or altered mental status
• Difficulty walking or worsening pain
• New weakness or numbness 2

Follow-up Recommendations

• Primary care follow-up within 2-3 days
• Consider outpatient neurology evaluation for persistent dizziness
• Physical therapy evaluation for hip pain and fall prevention

Potential Pitfalls and Caveats

1. Age-related considerations:

   • Elderly patients (>75 years) may have atypical presentations of serious conditions
   • Falls in the elderly often have multifactorial causes that require outpatient workup 2

2. Medication review:

   • While not on blood thinners, other medications may contribute to dizziness and fall risk
   • A thorough medication review should be completed prior to discharge

3. Communication challenges:

   • Studies show that approximately 20% of patients fail to fully comprehend discharge instructions 3
   • Use clear, non-medical terminology and written instructions to enhance understanding

4. Delayed complications:

   • While rare with normal initial studies, delayed complications can occur
   • Ensure the family understands the importance of monitoring for changes in condition

By following this systematic approach and ensuring proper discharge instructions and follow-up care, this 75-year-old patient with normal studies and adequate social support can be safely discharged from the emergency department.