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Do you want to square your share? Your screen angers? Yeah. Just bring the chat up. Okay, So can everybody see the first slide? Just message in the chat that you can. I don't think it's shot yet. Sorry. Not so me. Yes, It's just being a little bit slower. There we go. Right. There we go. Yeah. Should be able to see it now. Yeah, that's fine. Just give a couple of minutes for people to join, and then we can start. Yeah, All right. Um, we'll start now. So Good evening, everyone. Thank you for joining us on this, Junior doctor. Staff two series, um, organized and hosted by you medics. Uh, we've got Doctor Angus Park, who is one of our fy once in w w o hospital will be taking, uh, we're talking about falls for us today. If any one of you have got any questions, please feel free to put it on the check box. This is an interactive one. So if you can put your answers on the checkbox while Angus ask us questions, please feel free to do so. Um and yeah. Thank you, Angus, for coming in. Thank you very much. for introduction. Um, so I'm an f y one. I've been working for two months now on acute internal medicine. So I work on em A You doing a kind of ward around there and also front of house doing some clerking and some post take ward rounds to I'm gonna be talking to you this evening about falls. Uh, thankfully, Microsoft Power Point gave me a really apt picture to use for the first slide. Uh, when I typed in the falls, I just couldn't resist using it. Um, falls are going to be a very, very common presentation when you are a junior doctor clerking in A and E. Um, over the course of most of my clerking shifts, the majority of the patient's that I've seen have been falls. Uh, there are very common presentation with high levels of morbidity and sometimes mortality. So it's an important subject, but really, there's also a kind of subtext to this teaching, which is more about the benefits of having a really good system. Uh, when approaching a complex presentation, which falls can be they can often be multifactorial. Uh, and it's not always clear exactly what is going on Hopefully, by the end of this little teaching session, you'll feel a bit more confident approaching falls a bit more confident, approaching a vague history. Uh, and hopefully it will give you a maybe an introduction to a system that could be useful in both an Oscar environment, but also in your clinical practice going forwards. So that's just basically summing up exactly what I've said I want. This is our kind of the goals of the teaching. I want you to go away, having a better understanding of why falls are important if you haven't thought about them already. And then the word systematic is obviously the most, uh, this front and center of the teaching that I'm going to be delivering this evening. So, yes, bit of background falls very common. As I've already said, many of the presentations that I've clerked into the acute medical wards have been related to falls. Uh, they can be very complicated. They can be very simple. Uh, it may just be someone that's come in. They've slipped on some ice or they've tripped on their cat or whatever bit of furniture they have lying around their house. Um, but they can also be complicated. It can be difficult to elicit a history. Sometimes memory can be a bit of a problem, um, cognitive decline and simply just having multiple comorbidities, which could all be contributing to the full. And like I've already mentioned, falls are associated with morbidity and mortality. If you think of, say, your elderly patient's who have a fractured neck of FEMA, um, they have something like a 50% mortality and morbidity or mortality within the next year of their life. So these are really important diagnoses and presentations. So here's your presenting complaint. I'm going to try and make this session as interactive as possible, and I'll be keeping a close eye on the chat. So please feel free to ask any questions, first of all, but also to answer the questions that I've got for you. So picture this. You are the medical fy one clerking in a and E. The next patient to see is an 86 year old female who has presented following a fall. I'd like you to have to think about what your initial considerations are, and also what your initial sort of plan of action is. What you think you're going to do going into this consultation and just feel free to fill it out on the chat. And don't be shy. I appreciate it's a Wednesday evening. Oh, we've got an initial answer. So yeah, A B C D assessment. That's entirely fair. That's definitely something that you need to think about doing. It forms the basis of any examination that I use when I'm clocking in a and a any other offerings. So, yeah, we've got an offering from Gun Taj that saying that you know, he's considering diagnoses. So he's thinking about hypertension, stroke and a C s, all of which we will be covering a bit later on when we're thinking about history. So, yeah, maybe we've got a burgeoning orthopod, uh, young young who's given us any fractures. So, considering fractures like we've already told, sport spoken about there are leading cause of morbidity and mortality. So those those are all valid, Definitely valid. Um, it's a bit different if you're going into an OSK e situation, your structure is going to be very different as a junior doctor. What I'm going to be doing first is I'm going to be looking at the a and e clerking to get a bit of a background on what's happened to see if they've gleaned any details. We've also had an offering of hypoglycemia, So yeah, again, an important cause of falls which needs to be ruled out. Um, yeah, I'm going to be looking at the a Andy clerking. I'm gonna be looking at the paramedics record. I'm going to be getting a bit of an idea about past medical history. Uh, any medications that they may be on just so that I'm not going into the consultation blind. Unfortunately for the medical students who are in the chat, um, you don't have that benefit before going into a Noski station. You know, you have a minute or two with the presenting complaint, perhaps to have a think about what you're going to be asking what you're gonna be doing, uh, and what your initial plan might be in a real world environment, you have a bit more time, uh, to do a bit of digging in the background. And, of course, this wouldn't be medical education without bringing up the hero William Osler. Just listen to your patient. He is telling you the diagnosis 83% of diagnosis is glean from the history. So it's really important to get a good history. And that's when you're seeing any patient for any new complaints, or even just to get a bit background. If you're gonna be starting a new medication, for example, it's always going to be in your best interest to get a really good history. With that in mind, falls aren't necessary. That clear cut they could have many different causes. So it's going to be important to have a bit of a system in your history in order to rule out what might be the cause of the four. So with the presenting complaint, there are sort of five key questions that I like to follow. So first of all, you want to find out when it happened. Can anyone tell me why they might think it's important to find out how long ago that four has happened? Oh, how recently again, just put any answers in your chat. Why you think it's important we find out when it happened? Okay. Yeah. Great. So we've had, uh, 48 hour window with stroke, so Yeah, there are certain conditions where treatment there's a treatment window, uh, things like stroke A C s. We've also had an offering of hypothermia. So Yep, it's a It's a good consideration. One that came to my mind or that comes to my mind a lot is that if someone, for example, had fallen last night and they weren't found until the morning, then we might need to be thinking about long lie and getting a c k to check that, uh, their kidneys aren't being damaged by the rhabdomyolysis mile Isis. So where did it happen again? Very important. If it happened in the home, if it happened out of the home in the community Um, if it happened in a kind of Children's soft play area, then we might be a bit less concerned about a stroke. Perhaps. So what were they doing? What happened before, During and after. So this gets a really nice this. This will give us a really nice timeline about what happened around the fore. Um, certain conditions. This is going to be particularly pertinent for so if they can remember what happened before, during and after the fall, then that might lead us down a route of thinking more about a mechanical fall. So a trip, a slip, that kind of thing. If they're unable to remember what happened before the fall, if they are unable to remember what happened after during it. And if afterwards they felt a bit drowsy, perhaps What would that make you guys think about again? Concussion. Yeah. So concussion generally. Yeah, So they might have a bit of anterograde and retro game memory loss again. Yeah, hypoglycemia they might. Their Their memory of the event might not necessarily be as impaired with a hypoglycemic episode. If they're really drowsy for about half an hour, does that help? So I'm thinking what I'm thinking of is seizures. So if they have no memory of what happened before the event during the event and then afterwards they have this kind of groggy, postictal phase, then you might want to think, you know, that might lead you down a more sort of neurology seizures kind of pathway in your further questioning. So how many times have they fallen? So this isn't necessarily so important for getting the history getting an idea of what happened, but it definitely becomes more pertinent when we're thinking about management in the future. If this is a one off for, then we may be less concerned about having to implement, uh, more social support or providing additional mobility, aids, that kind of thing. However, if they're falling a lot, then this is, uh, obviously a lot more serious. And we need to think about interventions in the community. Long term planning, going forwards a bit more, and then who was present? Why? Why do people think this is important? The answers as simple as you think it is. But I like to keep you engaged, if at all possible. Okay, they may be able to explain. Exactly perfect. It's that simple. There may be someone that's witnessed it that can give you a bit of a background, a bit of a collateral history, which is always useful. It's always good to get several different reference points of information. So this is how I approach falls, falls. Like I say, they can be very complicated with a lot of different factors which influence the influence the event. So how I like to approach a force history is by doing it by body system. Uh, it took me a while at first when I started clerking. You know, being very rigorous about going through the body systems. But once you've practiced it, a few times will start to come very naturally. So we'll start and I do a top to tail. So I start in the brain. So can anyone give me any examples of any neurogenic factors that might contribute to a four? Any diseases, any acute pathologies, anything that comes to mind at all, it might affect the brain nervous system, that kind of thing. Anything related to neurology. And they'll be extra marks for people who can give me a pathology and then some symptoms that they might expect that pathology to come along with. So you've had stroke and seizure from Gun Taj. Thank you. They're both from my list. I'm going to see if anyone offers up any pathologies that I haven't thought of. We can do a bit of two way learning stroke, a mess and Parkinson's. Yep, that's a pretty good spread. So I've got C V A or Stroke uh, seizure. Syncopal episode. Although it's arguably more cardiogenic, um, people will describe a sort of loss of consciousness, got normal pressure, hydrocephalus, that is one that I do not have on my list. That's actually a really excellent offering. Thank you. For, uh, I've also got peripheral neuropathy, and within that, you could arguably put m s as well. Um, Parkinson's disease. It's already been suggested. And then we've also got delirium. Does anyone know what pinch me stands for in the context of delirium? So it's a good way of remembering the causes of delirium because they can be quite varied. Does anyone has that job? Anyone's memories exactly. Thank you Can touch. Yeah, I think you're on. I think your top of the pile of offering up suggestions this evening. So thank you. We've got pain, infection, nutrition, constipation, hydration, medication and environment. I also like to put in, um, endocrine into environment. If we're thinking about different electrolyte imbalances, that can cause delirium. So those are kind of neurogenic factors to consider inner history, and you can kind of quickly rule those out a c v A. Is there a acute neurological focal deficit? Seizures like we've spoken about. Was there a witness seizure? Was there a postictal phase syncopal episode kind of five minutes of loss of consciousness with quick resolution peripheral neuropathy. You can kind of pick that part from, uh, perhaps them feeling off balance. And then you can yield more data from an examination. Parkinson's disease? Likely. They've already got quite an established diagnosis. Um, but you can also, of course, rule out, uh, symptoms by screening for tremor rigidity. Um, postural instability, bread akinesis, that kind of thing. And delirium is a bit more of a funny one. It's a bit more of a kind of a spectrum of symptoms. So why do CVS or strokes cause diagnostic difficulty when we're thinking about falls? This might take a bit of lateral thinking. Okay, Any ideas? So, CVS or strokes? Um, they can cause falls. But also, if someone's had a fall and they've got symptoms, you know, if they got new onset confusion, if their G C. S has changed at all, then it may be that the fall has caused a stroke. So when you're taking history, it could be a bit of a red herring. You could think that it's caused a stroke, or it might. It might be a result. Sorry. It could have caused the fall where it may have been a result of the food itself. So moving from the head, the next place I get to is the heart. It's right in the center of the thorax. It's the next step. Logically. For me, this may not make sense for you. You can develop your own system, but this is how I like to approach it for Can anyone think of any cardiogenic causes of cardiovascular causes or factors that may contribute to a fall? And again, we've already mentioned some of them earlier in the teaching session. I think we had a C s earlier, so Yeah, excellent. We've had arrhythmias. That's a really important one. Yeah, A C s hypertension, cardiac arrest, Uh, heart failure. Yeah. Again, really, really good answer there. So I think you've covered all the ones that I can think of as well. Um, so I've got arrhythmias, and there's a lot of arrhythmias that we could talk about. And this is why I'm kind of doing a bit of a light touch on the body systems because you could spend a lot of time going into each of the different etiologies and signs and symptoms of each one of these factors. But it's just good to have a system that you can work through when you're dealing with a complex subject such as falls. So exactly arrhythmias. 80 s heart failure, orthostatic hypertension. And again, Yeah, Vasovagal I I mentioned it in urology, and it's Yeah, arguably a bit more cardiovascular. Uh, now that I think about it, respiratory causes. This one is quite straightforward. Has anyone got any suggestions of any respiratory pathologies that they think might contribute to a full? There were only two that I could think of, sire. If we get more than two, then you guys are doing better than me. Okay? Yeah. We've got got more than three. So we've had offerings of COPD pe, uh, opioid overdose leading to respite suppression, which quite like that's quite a nice answer. That's, uh that's, um, lateral thinking there. So I've just got pneumonia and COPD. Um, but yeah, pee. If you have circulatory collapse as a result of a massive P, then absolutely, that could contribute to a full. Um, so pneumonia. Pneumonia is slightly cheating. I must admit, um, but yeah, severe infection. So any kind of infection is going to predispose to a full, um, and COPD any any kind of acute breathlessness. So I suppose you could arguably put a acute asthma attack in there as well. So both of those, All of these things that we spoke about in the respiratory system could definitely definitely contribute to force G. I factors. You guys are on a role, so keep it up. Any G eye diagnoses or pathologies that might contribute to a full, it might be the cause of the full splenic rupture. I think if someone's got splenic rupture, I'm not saying you're wrong, but I think the fall might probably be the least of their concerns at that point. Uh, probably the same with perforation, but yeah, you're absolutely right. They could cause falls. Massive GI bleeds. Yeah. So an upper GI bleed is something that I thought of as well. And even just simple stuff. Diarrhea and vomiting. Can anyone sort of think about why? Yeah, So, going to just got it as well. So why would why would diarrhea cause a fall? There are a couple of ways. Yep. So one of them electrolyte imbalance, any specific electrolyte imbalances can think of. And again, it will probably might take a bit of second order thinking. Yeah, so sodium potassium irregularity sodium definitely, and potassium again could lead to arrhythmias could lead to a fall. This is a bit of second order thinking, Um, there is another sort of more mechanical way that diarrhea can lead to falls as well. Let's say you have an elderly patient. They're not particularly mobile, their toilets upstairs. If they're having to struggle to get to the toilet quickly and they're having to try and get up the stairs before they have an accident, then that can predispose to a full. Um, so it's something, you know, something a bit more social to think about, but still an important factor that could cause that could lead to falls. The vomiting, I think, is probably quite straightforward. GI bleeds. If you're having a lot of bleeding from somewhere, you can end up quite anemic. Uh, and that can lead to dizziness and falls. It seems quite straightforward. Can anyone think about? And then constipation is, um, more to do with how it can cause confusion, um, potentially to infections as well. Uh, hepatic causes. Does anyone have any idea about hepatic causes or factors or hepatic factor in the fall so you can think about hepatic encephalopathy. And that could be whether it's caused by vitamin insufficiencies or by alcohol Excess. Yeah, son has got it. That sounds on a bit of a role. You know, they also got arrhythmias. So nice one. So we got some endocrine and metabolic factors. Can anyone think of any endocrine and metabolic factors again? Some of them have been discussed. There is a lot of crossover between the different body systems. Um, but it just helps to give a bit of a structure for yourself more than anything. Any thoughts on any under crying metabolic factors that might precipitate a ball? Yeah, we've got diabetes. And on the flip side of diabetes, the other side of that coin. Something that we've spoken about already? Yes. So hypoglycemia. Exactly. So I just put that under the umbrella of glycemic control. Um, thyroid dysfunction can also cause falls. Hypercalcemia syndrome have been appropriate ADH yet that's that's niche. I kind of I focused more on broad brush with under crying and metabolic factors. Um, I'd like to say that SIADH is relatively rare, but I've come across a surprising amount in the last two months on M A. U Um, so yeah, so we've already spoken a bit about potassium and sodium hypercalcemia. What's the classic group of symptoms that you get with Hypercalcemia? Does anyone know the rhyme? Give it another couple of seconds. I'm gonna be really proud of anyone who knows. He's cool enough to know this rhyme. So it's stones, bones, moans, groans, psychiatric atones. That's how I remember the symptoms of hypercalcemia. So you get stones in your renal tract. Uh, you get grown. So that's groans of constipation. Strange for me, please. Um, psychiatric overtimes. You can get a bit delirious. You're a new tractor. Factors. I think we've already spoken about some of them. Calculi. Specifically, pilot arthritis will fall under your kind of infection umbrella as well, UTI Um but chest, abdomen and bladder are going to be a sort of leading places to look for an infection. Um, and then urinary retention as well. That can sort of lead to a delirious state confusion and falls. Does anyone know the geriatric Giants? This is what you can kind of use to round off everything. If you've managed to cross off all the other body systems. There are six geriatric giants really helpfully. They all begin with I, and these are common problems that geriatric patient's commonly face. All begin with. I all can in some way contribute to morbidity and certainly falls, which is why we're talking about them tonight. So immobility? Yeah, that's one of them. So someone's in mobile. They're not moving. They're losing their functional reserve. They're going to be more prone to a full infection infections. Not one of them, but incontinence definitely is. So again, we've already spoken a little bit about diarrhea and incontinence falls into that same kind of category. If someone's having to rush or struggle to get to the toilet and they're not as mobile as they usually are, then they're going to be more predisposed to a full. So we've had immobility and incontinence. Therefore more. I won't torture you too long. I will. I will move on if we if we hit a bit of dead end instability. So instability kind of comes into immobility for me. Um, I think it's a factor. That kind of code factors in in 11 of the geriatric giants to have got immobility, a hive put instability. I'm sorry. Oh, I've got egg on my face. Oh, well, we've We've had immobility, incontinence and instability. Apologies. We also have impaired vision in hearing. If someone's eyesight isn't as good, then they're not going to be as, uh, perceptive of potential hazards. Um, and causes of a fall if they have impaired cognition. Similarly, uh, they're gonna be more predisposed to fall now. Iatrogenic caused by, uh, the very people that are trying their best to help them. Specifically, What I'm thinking about here is drugs. So medications, um, if a person is on five medications, if an elderly person is on five medications, every medication over that five, that magic number of five increases their risk of falling by 20%. So if someone is on 10 medications, the chances of them falling are fairly high. Uh, if not a certainty. So we need to really think carefully about medications, and that can lead us on thinking about, uh, other factors going into the kind of medical into more the more social history. So anything like alcohol dependence, I kind of throw in there, um, and things like that. So history is vital, and having a good system for a history is vital. It means you can kind of check everything off. Make sure you've ticked all the boxes and make sure you've had a thorough review of the body systems. As I've discovered, a history is vital, but not necessarily possible. There has been more than one occasion where I've gone to take the history, and the patient has been way too confused to give you a clear idea about what's going on. Um, they may not even be orientated to time, place or person, which can make trying to decide next steps quite difficult. So your patient has been admitted from home. They have an established diagnosis of mixed dementia with Q. D s package of care, so they have carers four times a day. They're confused, disorientated and unwilling to answer your questions. Another situation. I found myself in a patient becoming very aggressive and just unwilling to answer any of my questions. So what other source of information can you use if you're unable to get them from the patient? And this is obviously going to become important in your clinical, um, clinical work going forward? But in Oscar, he's thinking about these other sources of information can get you those kind of extra points in cohesive management of patient's. So can anyone think of any sources of information that we can use that aren't the patient We've already spoken about A and e clerking and paramedics. They might give you a good bit of history about how the patient ended up in front of you. But what other sources of information can you use besides that? To get an idea of patient background, past medical history, that kind of thing? Yeah, excellent. I think you've You've got them all between you can Touch Fire and the Angel. We've got collateral history from carers, from family members from their primary care record one that's really important because you can get their medications from there as well. Um, and you can also have a look back through previous admission's as well. That might help to give you a bit of an idea about that kind of functional reserve again, any new diagnoses that may not be updated on the GP record yet anything like that, really. So it's a good idea, as I've already said, to kind of go in already prepared, uh, into the history and examination so that you kind of have an idea of where you're going with it before you get started. So I think earlier on when we were talking about first consideration, someone said eight. We assessment it's the keystone in any clerking document that I put together. I always do an eight. We examination full body systems review. This is going to be easy marks, and we should all fly through them. What does they stand for? Can anyone tell me Bonus points for the kind of things that you'd be looking for and extra bonus points for ones that are particularly relevant on the background of the fall. So, airway, always the place to start. They don't have a patent airway. You're not going to be too concerned about what caused the fall. I'm gonna have other things on your priority list, I think. Uh, what about B? Now? I wanna obviously we all know it's breathing. Um, but I want you to tell me what specific kind of signs and symptoms that you might be looking for that might that might lead you towards a diagnosis or a cause for the fall try and get you a clinical reasoning thinking, going So we've got pallor, tracheal deviation, cyanosis. So, yeah, increased work of breathing it can lead you to A lot of different diagnoses were spiritually issues. It will be more common to tack it neck than Braddy. CRP CRP is in c reactive protein. If you can get CRP from an examination, you need to tell me your secret, because that's impressive. I mean, we've got a lot of good peripheral signs, but don't remember. Oh, unless that's, um Yeah, don't Don't forget to always check expansion percussion Oscar rotation because as good as those peripheral signs are, that's not what the consultant is going to be really, really focusing on. I'm going to assume you meant cat prefilled time. Yeah, yeah, Capri. Full time. So that that's again? Probably something, maybe more that you think about in circulation. Um, so we've spoken about capillary refill in circulation. What other signs? Symptoms. Signs. Might you yield in a in the kind of circulation part of your exam and for the medical students specifically, what else do you need to think about when you're doing your the circulation bit of your eight we assessment in a Noski, for example? Yeah. So the things that I look for, uh, cap refill time. Check the pulse. Check that There's no radio radio delay because that could be an important sign of anyone. Got an answer to that radio radio delay. I'll leave that one out there. Um, I then do I. Then check the pulse and I lift the pulse. The arm that you're measuring above the head and I'm looking for collapsing and slow rising pulse. Does anyone know what those two things might make us think about? Not very common signs, Not ones that I've come across very often. Yes, we've got a s. That's the aortic stenosis. So yeah, thinking about valvulopathy these that we can feel in the radial pulse when we lift it above the head. Um, also attract the JVP That gives us a really good idea. Yeah, So, uh, Asana and Angel both got the valve Europa Thies there. Thank you very much. We also look at the JVP to check for signs of circularity overload. Um, we I also look for signs of anemia. Uh and I also look at mucous membranes before moving onto the chest and doing for auscultation feeling for thrills and heaves as well. And checking for edema. Uh, in an Oscar situation, obviously in circulation, this is a good product to say that you want venous access via cannula. Disability will be looking for things like reduced GCS looking, whether the pupils are equal and reactive and then in exposure. We generally it's considered that, you know, exposures, you know, your abdominal exam. But in the fall, it's so important to do a full body survey top to tail, looking for any head wounds that may have been missed. Any fractures that may have been missed any site of infection. So that could be like a sacred pressure sore that hasn't been noticed because the patient hasn't been rolled over. So it's really important to do a full body survey. And that's in both Oscar land and clinical environment land. So you have your examination findings. You've done a really thorough history. You've done a fantastic, thorough examination what your next step is going to be. Yeah, so, in the full body review sign of anaphylaxis over skin. Yeah, that's really good. Uh, that's a really good point. And you can also look for things like non blanching rashes. So you've done your history. You've done your examination. Yeah, going to think about some investigations. So I like to separate investigations into bedside bloods and imaging. There's some clues about the kind of things that you may want to order. Um, so bedside tests there are three that I could think of that I always include. If I've had a patient who it's a difficult historian, an examination that doesn't necessarily yield any positive findings. So urine dipstick, yet great, really important, not necessarily so useful in elderly populations, elderly female populations particularly, however, uh, if someone's got symptoms good going leukocytes and a good going nitrites positive on the urine dip, then you can start thinking about urine infections. So blood's E C G. We've got the E c G probes. There is a little prompt You've got dip stick. You can also include kind of your, um so you could include blood sugars here as a bedside test. Basically anything that you've done by the bedside, uh, so that for me would include bladder scans and bedside echoes. If you're somewhere that can facilitate that in terms of bloods if you're going to be training at, uh, Wiggin writing tongue and Lee on his there's a fantastic order set called the Frailty Lab Order set, which has everything. It has, um, all the electrolytes, vitamin D, um, clotting, full blood count. Uh, so yeah, using these all the funny, like vitamins? Um, who else does have? See? That's the thing I've I've gone very lazy cause I just click the box now. I don't know. It's not that I don't Look, it's just you click the box and you do it without thinking a little bit. Um, but you want to get a full baseline set of bloods anyway. And if you're thinking there's any signs of respiratory distress, then yes, it's on an A. B G would be entirely reasonable in terms of imaging. That's very much going to be dependent on the kind of presentation that you've got in front of you. If you're worried that there might have been a head injury or a stroke, then obviously you're going to get a CT head. If you've got positive respiratory signs or new oxygen requirement, then you might think, Okay, maybe there's something respiratory going on. Uh, Similarly, if they're constipated, they haven't opened the bowels. Um, they're in serious abdominal pain. Then you might be thinking about obstructions CTS that kind of thing. So it's very dependent on the presentation when it comes to imaging imaging should be to, uh, confirm the diagnosis that you're already pretty sure of not to, uh not to try and, uh, screen someone for anything that may or may not be going on. So we'll do some e c g practice. Seeing as we've got the probes there, and it's always seems to be, it's always it's always fun to look at E C. G s, isn't it? And just get a bit of practice. So spot diagnoses. What does the C C G make you think? And these are all factors that could contribute to a full Yeah. Can anyone identify any P ways? S p T Hmm. You know, I would say it's more a-fib. I can't really see any P waves. There's an irregular gap between the QRS complex is I would I would lean towards more of an actual fibrillation kind of picture. Yeah, about this one, this one's may not have come across this pattern of egg before, But I would say Look at the QRs complex is it was a little hint. So we've got these kind of I don't know if you can see my mouth, but if you're looking to lead to you've got these different voltages in the QRS complex and again in three in aVF kind of all over the shop. You've got these varying heights of QRs complex, so this might make you think about a pericardial effusion. So you've got bigger fusion. You can get these varying sizes in QRs complex. And if you've got a bigger fusion, it can lead to circulatory collapse. What about this one? Anyone think there might maybe be some ST Elevation here? This is actually a little sign called Tomb Stoning. This is a very, very severe severe sign of a C s. Yes, Stemi. What about this one Left bundle Branch block? Yes. Got left Bundle Branch, maybe? Yeah, I think more about the Oh, is that was that for the last one? I think more about the is Well, is this Sinus rhythm? Simple? Yes or no answer. The answer is no. We haven't got nice P waves followed by a Q R s and then a t. We've got some peas, which seemed to be a fairly regular interval. You've got some QRS complex, which again seems to be a fairly regular interval. But there's Yeah, there's no relation between the two. This is a third degree heart block. I think if you see this on an e c g, it's probably above your pay grade as enough one. It's time to get the cardiologists involved. What about this one? Completely. So we've got a lovely bit of ventricular tachycardia here. I think if they've fallen as a result of this, and once again, we're in a situation where the fall is probably the least of their concerns. It's a shock, a bill rhythm, and they're probably on the way or, if not ready into an arrest. So in terms of management, this is when we're talking about management here with talking about more of a long term management of, um, surrounding the four. So thinking more about the social input and that kind of thing, because ultimately, if someone presents with pneumonia, what are you going to do with pneumonia? If someone presents with a F what you're gonna do with the A F. You're going to treat it, and we could spend a lot of time going into how how we can treat the underlying pathology for each of the pathologies that we've spoken about. But I think it would probably be more important for this session to think about management of Falls. And this is more about holistic planning and long term management. Does anyone have any ideas of the sort of referrals that we could make? The sort of investigations that we could perhaps order as an outpatient following the resolution of the acute issue anything like that that would just help, too. Manage the manage, the patient going forwards, try and ensure that they don't have any more falls. Try and make sure that any falls that they do have aren't necessarily associated with more risks. More morbidity, more mortality, worse outcomes, anything like that. Give it another couple of seconds. I'm sure you guys already know all of this anyway, so these are just some of the things that I came up with, and they're obviously not all going to be relevant for every single fall that you encounter, but it just helps to kind of really drive home. The point that falls can be multifactorial and complicated and therefore your kind of approach to them. Going forward has to be kind of multifactorial and complicated, too. So not every where will offer a Falls Clinic service. But there is one in the north west of England. Um, and that will just, you know, that it's just going forwards how we can try and avoid falls, investigate forward a bit more bone protection, dexa scans and osteoporosis clinic again not necessary for every single fall. Um, if you're worried about fractures, especially in our elderly female population, then these are things that you can consider because obviously, if someone has a fall, if someone then fractures then like a FEMA, the outcomes are going to be a lot worse. So if we can avoid that happening, going forwards, then all the better medication review. So that kind of comes into the iatrogenic geriatric giant that we spoke about earlier. So that's just making sure that they're you know, they're gonna be certain medications that are going to probably increase your risk of falls. Things like your BP control, uh, things like benzodiazepines things like opioids. You know, these are all factors. These are all medications that can increase our risk of falls. Um so always good to review those medications, as we've already spoken about thorough social history, to get an idea of whether they need any further support at home or if there are any factors at home, which might be contributing to them falling more frequently pt ot and Home review pretty much essential for any kind of elderly patient, particularly if they've had a fall. See if they need any further, um, support from packages of care or if they need any adjustments made to their home in terms of walking rails, chairlifts, that kind of thing. Um, and then a raid psychiatric review. If you're at all worried about their mental capacity, whether they need, um, perhaps a more formal diagnosis of cognitive decline, which might be contributing to therefore So that's me. Thank you very much for listening for the last hour and for contributing on the chat as well. I do really appreciate it. Um, I hope that this gives you a kind of introduction to why a good system when you're approaching falls is important. and yes, please fill in the feedback. Um and Yeah. Thank you. I hope you have a good evening. I hope you have a lovely dinner. And that's what I'm gonna do. Yeah. Yeah. And if you have any questions at this point, um, just let me know. Similarly, if you have any questions Uh oh. I can't join the conversation. Um oh, Devia, would you be able to share my email in the trap? Would that be OK? My work. Email? Yeah, of course. Oh, thank you. Because that way, if if you have any questions about any anything clinical or anything to do with S j T or medical school going forwards, then feel free to just get in contact with me. And I'll do my very best to get, um, to give you any sort of help. Feedback advice for any pointers. I guess there's no more questions. Um, if there's anything you can always feel free to email Angus, you'll be happy to take them. Thank you, everyone for joining. We have the series going on every Wednesday. So if you just follow on uh, follow the medal page will be great. Thank you all. And heaven good the rest of the day. Thank you. Bye. Thank you.