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I've got the chart up on here. Oh, how many x-rays do you have? Not that many? Hi guys. We'll give it till five past before we get started. Ok. Should we get started? What do you think about maybe give it a few more minutes? OK. All right, cool. So we stop. Yeah. Uh OK. Can you see my screen? Yup. OK, perfect. So today guys, we're gonna be talking about falls. Um So we've got a bit of uh some ba s and bit of content to start off with and then uh Bart's got a case for you guys that he'll go through. So if you're new to teaching things, this happens weekly. Um and it's run by 5th and 6th years or fourth years. And OK, so I'm gonna talk a little bit about some differentials for falls just before we start. Um So why are falls important? So one in three people over 65 have a fall at least once a year. So as you can see, it's a massive cost to the NHS and a really high yield topic in exams as well. It's caused by intrinsic factors and extrinsic factors. Intrinsic being things that happen within the body such as age, muscle weakness, gait, any other medical conditions. Um and extrinsic factors are environmental hazards. For example, we'll mainly be talking about intrinsic factors because that's particularly important for you guys. In fourth year falls come with many different consequences to have physical mental and social consequences. And the main specialties where falls falls into um is neurology, cardiology, and ent so what we're gonna do is we're gonna start with an SBA. Um And that's gonna put a pole up. Um I'm sure ma many of you might not have done some of these um uh so out of cardio neuro ent, but just do your best and try and try and make an educated guess if possible. So I'll give you guys a minute or two to try and vote is the pull up. But yes, we got 50% going for vestibular neuritis, 25 for BBP BPPV and 20% for labyrinthitis. OK. Great. Um So we've got the majority going for the right answer. Vestibular neuritis. Um So we're gonna go through a little bit about vertigo and particularly the peripheral causes. So the bits and ent that you need to know about. So there are four main causes um that you need to know. So which are viral, labyrinthitis, vestibular neuronitis, BPPV, and Meniere's disease. So we'll go through each of them um just uh briefly. So, VR viral labyrinthitis is an inflammation of the bony labyrinth of the inner ear. So the bony labyrinth includes the semicircular canals which you can see in the picture on the right. Um and the vestibule and the cochlear. Um So it can be, it can be caused by viral upper respiratory tract infections. So, in a history, they might um have um an upper respiratory tract infection recently. Uh and it causes acute onset vertigo. So, unlike vestibular neuronitis, it's actu it is associated with hearing loss and tinnitus. So tinnitus is a ringing. So I remember this as l labyrinthitis for loss of hearing. Um and it can also be associated with some nausea and vomiting. Um And so vestibular neuronitis um similar. So they might present with a viral infection before. Um and the uh so uh it's the difference is that it won't cause any hearing loss and the vertigo will be much longer. It can often be hours or days that's reported by patients. So importantly, um an exam that's really useful um in clinic is the hints exam. Can anyone in the chat? Tell me what the hints exam stands for? That's OK. If you're not sure I'll give it. OK. So the hence exam is the head impulse um nystagmus and test of vertical ski. That's what um hence stands for. So it's important to diagnose the um peripheral causes of vertigo to um to strokes, for example. Um So the, so the important bits are, so if we talk about the head, I um an abnormal head impulse is a positive sign. Um So essentially head impulse is when they um they have the patient looking forward and they quickly move, move the uh patient's head to one side if the patient has a circa. So this jerky eye movement that moves backwards, that suggests that it's a peripheral cause of vertigo, which is good, but it's not a stroke. Um And so, and also we've got a test of vertical skin. If there's no vertical ski, that's also good. It suggests that it's not stroke. Um And nystagmus, if there's unilateral nystagmus, then it suggests that it's not a stroke. Um So these are all uh good findings because peripheral causes of vertigo a lot less sinister. Um OK. So another one that's very common in exams is BPPV, which is benign paroxysmal positional vertigo. So here we got tiny calcium crystals called otoconia which um come loose from their normal location. Um And they become displaced into the semicircular canals um causing this vertigo that's triggered by changes in head position. So they might report either rolling over in bed, um C um causing them to feel this dizziness and the dizziness uh often lasts 10 to 20 seconds. Now, a diagnostic test for BPPV is the dix Hallpike maneuver. Um So if I describe it, essentially, it's when a patient is lowered to a supine position with an extended neck and a positive test creates the symptoms of BPPV, and it creates a rotatory nystagmus. So the doctor will look into the patient's eyes. And if they have this rotatory nystagmus, this suggests BPPV. Um treating Boo boo um is often by the Epley maneuver which is suc successful in about 80% of people. Um And here, it's a similar movement and these movements are done to try and um move these otoconia or these calcium crystals um out of the, out of the semi circular canal. And finally, we've got Meniere's disease uh which is caused by a buildup of endolymph in the inner ear, which leads to dysfunction of the vestibular and cochlear um systems. So this does cause hearing loss. It causes a feeling of fullness. So that might be a trigger in the SBA if you think about men's disease and um it uh is normally unilateral. Um This may be a long term condition. So for many, it might be 5, 10 years and it could resolve um itself um and it caused recurrent attacks of vertigo, tinnitus and hearing loss. OK. So that's a quick uh overview of the vertigo. Um the main four causes of vertigo. So we've got another SBA moving towards cardio. So, but if you can put a pole up for this and whilst you're doing this, if you have any questions on what I've said about the vertigo, please just shout or write in the trap. Yeah. OK, great. Just wait for one more. OK. So I can see on the poll mo uh 75% of you have gone for hypertrophic cardiomyopathy, which is the correct answer. Um So let's go through it if we look at this SBA. So we've got a male who's had a recent fall at the gym. Um And he says that his father died suddenly of in middle age of an unknown cause. And then we've got a little bit about his ejection, ejection systolic murmur and a biphasic pulse. And the ECG show signs of left ventricular hypertrophy. So, let's talk about ho cm and all of those um uh the and then we can go through some of the hints there in the SBA. OK. Ok. So HCM is an autosomal dominant disorder of muscle tissue. Um And it, this is essentially the pathophysiology. So there there is light left ventricle hypertrophy. So the tissue becomes less compliant and it decreases and there's overall decreased cardiac output. So, characteristic murmur, I've, I've already um mentioned it in the last slide, but it's an ejection systolic murmur. But importantly, it increases with the valsalva maneuver and decreases on squatting. So some, you might see that sometimes on SBA S but that's quite niche. Um And you can also have a pansystolic murmur because of the mitral valve moving anteriorly causing some mi mitral regurgitation associated with H cum as well. So, the symptoms are um exertional dyspnea. So, like in the SBA, we had the man going to the gym, there's angina. So chest pain syncope and a high risk of sudden cardiac death. So this tends to when there is um young men with a family history of um sudden cardiac death. Definitely think of am does anyone know any drugs that we should avoid or any types of drugs we should avoid in HCM? Put it in the chart if you do? Ok. So the main types of drugs um to avoid are drugs that have inotropic effects. So the three that I um remember are nitrates uh ace inhibitors and just inotropes. So because there is increased um left ventricular outflow obstruction if you ask uh if you make the heart work harder um because of this thickened, left um ventricle, so cannot give these drugs to people with a two cm. OK. So the management um you can remember as ABCD. So, amiodarone got beta blockers um or Ramil for symptoms and then cardioverter um defibrillator and dual chamber pacemaker. So the implantable cardioverter defibrillator is really important um to avoid the sudden cardiac death. So that's just a quick summary about HCM. Any questions. So just keep putting them in the chart if you do have any questions. OK. So we're gonna move on to a bit of neuro so have a read of this SBA B but you can put up the poll. OK? So I've just read there uh three type three drug types to avoid. So, nitrates ace inhibitors and inotropes, she can't give those drugs to people with atrium. Ok. I'm just gonna wait on a few more responses from the SBA. OK. So we've got a bit of a mixed response this time. Um So before I tell you the answer, does anyone that put VP shunt wanna tell me what condition um this could be suggesting. Um OK. That's all right. I'll tell you. So here, um we are looking at normal pressure hydrocephalus. So that has a triad of symptoms, which is urinary incontinence. So you can see episodes of urinary incontinence, dementia. So, short term memory decline and also the um shuffling gait. So because of that, it's thought to be similar to Parkinson's but because of the triad being in this SBA, that's, it's a bit of a tricky one. The answer is a V patient. So we'll talk a little bit more about normal pressure hydrocephalus. So you can remember, I've got a little diagram as wacky wobbly wet. Um So that's um that's the way that I remembered normal pressure hydrocephalus. So it's a reversible cause of dementia in the elderly. So it's thought to be um caused by reduced CSF absorption at the Arachnoid villa. So there's a build up of CSF in the ventricles. Um So it can be secondary to head injury, um subarachnoid hemorrhage or meningitis. So, the trial is the main symptoms that you need to know. Um and in imaging. So they might give you the, the ventricular, as you can see in the middle, um a lot bigger than a normal ventricle, but there's no sulcal enlargement. So there's no increased pressure. Um So you can see the Sulci as normal. Sorry, I meant sulcal atrophy. Um OK. And the main management, um definitive management is ventriculoperitoneal shunt, which is where they uh put in a shunt from the ventricles. Um And uh the CSF is taken out and um drained into the peritoneum. OK. So that's, that was just a bit of a trick question. Um And, and in a slightly interesting cause of falls. Um So we've got another, sorry, there's a lot of writing on this one. We've got another SBA so just have a read and if we can have to pull up, please and please. Um if you have any questions about anything we've talked about, just keep putting it in the chart. OK. All right. We've got 100% of people saying administer aspirin 300 mg immediately and arrange urgent assessment by a stroke specialist within 24 hours. So I think you all got it. That is ati m so ti a uh just a little bit about it. So this th this is the definition of transient episode of neurologic dysfunction caused by focal brain, spinal cord or retinal ischemia without acute infarction. So, previously, um it used to be um a tissue based definition. Um No, it used to be a time based definition um being a short, short or mini stroke and now it's a tissue based definition. Um essentially saying that there is um there is a transient decrease in blood flow which can cause ischemia um but not, not infarction. So it's not necessarily about the l the time of the symptoms. However, it does usually resolve within an hour. Can anyone in the chat tell me some possible clinical features of a tia anything at all? Oh, weakness in the arm? Perfect. Yeah. So you can have unilateral weakness or sensory loss. Thank you. Anything else? Ok. So a couple of other things um so you can have vision problems. So you can have diplopia, you can have um loss of vision in one eye, which is called amero fugax. Um You can have homonymous heia um which is loss of the peripheral um parts of your vision. You've got facial asymmetry. Great. Um Anything else about speaking, you can have difficulty speaking a or aphasias or dysarthria and you can also have ataxia um loss of balance. There's many different things and it's all dependent on where the loss of blood flow is. So you guys were all right to say that referral may um needs to be done within 24 hours. So they need to be given aspirin 300 mg um unless it's contraindicated um and then they need to be assessed within 24 hours by a stroke specialist. Can anyone give me a common um mimic of ati A. So something, something that can look like ati A but isn't. Ok. So this is a common question that comes up. Um, hypoglycemia can mimic tia like symptoms. So if a patient comes in a very simple bedside test is just to check their blood sugars, um to make sure that is not a cause of their symptoms. And because that's very easily reversible. Ok. So I've got this little table it's from um passed. Um But it really clearly uh kind of describes how you should manage a patient. So you've got the 300 mg, aspirin, um straight away that needs to be done within those 24 hours. And after they're reviewed by, reviewed by a specialist, they need to go on dual antiplatelet therapy unless they um uh unless this is contraindicated um is seizure one. So are you a, are you answering the question about um mimics for a tia if uh if you are answering that question? Um Yeah. So seizures can, so hypoglycemia can um can induce seizures but seizures not, are, not so much mimics of ta but um but good question. Um OK. So did that answer your question? Just type in the chart? OK. So in terms of um so after seeing the specialist, they should go on dual antiplatelet therapy if they can tolerate it if they can't uh ticagrelor and clopidogrel together is um an alternative if they can't tolerate that um the, the aspirin and clopidogrel and then long term secondary prevention of the TIA A is clopidogrel after those 1st 21 days. Um OK. So other things that we could talk about is uh um carotid imaging. So tia S can be caused by atherosclerosis in the carotid artery which um is a source of emboli. Um So this can be done. Uh It's a carotid duplex ultrasound or CT angiography um can be done to uh check the carotids to see um if they could be a potential source of emboli. Now, there are two different cutoffs. So, one of the councils say if it's um more than 50% tenosis in the carotid artery, then you should get a endarectomy, which is the removal of the stenosis of the plaque that's built up and another cut off is 70. Um So, um I would normally use, I think dependent. So normally it will be quite clear um whether you're using the 50 50% cut off or 70 because um the patient will have symptoms in the contralateral side. Um Any questions about ti A s that was a really quick run um run through, but it's a very high yield topic. OK. I'm just going to move on. I've only got a few more left and then we'll move on to the case. So, have a look at this question if we can have the pole. OK. We've got a mixed picture for this one. does anyone want to justify their answer in the chat? What bits of the question that um stood out to them and why they pick their answer? It's OK. I can, I can go through it. Um So the answer for this was focal impair awareness, se seizure. Um Anyone that wrote that want to um maybe mention why they picked that one. No recollection events. Perfect. Yeah, that's really important. And OK, we're gonna go through a little bit about how um how different focal seizures present and what the difference is. So firstly, um the the topic is epilepsy. So a seizure is spontaneous, uncontrolled period of abnormal brain activity and there are loads of causes. So generalized seizure, as you can see at the bottom here is where both hemispheres are affected. Um whereas focal seizures or where particular parts of the brain are affected and we'll talk about those in a little bit more detail. So I'm gonna start by just talking about a bit about the generalized seizures. So we've got absent seizures. Um and this is where they have brief sudden laps of consciousness. So the stem might mention a blank stare. Um And this is this is more common in Children got tonic clonic seizures, which might be which is the typical seizure where um someone would convulse. So they have a tonic phase which is stiffening and a jerking movements phase, which is the clonic phase. So both occur. So it's called tonic clonic. Um myoclonic is where there's just the jerking of the muscles and twitches and the there's no loss of consciousness ty typically in this um and atonic seizures are also known as drop attacks. So they lose all their tone and they just collapse. And tonic seizures are where the muscles just stiffen up and this can also cause falls. So all of these apart from absence can cause falls. Um ok. So, so this is quite important. So these are all the focal seizures. So focal seizures can be split into focal aware and focal impaired awareness. And those will be quite obvious in the stem by whether they uh recall the events um uh or not. And then um a the one that the um the SBA had was temporal lobe. So they, she had this um period of staring blankly and then she started smacking her lips. Um So that is called an automa a automatism. Um So essentially they will start grabbing, grabbing their clothes and um lip smacking, for example, and that's very common in temporal lobe seizures. Um There's also an aura in a lot of patients. So they might describe a rising epigastric sensation, um some kind of uh phenomena like deja vu uh and less commonly hallucinations. Um OK. And so that's quite uh that's quite a common one that comes up in questions. Um the frontal lobe um is um a motor um seizure. So we have head or leg movements, um posturing. So the body ho uh like holds the body when moving. Um And you've got this post ictal weakness, so, might mimic almost ati A. So actually you uh so the person that mentioned seizures, um specifically frontal lobe seizures where there's a weakness, there can be post weakness. Um On one side, this is called Todds pare that can mimic a tia a sorry, sorry about that. I didn't make that clear but that, that the um a good, a good point. Um Jacksonian March. So um this is where um it essentially you've got it, it looks like something's marching up the limb. So you've got twitching that starts and more distally and it works its way up, the limb starts a Jacksonian March. Um So prior to lobes, um there's uh the main symptom is paraestesia, so tingling. Um And occipital has there's generally visual seizures where there's floaters and flashes in the vision. So that was a very quick recap of some of the causes of falls. There are many more. Um But these are, these are quite high yield. Um And I hope that was helpful and that's um and I'm just going to send a feedback form on for my section of it and before I hand over on to bot, so please message any questions um if any of it was confusing. Mhm Thank you. OK. So um you can take a minute or two's break here if you would like. So um yeah, if you need to get, get, grab a drink or go to the loo you can go for a minute or two and then we'll start again at 36 past. So, yeah, just a couple of minutes and. Ok, I'm sorry. Uh I can do the pa it's fine as, as long as you just show the S. Ok, that's fine. Yeah, thanks. Ok, so we'll make a start again. So if I can add the next slide and we have a question to start off, so if you can have a look through this, s pa, I'm going to put a pole up. So you have a look through this and then try and also think about which elements of this patient's history are important and might have contributed to this patient's fall. So what's very important with FS histories is that there might be a lot of different things that contribute and a lot of the things may add together, they might be red flags, they might be red herrings. Um So just consider these, read this history and um, yeah, see what you think. OK. So we got two responses. We'll just wait for a couple more and then we'll get going. Is anyone brave enough to type in the chart? Why they thought um, impair sensation, difficulty in foot placement or um or no or if you're in? So you can just type that you're instore that's also fine. Ok, fine. So, yeah, we've got a bit of a spread of answers. Nice. Um So for this question, if you have the next slide. Um Yeah, great. Yeah. So Nikita's got it. So they're on diabetic medications. So they're on Dapagliflozin, they're on Metformin. Also. Gabapentin, gabapentin is used for neuropathic pain. So that means that somebody's got diabetes and they're gonna have peripheral neuropathy. Ok? And at that point, they're going to probably have some sensation loss which could lead to this difficulty in foot placement. All right. Um And I agree, I think, you know, orthostatic hypotension could very easily be a case. Um You know, with diabetes, people do get this disease too. Um Although there's no mention of any other antihypertensives um or sort of hypertensive medication and the visual retina, the the visual impairment. Again, they are on diabetic medication. They could have this visual impairment, but there's no other mention in this history. So it could be all three, they could all be very important. Um But in this case, the single best answer, the one that is most likely to be listed from this history is this impaired sensation? Ok. So just out of interest, could anybody type in the chart, which elements of this patient's history are most important in you deciding which um which of the differentials it was? Ok. Um Yeah, I mean, fine. So yeah, a lot of them were important. So, drug history is important. Um The fact, they denied dizziness and loss of consciousness. Um The place where it happened. So that happened at home. Um All these things are important. So if, if you're going to have it in the next slide. So here we've got a case. So we've got Mister Smith who's a, is a 72 year old male who's presented to A&E following a fall. You're an F one in A&E. Um And so you, now you think what are you gonna ask him? So he's coming with a fool. Um He's a 72 year old guy. So what are you going to ask him? And which parts of his history are important in finding your differentials and finding out what happened? So again, you guys can put it in the chart or you could just shout out. So these are very common ay scenarios also very common, just hospital scenarios. Um Again, they can be SBA S. Um It's all very, very relevant. OK, fine. So everyone's a bit slide. So can we go to the next slide? Um Yeah. So this is all the parts of the history. So you would have all covered histories already a little bit in your clinical placements. So the presenting complaints. So what happened, why are they here, the history of presenting complaints? So what happened before? You know what, what happened leading up to the event, any past medical history and what's important is, you know, a patient might come and might tell you, um, you know, all sorts of things. Yeah. Um, but it's important to think, ok, which parts are relevant or which parts, you know, tonsillitis age two isn't really that relevant. In most cases, drug history again, patients might have a very long drug history. They might not remember their drug history necessarily. Um, so it's good to get doses. It's good to get compliance allergies, all that stuff, family history, very important Social history assistance review. So it just helps you exclude anything else that might be there and then icing the patient. So which of these elements are important in falls histories? So, um again, just type in the chart or shout out which of these do you think might lead to falls or might be important in falls? Mhm If you can have the next slide, yeah. So all of these parts are important in four. So answering every single one of these could have an impact on what your differentials are, what your management is. So you need to, to try and target your questions to narrow down any differentials from the start and exclude causes. So any red flags particularly exclude anything that might be going on. They might not know about already any new diagnoses, et cetera. So next slide, um All right. So when you answer the presenting complaint, the first thing you need to ask what happened before the fall and this is a good strategy. So asking before during and after and that's going to give you well to start as most of the marks and osk. But also an idea of really what could have happened. So, um, when and where did they fall? Any previous falls? So, if someone's, you know, a very old person constantly falling, it's very different to somebody who's 40 years old, quite fit and healthy and they fell over at the gym. Ok. So thinking about to our previous questions and then what happened before? So, yeah, what happened before? Um Yeah, so any chest pain, any dizziness, any palpitations. So again, thinking of all our previous differentials that we went over, did they know they were going to fall? So if somebody knows they're going to fall, it's very different to somebody who just fell over, you know, out of the blue. Ok. Somebody knows they're going to fall. Maybe they felt unsteady, maybe they felt dizzy, et cetera. Did they eat anything? So if someone's diabetic, they might have a hypoglycemic episode or anyone might have a hypoglycemic episode. So knowing if they ate anything before, if that might not be a reason and then, yeah, continue any trauma. So, you know, people might fall due to trauma, they might fall because they were in a car accident. They might have been knocked over by a cyclist. You know, you need to ask these questions because you might not know otherwise, um also any trauma during the fall. Ok. And once you've ascertained exactly what happened before, so knowing, did they know they were going to fall? Did they eat anything, any trauma, you know, sort of getting a good clear history of what happened before you can then ask what happened during and after the fall. Yeah. So when you're asking during, you used to think, was there any loss of consciousness? Did they catch themselves? So if you think if someone's caught catching themselves, they might fall on an outstretched hand and they might get a fracture, for example, or any other fracture. Can they remember the episode? And importantly, gaining a collateral history is so so important. A collateral history is a history from somebody that witnessed the fall and it might not always be available. But if it is, it can give you a good idea of any seizure activity. If the patient was pale and flushed, did they look well before? Did they look well during and then how long they were down for? Cos these are questions that maybe the patient might not be able to answer for you themselves? Um Maybe they might still be a little bit traumatized following the fall. So they might not be fully available to tell you this um on their own. And then when you go to after you need to ask, how quickly were the was the patient up again? Um Were they in any pain? Um and ask your Socrates questions? So, um yeah, you can use your pain histories and then when did they present to services? It's very different if somebody presents instantly or if somebody presents two weeks later and they would just say by the way, I had a fall. Yeah. Um and that can again give you some hints as to what might be going on any confusion. So the post actal state um following a seizure. So if they're a bit drowsy confused, that's a good idea that maybe it's a seizure, any weakness. So uh or speech difficulty, again, signs of a potential neurological cause of fall. So maybe a tiaa stroke um again, a seizure, for example. So toss Pais OK. Any questions about any of that again, you can just raise your hand. Shout out, put it in the chart. No, OK. Next slide. So let's go back to Mister Smith. So you asked him all these questions, Mister Smith described that he was feeling a bit dizzy whilst preparing his morning coffee at 5 a.m. So quite early and he reached out to the counter to steady himself. His foot caught on the edge of a loose kitchen rug causing him to lose balance and fall. He landed on his left side experiencing immediate hip pain, which he described being eight out of 10 in intensity and had a minor bruising on his left arm. He denied any loss of consciousness but admits to blacking out for a moment before the fall. OK. So, and then this happened at home and he was found by his neighbor. So, based on this, can anybody give me any ideas of what might be going on? Why might Mr Smith have fallen? Um, have you got any ideas of differentials, any ideas of, um, things to ask further? So you can just type it in the chart so you can, um, put your mic on a chart out. Hypotension? Yeah. Good. Um So why do you think hypotension? It's a, it's a good differential. Yeah, I agree. Um Any others that you think so apart from postural hypotension or, or just hypotension in general, early morning? Yeah. Good. Nice. Um Yeah. So it's very early morning. 5 a.m. Any other things that might be, might be differentials apart from hypotension, the dizzine, the d the, the uh the dizziness as well as the hypertension instability weakness. Yeah. Cool. OK. So next, next que um next slide. So you've asked him now about his past medical history. So you can ask previous falls. So how many times a person fallen previously if somebody's a regular faller? Um it's very different to somebody who again fell for the first time. Um So yeah, ask him about previous falls, previous episodes of falls. Um Yeah, next bit um encounter a false differentials. So going back to, you know, you can ba ba base it on this patient think, have they ever had any epileptic seizures or any seizure activity. Um Yeah, next, um any cardiac disease, any stroke or CBD risk factors um at the age, um any vestibular problems. So that mean that's meaning balance problems, any visual problems, um M SK problems, basically anything at all um that you think might have led to that fall. So asking all of these questions, um you know, is important and a lot of patients will have quite a lot of them, especially as you get older into the more geriatric populations, very many will have some arthritis somewhere. They might be wearing glasses, they might not have worn at the time. They might be quite old, they might have had a stroke or they might have had, you know, hypotensive medications. Um, some may have epilepsy and others may have other problems as well that haven't listed her. Um But if you think if it can lead to a fall, have they got it? Have they previously had that differential? And then surgical history and reactions to anesthetics are also very important because if you think this patient here presented with an eight out of 10 hip pain, you're very likely going to try and refer to surgery, see what's going on, maybe if they had a hip fracture, they might be going in for operations. So knowing if they had any reactions to anesthetics, any surgical history, gives you a good idea of how well you can manage the patient. You can do it quickly easier or if there might be complications to underline that. Um, and then other past medical history again, very important because if you're a bit between the patient, you need to know what they have. So, you know, even though tonsillitis two might be a little bit, um, you know, unimportant, it's still useful to know because you just, it's good to know all this stuff. Um, just to draw that picture. Ok. Cool. Next slide. So, um, for Mr Smith, his past medical history is hypertension type two diabetes mellitis, osteoarthritis, which is bilateral in his knees. He had a tia a two years ago and no past surgical history. Um, and he also said that his memory has been going a little, um, so a pretty standard past medical history. So he's got quite a few differentials, quite a few things that might have led to his fall, quite a few things that might have, um, affected him in a way. Ok. Next slide. So, and then asking drug history. So when asking drug history, many, many drugs can increase the risk of falls. Um, and always ask about compliance and allergies. So again, people might be on antihypertensives but they might not take them, they might be on diabetic medication, they might not take them, ok. And with compliance, it also comes how regulated they take them. People might take a double dose because they forgot the day before, but that's not very good. Sometimes that can lead to hypoglycemic episodes. Um, it could lead to massive decreases in BP. So, no compliance when, how that they take the drugs and not assuming that everyone takes their drugs. Very many people don't at all. Ok. So we just rattled through these drugs now. So these are all ones to be aware of when looking through. So you've got nitrates, diuretics, anticholinergics, um, antidepressants. L dopa. So, levodopa Parkinson's beta blockers, antihypertensives. Um, yeah, and there's a, there's a few more. So, benzodiazepines, digoxin, um sedatives, um opiates and codeine. Ok. And diabetic medications. So all of these drugs can influence falls. So as you can see, it's probably most drug that you can think of can influence falls in some way, it might be a cause of falls or might be a contributing factor. So for the first set, all of these medicines, um So yeah, expert, um all of the first few medicines that we have um can influence falls by increasing postural hypotension. So, taking any of these medicines will I influence falls via the postural hypotension pathway. Um for the case of beta blockers, um they will weaken the virus after reflex. So the virus after reflex, going back to your first preclinical year um will be a reflex tachycardia in response to a fall in BP. Ok. So a patient stands up, um their blood pressure's going to fall and then you might have a reflex tachycardia. So your heart starts beating a lot faster to counteract that loss of BP. But somebody who's quite old and taking some beta blockers, maybe they took a few more than they needed to. Um, their heart isn't going to be able to pump quite so quickly. So they're not gonna be able to increase their BP, their BP will fall and they'll have a fall themselves. Ok. And the other set influence falls by other mechanisms that we're not gonna get into. Um But again, it's just useful to be aware that most medicines can influence fools in some way if you're a bit um unsure of how they are. The B NF has good guidelines. And again, polypharmacy is more of a year five topic. But if it comes from an O you that you're doing, um or a CPS A that you're doing a false history and you're asking the drug history, you can justify that. It's good to know it's good to consider and you can always try and stop or start medications as they are based on any interactions with polypharmacy. Ok. Um So Mr Smith is on amLODIPine 10 mg once daily, Metformin, clopidogrel, atorvastatin, gabapentin, and some multivitamins. So, going back to the drugs, a lot of these um can influence for. So you've got some antihypertensives, you've got some diabetic medications. Um you've got a statin and we've got some painkillers and multivitamins, um probably don't do too much, but um again, useful to know All right. So continuing onwards. So family history again is very important because many people have different f differentials. So family history can give you an idea of what happened previously in the family. Is there anything hereditary and anything um perhaps more insidious that might be going on behind the scenes? And also gives you an idea of general timeline. So if somebody is 70 that, that both their parents had heart attacks at age 70 or both their parents had ti A s at age 70 it's much more likely this patient is having this at that time as opposed to somebody who's much younger, much older. So asking family history and asking the time of onset is very important. OK? Um Yeah, the next bit. Um and then by this stage, we need to do family history, try and have your top differential. So you, you'll have an idea of their drug history, you'll have an idea of their past medical history. Um Family history is kind of more of an embellishment. So it can give you more of an anti eric and then general assets reactions. Again, you can use that for any management that you're going to do for the patient. OK. So your next slide. All right. So Mister Smith, um his mother died of a stroke at age 80. He has rheumato and she had rheumatoid arthritis. His father died following a heart attack at 78 and there's no other past history of notes. Ok. So for the family history, we're not getting too much more information. Um I think the drug history is more important. I think the past medical history is more important. This is important paps the arthritis. Um, but we already know that he has bilateral osteoarthritis in his knees, which would probably influence his for much more than the hereditary aspect of rheumatoid. Any questions at this point, anything anyone wants to clarify? No. Ok. So we'll carry on. So social history is very important, perhaps the most important part of this history. So knowing the home environment is so so important because most patients, especially elderly ones are going to fall at home. Um They're not gonna be out and about on Oxford Street, they're going to be at home, they're going to be walking down the stairs. Um, in the case of Mr Smith making a cup of tea at five in the morning. So knowing if they're um able to do the activities of daily living, so ad LS activities of daily living. So can they wash, can they clean? Can they cook? Um who helps them do all these things? Ok. So knowing if somebody's fully independent is very different to somebody who's fully dependent on somebody else was going to the toilet, but normally can't do that themselves. It's a very different picture. Ok. So ask him about carers, anyone in the home environment and do this for everyone. So even if somebody looks pretty independent, still ask them, have they got any carers, have they got anyone in their home with them? You know, partners, wives, husbands, Children, um, and any stairs again, just asking have they got stairs? Are they able to make up the stairs? Um, have they got any stairlifts, any, um, barriers, anything else? Finances. Again, this is an important aspect, you know, asking about pension benefits, patients, you know, might be quite not, you know, well off or not well off and not knowing, can they feed themselves, can they heat their homes? All these things are important and can help you build a more holistic picture of what's going on, especially with management. So managing a patient is important, you know, giving them the correct drugs is fine. But if you're discharging somebody to a house where they can't heat, they can't afford to um buy their food. It's not very good. So you need to make sure that you're on top of all these other things um to make sure the patients get the best out of whatever they're getting. And you work in sick notes. Again, patients who are younger may still be working. So making sure that you can arrange sick notes, making sure you can arrange their work. Um And with the work, knowing if the patient drives professionally is important because of the D VLA rules which we're not gonna go into today. Um, but patients following heart attacks following epileptic seizures, um following many of the fours differentials may not be able to drive for a while. So questioning if they drive, especially if they drive professionally is so, so important because this influences your management and again, it's high marks and Aussies to know this kind of stuff and then drinking, smoking and drugs very important and don't be shy to us, even if a patient or an actor in the Aussies or anyone else looks quite old, looks quite innocent. Just ask. Um, you know, you don't know what people do and you need to know. Um, and it's very important and if someone tells you they're drinking 100 units of alcohol a week, um, smoking two packs a day and taking loads of drugs, you can consider cessation and withdrawal advice at this point. So, you know, it's unlikely that in your CPS A you'll be able to do this in time. But you can say if they, if you have any questions at the end, I would consider giving some advice, give some leaflets. Um, you know, drinking itself can be a massive differential of falls and can lead to a lot of different instabilities. Ok. Next slide. Um Yeah, and here's a good, so if we go back, so a fall is a time to consider if a patient that's hoping well, is coping well at home and if they're falling, they're probably not coping very well at all. Ok. So a fall is kind of a wake up factor to the social situations that that are going on. The general holistic overview of the patient if they're falling is kind of a sign that things need help. Ok. So going back to Mr Smith, he uses occasional alcohol, 1 to 2 drinks per week. So nothing significant. He has no smoking history and limited mobility due due to knee pain. So he uses a cane for walking, which is very important because he fell over, tripping by a rock. So if he shuffles, if he's got ar arthritis has pain, he's unable to walk very easily. Um That's a big risk factor. He lives on a ground floor flat. So there's no stairs to worry about necessarily. Um and he's independent for all A LS, but he orders food for delivery. So someone who says this, they're independent but they can't cook, so they're not fully independent, they can get it by just enough. Um But they might need some more help very soon. So remember in a hospital patients don't always get better. Patients do often get worse. So somebody who's been in a hospital for months and months after a fall might not be able to go back home to shower, to cook, to clean like they did before. So using this as a time to consider when they go back, can we support them in any way? Very important? Um And the patient doesn't drive so you don't need to go to the, the D VA, the D VL E stuff. But if they did, um it's a good time to speak now. Any questions based on this? No. OK. Um And then, so your penultimate part of your history is your systems review. So your systems review is your time to consider all your differentials. So, is there anything that you haven't already asked? Um that might be going on? So even though the patient might have said, you know, hinted at their arthritis. So in the case of Missus Smith, you might have said, I've got arthritis, I use a cane to walk. I've got horrible knee pain. You know, you're thinking arthritis, you're thinking maybe postural hypertension, like we said, um and you're kind of sure about this, still ask about everything else just in case. So ask, have there were any focal neurology? So that means um as you said earlier, any weakness or sensory loss in that one area, any epilepsy, so any automatisms during the fall. So um lip smacking clothes splicing, um the postictal period, any movement disorders. So are, is the patient shuffling, is the patient able to right? Is the patient able to speak as they did before any dementias? Um And then which dementias might they have. So for example, a Lewy body dementia with hallucinations might present with drop attack in itself. So with the dystonic um seizures. So it's very important to question these kinds of things. Um for visual um system, it's considered double vision. So if someone's got diplopia, double vision, they might have a lot of trouble doing the stairs because you can't aim where your foot's going. So if somebody has double vision, diplopia, very important and then cataracts, macular degeneration, glaucoma, people have these ask because again, this could be maybe not the main factor but definitely a precipitating factor that might have added towards it for cardiac factors, questions, syncope, orthotic hypertension and to test for that, you can perform a lying and standing BP. So um just a another diagnostic test, the audiovestibular gi system M sk endocrine um infections, blood, all of these things need to be tested, ask questions, not too many and try just rattle three. So be, you know, you can say, OK, so I'm gonna ask you some questions. They're gonna be yes and no. Um uh Do you have Xy and Z and you can just rattle through these exclude differentials? Um Don't ask everything, just exclude the things that you think might also be going on. Um And definitely exclude any ready s so any cancers, anything like that and a good way to do it is a top to toe assessment. So start with the head, start with neurological, visual um auditory and then go down. So you can do heart and lungs and at the end do the feet. OK. So any questions? No. OK. Next slide. So, and then when you ice the patient, everyone says, you know, make sure you ice your patients, make sure you ice these questions. It's very important because the patient will give you the answers. They'll tell you what they think might have gone on because if he knows that he didn't eat and he's diabetic and he just felt a bit unsteady, he'll tell you the answer and that is probably going to be the answer if he's got hypotension or hypertension and he's not taking his medicines again. Very important. The patient probably has a pretty good idea of what's going on. Um, they might not, but they'll have a good enough idea to give you some hint as to what's going on or maybe list your differentials in, in priority. And then with regards to concerns again, if the patient is very concerned about one thing, you can put them at ease or you can investigate that a bit more just to put them at ease, to put yourself at ease, to make sure you're not missing anything out and then expectations, um, are always important because you need to know, you know, can you help them in any way apart from just making them better? Um, and it's always big marks and osk and for a poor building. So, um, I know I've said it last, but maybe, don't leave it to the last day, maybe do it a little bit earlier. Um, just integrate it throughout your history. Don't make it a, a set thing. Ask the patient have a chat. Don't be robotic. Ok. Um And then finally examination. So when someone's coming to the four, so you're the fy one in, in A&E so do an A two E assessment. Do you know, do your four A two E make sure there's nothing going on acutely that you can fix. So any heart attacks, you know, strokes, you don't wanna miss that kind of stuff out of P ES. So your A two E, that's your first step. Every time any time anyone comes into A&E do your A two E assessment. Ok. Next. Um so you want to see your cranial nerves, your upper limb and your lower neuro exams. Um again, just excluding any neurological deficits, excluding anything else, you've got your cardiovascular respiratory gastro exams, any that you can think of do it because any area that you think might be affected might have some signs. So doing a full examination and then expecting an infected areas. So in the case of Mr Smith, you mentioned his left arm and his right hip or the other way around inspecting those is important, inspecting the hip, making sure. Is there a fracture. Is there anything going on inspecting the arm for bruising? You know, is the bruising sig significant of anything, examine everything and anything that you think might have contributed to the patient's situation and have a look at the patient generally are they? Well, are they not? Well. Ok. So on examination, Mr Smith had vital signs of this. So he had a, a regular BP. His heart rate was a little bit high but not too high. His re rate was normal again, maybe a little bit high. He had fine sats, he was afib, he was alert a bit fatigued in a bit of distress due to the pain. Um and he was a little bit clinically dry. Um for his neurological examination, he had mildly decreased sensation in both feet with no additional focal deficits and cardiovascular regular rhythm, no murmurs, some orthostatic drop of 15 millimeters of mercury. His M SK exam had some bruised and tender over the hip with a limited range of motion and no obvious deformity and his gait. Um He's unable to ambulate due to the pain, so he's not able to walk. Ok. Um So what are your thoughts based on this? Can anyone give me more differentials based on this examination based on what we know already what's going on? Why is Mister Smith here? Why has he fallen again? Just type to the chart or um shout out which of these might have caused Mister Smith to fall. Mm. Any suggestions? Yeah. Um So orthostatic dropping BP. Good. Yeah. Nice. Um Yeah. Sensory in neuropathy. Cool. Um So yeah, in this case, there's a few different things. So um this case is built in a way to show that everything in this guy's history was a false differential. So there's no one thing here that's telling you what the reason to a fall was. It's all of it together. So it's a holistic overview of the patient. Everything here could have led to a fall. There's no one main differential necessarily in this case, perhaps it was your like a BP. It could have been the polyneuropathy, it was all about everything. OK? Um So next slide. So the way to manage Mr Smith, first of all is pain control. He's a lot in a lot of pain. He's got eight out of 10 pain in his hips. Um He's not doing well. So give him some morphine and give him some pain control, make him comfortable. Um You want to believe the orthopedics to assess the patient and consider a hip replacement? So he had a grade three fracture. So probably a hemi arthroplasty or total hip replacement. Um depending on how well he is. Um you wanna get some endocrinology input. So his HBA1C was pretty high. So you might want to get some he endo input for some glycemic control, review, any medication, review compliance overuse and then also get input from therapies. So, occupational therapists are the ones that can go to the patient's house. They can make sure the patient's living situation is as it should be. And then physiotherapy will get the patient back and walking again and doing everything they want to be doing. So a holistic overview, managing the patient with initially pain control because that's what you're doing in A&E getting orthopedics involved to fix the patient's hip endocrinology for his diabetic control and then reviewing his medication generally. Um just to make sure that he's optimized to stop over medicating or under medicating him in any way. Um and then giving him a holistic overview of therapy input. Cool and then, yeah, so in summary, every system can cause falls. So we've got some listed here. So cardio neuro ent visual M sk everything else can cause it as well. So we've mentioned a lot of different differentials today and the whole history is important. So asking everything is important, it's your whole idea of the patient. It's a holistic overview, an approach as a timeline. So that's the most important go before during and after what happened at these points. And that's going to be most of your answers. Ask the patient they'll tell you you've got intrinsic and extrinsic factors. So what's inside the patient, their age, their gender, um their, you know, um that, that the current medications, the illnesses and the extrinsic factors. So where are they, how is the house? You know, all that kind of stuff is very important and the general management is holistic. So there's no one cure, 11 size fits all. You manage the patient. Generally you give them general feedback. Um and you sort of help them do everything individually. OK? Any questions at this stage, anything you guys wanna ask or um you're not very sure of you can again, type it in the chart. You can shout out. Yeah. No. OK. So you can keep providing things in the chart. So I'm gonna send the feedback form now. Um Oh OK. We, we've already got a feedback form. Um All right. So just fill out the feedback form again. Uh, if you have any questions, please, please, um, just type them in the chat and yeah, and have a good Christmas. Yeah, and enjoy the holidays. Um, it's been a long time. Thanks for coming to me.