Falls

Question 1

Falls history- When?

Answer 1

What time of day?

What were they doing at the time?

Reasons for asking:
Looking upwards (vertebrobasilar insufficiency)
Getting up from bed (postural hypotension)

Question 2

Falls history- Where

Answer 2

In house or outside?

Question 3

Falls history- Before?

Answer 3

Any warning?

Any dizziness/chest pain or palpitations?

Question 4

Falls history- During

Answer 4

Incontinence or tongue biting? (indicating generalised seizure)
Loss of consciousness? (Gen seizure or vasovagal)
Pale/flushed? (may indicate vasovagal attack)
Cyanosis? (Indicating seizure)
Injure themselves?
What part of the body had the first contact with the floor?- so we can assess this in MSK and do any imaging we might need

Question 5

Falls history- After

Answer 5

What happened after the fall?
Was the patient able to get themselves up off the floor?
How long did it take them?
Was the patient able to resume normal activities afterwards?
Was there any confusion after the event? (head injury)
Was there any weakness or speech difficulty after the event? (e.g. stroke/TIA)

Question 6

Falls history- Why?

Answer 6

Why do they think fell?

Question 7

Falls history- How many times in last 6 months?

Answer 7

• Allows you to gauge the severity of the problem

Question 8

Cardio exam- What causes are we looking for?

Answer 8

Look for Arrhythmias=
-Pulse

Look for Hypotension/Orthostatic hypotension
-L and S BP

Looking for Valvular heart disease=

• Bruits over carotid arteries (e.g. aortic stenosis, carotid stenosis)
• Murmurs: aortic stenosis/regurgitation, mitral stenosis

Question 9

Resp exam- What causes are we looking for?

Answer 9

Inspection: increased work of breathing
Auscultation: coarse crackles (e.g. pneumonia)
Percussion: dullness (e.g. pleural effusion)

Question 10

Neuro exam- What are we looking for?

Answer 10

• Cranial nerve examination: stroke or visual impairment
• Power: weakness (e.g. stroke, disuse atrophy)
• Tone: increased in stroke
• Reflexes: absent (e.g. diabetic neuropathy), hyperreflexia (e.g. upper motor neuron pathology)
• Sensation: may be reduced secondary to upper or lower motor neuron pathology e.g. diabetic neuropathy
• Co-ordination: may be impaired (e.g. chronic alcohol misuse leading to cerebellar degeneration)

Question 11

GI exam- what are we looking for?

Answer 11

Abdominal tenderness= Incontinence? ?UTI ?Fecal impaction/obstruction
Organomegaly

Question 12

MSK exam- what are we looking for?

Answer 12

Check for injuries associated with falls and examine carefully the point of contact with the floor
Check for arthritis or discuss atrophy

Question 13

ENT exam?

Answer 13

Is there any evidence of ear wax?
Are the tympanic membranes intact? Benign paroxysmal positional vertigo (BPPV) often no cause but can be due to debris in the inner ear, damage in surgery or long periods laying down

Question 14

Bedside falls investigations?

Answer 14

1. L/S BP- Ortho Hypo
2. Urine dip- UTI and blood if rhabdo
3. ECG- Brady + Arrthythmias
4. BMs- Hypo due to poor oral intake
5. Cognitive screen- AMT ? dementia

Question 15

Bloods for falls

Answer 15

1. FBC- Infection or Anaemia
2. U and Es- Dehydration, electrolytes abnormal
3. LFTs- Esp if chronic alcohol
4. CK- if laying on floor rhambdo
5. Bone profile- calcium abnormalities

Question 16

Imaging for falls

Answer 16

1. CXR- Pneumonia + 6 weeks after it as outpatient
2. CT head- Subdural haemorrahge or stroke
3. ECHO- Valvular heart disease (e.g aortic stenosis)

Question 17

Specialist tests for falls

Answer 17

1. Cardiac monitoring (e.g. 48hr tape)
2. Tilt table test- evaluates cause of unexplained fainting. Tilt them and monitor HR + BP- The result is positive if your blood pressure decreases and you feel dizziness
3. Epley manoeuvre- Benign paroxysmal positional vertigo