19. Fall/collapse

Question 1

history taking fall/collapse

Answer 1

PC: describe an episode in your own words from before, during, after… witnessed by anyone else? What do they say about what happened? Has this every happened before? Any injuries or pain? Hit head?
HoPC:
Before: Time of the day? What were they doing at the time? Any pain, injections, hot crowded rooms, emotional stress, prolonged standing? Dizziness, light-headedness, nausea, tunnelled vision, Aura: dejavu, visual or smell disturbances, strange feelings like epigastric rising, palpitations? Chest pain? Headache?
During: any movements? Tongue biting? Incontinence? How long did it last? Eyes open or closed? Awareness? Spinning feeling?
After: recovery? Confusion? Drowsiness? Weakness anywhere? Crying?
Any injuries or pain? Hit head?

MHx: cancer?

DHx: any new medications? diuretics, anti-hypertensives, antidepressants, anticonvulsants, drugs that lower seizure threshold
Allergies?
Alcohol - quantify
Smoking
Recreational drugs - specify

FHx: epilepsy? Diabetes? Migraine?

Question 2

triggers seizure vs syncope

Answer 2

Syncope triggers: Pain, heat, exertion, prolonged standing, emotion

Seizure triggers: Alcohol, sleep deprivation, bright lights, infections

Question 3

causes of falls to think about?

Answer 3

Dizziness: presyncope (N,C,O), vertigo, disequilibrium, psychological

Weakness:

LOC: syncope (N,C,O), seizure, hypoglycaemia, head injury, narcolepsy

Impairment/frailty: motor imp, sensory imp (vision, proprioception), cognitive imp

Polypharmacy

Environment

Question 4

what examinations would you like to do falls/collapse

Answer 4

UL and LL for any residual weakness etc
Cranial nerves - esp for visual stuff
HINTS for peripheral/central vertigo
Cardiac

Question 5

investigations falls/collapse

Answer 5

bedside:
- ecg
- lying and standing BP
- Urine test: urine toxicology screen

bloods:
fbc
U&Es (including serum calcium, magnesium and phosphate)
LFTs
glucose
CRP

consider:
echo
head CT
LP ?meningitis
ABG (For acute prolonged seizures looking for hypoxia and hypercapnia)

Question 6

syncope before vs seizure before

Answer 6

Syncope before: Dizziness, light-headedness, nausea, tunnelled vision

Seizure before: Aura: strange feelings like epigastric rising, dejavu, visual or smell disturbances

Question 7

syncope during vs seizure during

Answer 7

Syncope during: Sudden loss of tone May have tongue biting and incontinence Brief duration

Generalised seizure during - Tonic-clonic jerking movements. May have tongue biting and incontinence May be brief or prolonged

Question 8

syncope after vs seizure after

Answer 8

Syncope after: Complete and rapid recovery

Generalised seizure after: Post-ictal confusion and drowsiness. May have Todd’s palsy - focal weakness after seizure