Falls Flashcards
You are the IMT 2 assisting with a Falls Clinic in a community geriatric unit. You have been asked to see Mrs Redbridge, an 87-year-old woman who was referred by her GP following repeated falls at home. She has a past medical history of coronary vascular disease, hypertension, and type two diabetes.
You are the IMT 2 assisting with a Falls Clinic in a community geriatric unit. You have been asked to see Mrs Redbridge, an 87-year-old woman who was referred by her GP following repeated falls at home. She has a past medical history of coronary vascular disease, hypertension, and type two diabetes.
What would be the key aspects of the history that would help you determine the likely cause of her falls?
Ask about the falls - how would you describe the falls?
- Preceding symptoms (lightheaded / dizzy)
- What was she doing prior to the falls (getting up, walking …)
- Did she remain conscious? Does she recall the whole event?
- Any injuries?
- Any symptoms after the fall? Headache, visual disturbance, peripheral neuropathy Sx (e.g. weakness)
- Was she able to get up off the floor / require assistance
- Were all the falls the same?
Next, I would ask about her PMHx & medication lists. I would specifically want to know about:
* Antihypertensives
* Diuretics
* Does she use insulin
* Any new medications in the days/weeks prior to the fall
Also explore her SHx
- Where does she live (accommodation type), who with, any care in place?
- Baseline mobility - any aids/independent?
- Does she drink alcohol/smoke?
I would also do a quick system reviews
To complete my Hx, I would conduct a quick cognitive screening assessment
What investigations would be helpful to aid your diagnosis?
In the clinic
* Standing and sitting BP
* 12-lead ECG
* Blood glucose
* Basic bloods: FBC, CRP, U&E, bone profile, and vitamin D (to r/o hypercalcaemia + bone protection), and LFTs (alcohol)
Depending on my observations, I may consider
- 24-h ECG tape
- Serial BP monitoring
If I would suspect any vestibular cause of the fall
- Dix-Hallpike test or ask one of my senior colleagues to assist with this
Would you order a CT head?
I would if I had a reason. For example, if there is a:
* Recent head injury
* LoC during the falls
* Change in cognitive function
* The pt is on anticoagulant medication
Would discuss with my senior before ordering this.
This is a trick question as the answer is based on what you have found out in your history. The interview panel wants to make sure that you are not rushing into ordering investigations. There must be a reason for asking for it.
Mrs Redbrige’s daughter tells you that she has recently been put on rixarobana for atrial fibrillation. After her first fall, she hit her head and she has been increasingly confused. Would you order a CT head?
Yes, in that case I would order an urgent CT head that day whilst Mrs Redbridge is in clinic.
I would be concerned about subdural haematoma or intracranial bleed, as she is at higher risk when falling due to her being on DOACs.
The CT head report shows a chronic subdural haematoma. You have discussed this with the on-call neurosurgical team who have advised that this should be managed conservatively. She needs to be admitted for a period of inpatient monitoring. The consultant in charge of the clinic has asked you to discuss the result with the patient and her daughter. Please explain the result and the plan to admit her.
I would ask them to join me in a quiet room where we will not be disturbed.
I would start by explaining that the CT scan has shown a cause for the worsening confusion. (Warning shot)»_space; then that the scan has shown a bleed around the outside of the brain.
Explain that the blood is likely exerting some pressure on the brain which is why Mrs Redbridge is more confused. The bleeding likely 2nd to her use of rivaroxaban > increases her risk of haematoma formation after head injury
I would then explain that her scans have been reviewed by my surgical colleagues who do not think that surgery is required.
Explain that Mrs Redbridge will be admitted for a short period to monitor and assess the impact of the bleed before being discharged home.
I would then ask if the patient and family had any questions to ask me.
Daughter: Why is my mother not having surgery?
The surgeons have reviewed the scans. Decisions on surgery are made based on the presentation of the patient (is the bleed causing a threat to life), the success of surgery balanced against the risks. In this case, the risks of surgery would be high. The subdural haematoma will be resorbed slowly. We are monitoring to make sure that Mrs Redbridge remains stable.
Daughter: Should my mother stop the rivaroxaban?
Yes, we will stop the rivaroxaban today. This will reduce the likelihood of the bleed getting any bigger. A decision on restarting the rivaroxaban will be made with the senior clinician based on the risks and benefits of continuing to take it.
Daughter: Will my mother be safe to come home?
Your mother will be assessed by our inpatient therapy team during the admission to assess her current level of mobility and self-care. Based on this we make recommendations about her safety to go home on her own. She may need a reablement package of care for example depending on the outcome of the assessment.
You will now be given one minute to present this patient to your consultant as if it were the end of the clinic. Give an overview of your findings and tell us what the next steps of your management would be.
