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Um Hello everyone. Good evening. So my name is Devia. Um I'm one of the teaching fellows from Wigan. Um Part of my complete today, we've got Doctor Angus Park, one of our F ones going to our F twos, um who'll be talking about us to see my patient fall. Um And I think we can start now, Angus. Thank you very much. Great. Thank you very much Devia. So, as Dia mentioned, I'm uh one of the soon to be FWS at Wigan. Um I've had a couple of medical jobs and a surgical job and I'll be talking you through falls today. Um Just start the slide for you. So falls are something that you're gonna encounter quite frequently. Uh Whether it be during your on call ward cover jobs or uh when you're clerking new patients into um into the hospital as part of the medical team. Just so I've got a general idea of who's in the audience. So I know roughly kind of what level to put you at. Um Can you just sort of put in the chat uh what, what level you're at in terms of whether you're an F one F two into National Medical Graduate. Just, just like I say. So I've got an idea how to pitch this. Mhm. Can anyone else not see the slides? Cos some, I think Anastasia said that you can't see the slides. Just wanna check that everyone can still see it. Ok. Not sure what's going on. Anastasia. Um, yeah, I've got a bit of a technical issue there. Not sure. Um, cos I think some other people can see the slides. So I'll press on, um, and I'll be, I'll be doing a fair amount of talking anyway. So the slides aren't necessarily integral to, er, getting a bit more of an understanding about falls. So this is the session outline. We're gonna be talking about patients who present with falls, the history, examination, investigations and management that are gonna be relevant for falls. Er, and we'll be talking briefly about inpatient falls assessment as well. So this is gonna focus more on the kind of clerking uh perspective when discussing falls just because during your uncles, when you're covering the wards and you're asked to see a patient who's had a fall, you've got a bit more limited time. So the kind of review that you can do is going to be a bit more brief and focused, whereas this will give a bit more of a, a general overview of falls, especially patients who present with them to A&E. So wire fall is important, like I said, they're really common um you, I think probably, and this is, this is just a number that I'm plucking from the air, but it's probably 50% of the patients that I clocked in as a medic um have been falls related. So they can be really complicated. Uh Sometimes they can have multisystem involvement that's contributed to the falls. And the management isn't necessarily that straightforward either because you're not just going to be treating whatever's caused the fall. But you're also gonna want to think about how to manage fall risk in the future. And then probably most importantly, the fact that pools have a significant morbidity and mortality. So if you think if someone and a, an uh a female who's a bit older, if, if they have a fall, they have a fractured neck of femur and there's a 50% mortality from being admitted to hospital with a fractured neck of feur if, if you're above a certain age. So, so they're clinically important as well. They can have pretty serious consequences. So who would feel comfortable giving sort of a brief overview in the chat of what kind of elements we might ask about in a false history and the kind of structure that we can put, put in place to make sure that we're taking all the boxes. What sort of questions are we gonna be asking people who've presented with a fall? Ok, great. So we've had a suggestion of symptoms like palpitations. So we're thinking about different body systems, maybe that might have contributed to the fall. And again, you have things like short of breath, short, shortness of breath and chest pain. So an aura so that, you know, you might be thinking about neurological symptoms, there, a neurogenic cause for the fall. And again, with dizziness. Uh so dizziness can be neurogenic or it could be more to do with the vestibular system. So, yeah, whether there's been a loss of consciousness and that will fall into the kind of assessment that we do of what happened before, during and after the fall. So those are all really great suggestions. So like I say, this is how I break it down. Obviously, everybody will have their own approach, but this is how I how I lay it out in my mind and in my clerking to make it clear for myself and for other people who might be coming along to post, take the patient if I'm not there. So before, do they remember the preceding effects or symptoms? And we've spoken about some of these symptoms, like an aura, shortness of breath, chest pain, palpitations. So during as well, any sorry, there should have been a space there between symptoms and all. But yeah, any symptoms or injuries that might have happened during the fall. So whether they've got a bit of a bang to the head, they've got a bit of a headache. Um if they're a bit confused, groggy if they can't remember it and then afterwards, so how long were they down, could they get themselves back up? Was there any sort of lingering confusion? Do they have an awareness of the events? Were they incontinent? You know, all these questions will help us to narrow down our differentials for what's, what's caused the fall. We can also think about witnesses as well. So if there was anyone with them at the time of the fall, that's, that's, that's a really key person to be able to speak to because they'll have been a bit more objective to the whole situation. So they'd be able to tell you more about what happened or if, if the patient can't remember themselves, then, you know, you can get a really good collateral history from whoever's witnessed the fall. So again, we've spoken a bit about these complicating factors whether there's been any head trauma or potential fractures, cos that's gonna uh change our management plan. We might start thinking about different scans that we might want to get depending on if they've had a bit of a bang to the head and then associated symptoms. So again, we've spoken about some of these before, some dizziness, some incontinence, some chest pain, tongue biting. These are again, just helping us to narrow down which body system is most likely to be responsible. And then this is really important as well. So previous history of falls, whether this is a one off event or whether this is more reflective of someone who's becoming more unsteady on their feet, more frail and might need a bit more support at home. Um, ok, so we've got a really good history. The next step is of course an examination. What sort of examination are we gonna do in this context? So, you are clerking a patient and they're in A&E you've just seen them, you've just had a good chat with them. What examination are you gonna wanna do? Excellent. Yeah. So we wanna do an at E examination. Bang on the money first answer in any, in any situation, in any clerking or asked to see the patient on the wards kind of situation. I'm gonna want to do an A two E because that's gonna give me a really comprehensive and also logically thought out examination. Um, that's gonna be covering all of the, well, most of the body systems really. And then we've got a suggestion of some investigations that we'd like to do as well, but we can come on to that shortly. I'm not because we're all, we're all f ones here from the sounds of it. I'm not gonna patronize you by going through an A two E in quite as much detail as I might push you to do as if you were medical students. Um But of course you're just gonna want to, you know, and be rule out any uh respiratory causes. See, you're gonna be listening for murmurs, um that kind of thing and feeling the pulse, you know, all of this, you should know all of this. It's an A to e just do an A to E. So we'll do some cases just to keep everyone on their toes. Get you thinking a little bit. So we've got a 70 year old male that's presented following the fall and he was brought in by an ambulance. He says he feels fine. Now. However, on examination, he has a new right sided weakness affecting his lower limb. What's the most likely diagnosis that's led to this fall? Any ideas? So this is a gentleman that has a new focal acute neurological deficits. He's got weakness that's affecting his lower limb. So could be his right. Oh yeah, right sided weakness affecting his own. Then what do we think has happened? Peripheral neuro neuropathy? So that's probably got a bit more of a gradual onset. It's probably a chronic issue, but peripheral neuropathy is a good suggestion for a cause of uh a fall. So, yeah, so we we probably querying a stroke here because there's a new acute focal neurological deficit. So we'd be suspecting if it's on the right side, potentially a left-sided lacunar infarct just because it's motor motor symptoms that are affecting one of his limbs potentially. So the second case, so we've got a 65 year old female who's attended to A&E following a fall. She says it feels as though the room is spinning on further questioning. She also has noticed some hearing loss and troublesome ringing in her ears. Examination is difficult as she feels nauseated. What's the most likely diagnosis in this instance? So we've got some hearing loss, some tinnitus and some dizziness. So we've got vertigo. So vertigo is probably more of a symptom than a diagnosis, but it does sound like she's got vertigo. So thinking maybe Meniere's disease with this patient vestibular neuronitis. Yeah. Again, it's an important differential. Definitely. Ok. So case three, we've got a 60 year old male who has attended following a fall, see a common throat emerging here. He says he cannot remember exactly what happened but felt as though he blacked out on examination. He has a systolic murmur on auscultation, slow rising, pulse on palpation and he's got heaves. What do we think the diagnosis is? Yeah. So we've got a os aortic stenosis. I'm guessing A OS is aortic stenosis. Yeah. Yeah, exactly. Yeah. This is a, this is a patient with aortic stenosis that's resulted in a syncopal episode leading to a bit of a fall. So the next case, we've got an 80 year old female with a history of CO PD. She's been brought in by ambulance and is a direct referral from GP to medics with a curb 65 score of four. She's generally unwell and she's got harsh cough on examination. She has reduced their entering course crackles in the right lower zone of her chest diagnosis. Yeah, exactly. So, this is, this is pretty bond or pneumonia community acquired, um, infection is another precipitant of falls, which is why it's been, I didn't say she's been admitted with a fall to be fair. But, um, I think we can, based on the last three case studies, I think we can just assume that all of these patients have had a bit of a fall as well. So we've got a 68 year old gentleman. Now, he's attended with fluctuating alertness and consciousness history is difficult to elicit on examination. He's tachycardic and he's tender to palpation suprapubicly. What do we think the diagnosis is here? Yep. So we've got suggestion of a uti uti. Exactly. Yeah. So this is a bit of a mixed picture as well. Um So a uti I was going for this gentleman does have a UTI in males. It's probably a bit less common to get UTI S as I'm sure you will know. Um So one of the things that we need to think about with this guy is whether he's got um a potential outlet. A so a a urinary tract infection caused by a blockage somewhere in his urinary tract. So we need to think about whether he's maybe got an element of um prostatomegaly or whether he's constipated as well. And of course, he sounds a bit delirious. So it's likely, you know, that delirium could be caused by infection could be caused by the constipation. But until we've cleared those up, we're not gonna, we're not gonna really know either way are we? Um, but delirium uti S constipation, I can all predispose someone to her having a fall. So case six and then we'll move on to some investigations and some management, a patient presents following a fall. She has a background of arthritis, depression, neuropathic pain, hypertension, uh, non ST segment, elevated M I type two diabetes history and examination are unremarkable. You begin to prescribe her reg regular medications and note that she is taking the following medications. So she's taking amitriptyline, amLODIPine, atorvastatin, bisoprolol, cocodamol, gabapentin, indapamide, Metformin, Oramorph, paracetamol, and Ramipril. What do we think is happening here? And there's a bonus mark as well for the very eagle eyed. So we've got two really good suggestions, both of which are absolutely bang on. So it could be polypharmacy. It could also be drug interactions. So, polypharmacy uh patients who are on more than five me. So for every medication over five that someone is on, they have an extra 20% chance of having a fall. So by the time you're on 10 medications, you know, the chance of you having a fall are, are essentially 100%. Um But we can, we can also think about certain drug interactions as well. So, amitriptyline, cocodamol, Oramorph, um these all have like quite a high burden on, on someone's stability no as well. She's on Cocodamol and paracetamol. So we might wanna think about investigating that as well. Cos who, who knows she might have been, she might have been mistakenly overdosing for quite a while. So that's just something to keep an eye out for. So what I'm trying to, what I was trying to do there. So we started with case one, which was neurogenic case two, cardiogenic uh no vestibular sorry case three more cardiogenic case four respiratory system, you can kind of see what happens. And this is how I approach for um when I'm seeing a new patient in A&E. So II go through this list mentally and I rule out neurogenic festiv you know, all of these causes until we can get a better idea of what's caused the fall. It might be that there's more than one of these factors at play. So you'll, you'll have someone who's come in with a bit of a pneumonia, but then they might also have this iatrogenic cause of polypharmacy. Um It's also a good idea to ask about home environment just to just to check that there aren't any factors at home that might be contributing to the fall as well. But that again, that's something that we can think about when it comes to discharge planning. This is how I find it easiest to approach fools. This works for me. Obviously, as you go through your practice over the next year, you'll find your own ways that work. So, investigations, this is how I break down investigations. It's how I've been breaking down investigations for the past year and it's worked for me again. I like to have a system. So I always do b bedside bloods imaging and then special tests if they're relevant. So, a few clues here for bedside tests. So, what kind of bedside tests could we perform to see if we can get to the bottom of what's causing someone to have falls? E CG? Exactly. So what kind of, what kind of E CG er, changes might we might, we expect to see if someone's having falls? What can we look out for? So, yeah, we can, we can see kind of any arrhythmias. So, whether that's afib or whether that's any heart blocks, um, these are all, whether, in fact they're having a myocardial infarction, these are all things that can or bradycardia. Exactly. Yeah. So these are all things that can, um, cause someone to have some falls. So, bloods is what we'll move on to. Next. We're gonna focus on uh, bedside investigations at the moment. So if you can see the slides, you've got some visual cues there. So we've, we've had the ECG, what are the, what are the other three? Yeah. Glucose because as we know if someone's hypoglycemic, it can give them a reduced consciousness level. So BP. Yeah. So a low BP might cause someone to be a bit dizzy and have falls. But there's a particular kind of BP me measurement that we wanna get to make sure that they haven't got another underlying issue that might be contributing to the falls. Exactly. Yeah. So we're gonna get a line in standing BP because if there's a deficit then, um, you know, that can predispose someone to having falls cos when they get up, they feel dizzy. And if they're not aware of it, if they don't have good coping techniques that um they've been taught by a PTO T team, then, you know, they're more prone to have a bit before and then, yeah, urine dipstick. So we've already sort of briefly touched on it already. If someone's come in with lower urinary tract symptoms, we get a urine dip shows they've got a bit of an infection. That might be the, that might be the cause of the under, that might be the underlying cause of why they're falling. So, we've spoken a bit about b bedside tests, we'll move on to bloods now. So these, this is a list of blood tests that I would order. Why are we ordering an FBC? What kind of things are we gonna be looking at on a full blood count? And obviously it's gonna be dependent on what's presenting what kind of symptoms they're having. But generally speaking. So, yeah, so anemia is one thing that we can look out for cos if someone's got symptomatic, an anemia, they're gonna be dizzy, they're gonna have falls and then, yeah, again, so white blood cells, neutrophils is something else that we can look at. And what, what, what does that point towards? Yeah, exactly. It's an infection. So, user, what are we looking at in the user? Yeah. So what kind of electrolyte imbalances would maybe predispose someone to having falls? Yep. So hyponatremia good. Any other electrolytes that we might wanna look at? Keep an eye on? Yeah. So why would we be looking at potassium? So we have hypokalemia and hyperkalemia. Both of them, right? Answers. But why it's the, why I'm looking for? So what, what, what would a high or low potassium cause that might lead someone to having a fall arrhythmias? Yeah, exactly. So a high or a low potassium can cause arrhythmias, some of which are life threatening. So we need to keep an eye out for that. You can get TS as a baseline although you know, people can have hepatitis as well. Um or you know, cholangitis, cholecystitis, any of those kind of infections that can cause a fall CRP. It's already kind of been mentioned. We're looking at inflammatory markers here to see whether they've got an active infection. What about B12 and folate? Why would we be ordering that? So, yeah, it can get, give us a better idea of what kind of anemia someone has, can give her a bit of a bigger picture. Yup. So we've got suggestions of uh megaloblastic macrocytic anemia. There's another reason as well. So again, it's think it's thinking about neuropathy. Um cos chronically low levels of B12 can cause neuropathies and that can predispose to falls iron studies. We've already spoken about anemia. Um Yeah, peripheral neuropathy. Exactly. You guys have got it. Um So the T FT S and the T FT S and coagulation, they're, they're kind of part of a frailty screen. Um Obviously, if someone's hyperthyroid that can cause arrhythmias as well, um and coagulation isn't necessarily absolutely vital in everyone with falls. But is there a population of patients where we would definitely want to get a coagulation screen on if someone's had a fall? Why might we wanna get a coag? Yeah. So we're thinking about patients who are on blood thinners and that's, that's not just elderly patients. Um That's in all patients who are on blood thinners just because if they've had an unwitnessed fall especially, and they're on blood thinners, if they've maybe had some head trauma, then exactly like you said, there's a risk of intracranial bleeding there. So again, there are some sort of clues given away on this slide. Why, what sort of imaging do we want to order? And again, this is gonna be a bit more relevant for uh you know, different modalities of imaging are gonna be more relevant for uh different patients depending on the kind of symptoms that they come in with. But Yeah. So why, what kind of things we'll be looking, looking for on a chest X ray if we think back to case four of our lady who's got a bit of a cough. Yeah, exactly. So, we're looking for infections and then the CT head is for patients who've had head trauma or they're anticoagulated. They've had an unwitnessed fall. They've got this new confusion, anything like that, that might make us, um, suspicious that they've had a fall, bang their head and they've got a bit of a bleed. Um, and we're gonna need to get a CT head to rule out any bleeds. So these are some extra points of management falls. Essentially. What you're gonna do is treat the underlying problem, right? So if someone's come in, they're having uh an M I, then you're gonna treat the M I just as you would any other M I, if they've got a pneumonia, you're gonna prescribe antibiotics, um uti antibiotics, you know, you're just going to treat the underlying problem, but there's some additional management that you can do as well. If this is someone who's having persistent falls, then you can refer them to a Falls clinic and that's sort of done on an out outpatient basis. Once they're medically optimized, you're gonna wanna do a medication review cos you know, like we've discussed already can be iatrogenic causes including polypharmacy and drug interactions, especially if someone has a high anticholinergic burden, we can get physiotherapy and occupational therapy. So that's just gonna help with mobilizing, assessing whether they have any additional um mobility needs, whether they need any walking aids, whether, whether they need any adjustments made at home, um rails, uh modified baths, showers, that kind of thing. Uh And whether they need an enhanced package of care. So maybe they need one of those alert alarms if this is someone who's a bit more elderly, a bit more frail. Um, but they're still living at home independently. Uh, then if they have a fall, they need to be able to make sure that they can let someone know, so they can have one of those emergency buzzers. So this is just additional things that will need to be thought of at some point. So inpatient falls is gonna be a bit different again, much like clerking, getting called at about 4 a.m. about a patient that's had a fall in hospital actually. Yeah, that's a really good point that, um, Gabriel's just brought up, you know, if, if there are any safeguarding concerns here, then you know, those all need to be addressed before we discharge them, but just going back to inpatient falls. So you'll be bleeped. It'll be quite a common thing to be bleeped about night shifts out of hours work over the weekend, weekend, all hours of the day. Really? So you'll be asked to come and assess a patient on the ward who's had a fall this is gonna be a bit different because the chances are you're gonna have a job list that's as long as your arm and it's going to be growing by the minute you'll be leaked constantly and you'll have 100 things on your mind and, um, a to do list that never seems to end. So you need to be a bit more focused in these situations. So obviously you're gonna have to triage whether, um, when you get this bleep about how severe this fall is. So if someone's had a bit of a fall, it was witnessed, they didn't bang their head, they got themselves back up into bed. Um, they've been mobilizing on the ward since the nurses haven't noticed any new confusion. Um, no new weakness and everything seems to be ok, then you probably have a bit of a lower index of suspicion of a more serious underlying problem, but you will still need to go and see them at some point anyway, just to see if there's anything new that's changed, um, that's led to this fall. So, although you can sort of put it on a lower priority on your jobs list, you'll still have to go do a history, do a nice A two E think of any addit, uh, additional investigations that you need to order and any management that you need to start in the interim. However, if this is, so if this is a different kind of bleep where you've got an elderly person who's anticoagulated and they've fallen down a few stairs while, um, they've been with the physiotherapist. Very uncommon. It hasn't happened to me. Uh, I haven't, I'm not aware of this ever happening but just, you know, for the sake of, um, this teaching, let's say that's what has happened. So, they've had a bit of a tumble, they bang their head, they're anticoagulated and they're still on the floor. Do you think you need to go and see this patient a bit more quickly? Probably you probably need to go and see them straight away. Really? Um So if they're still on the floor, what you're gonna want to do is a bit of a trauma survey. So does anyone know what uh what you might do in this context? That's a bit different to clerking a patient in who's been brought in by ambulance. So this is an elderly patient still on the floor, banging their head after having a, a pretty good tumble. So what are you concerned about? What kind of injury he's gonna be at the front of your mind to rule out? Yeah, exactly. So you're gonna wanna check the c spine first. So you're not necessarily checking it for stability, you're more checking it for, for tenderness really. Um Because if there's any c spine tenderness, then this is probably isn't gonna be something that you're gonna be want to be dealing with alone as an F one So at that point, I'd be escalating pretty quickly to get some more senior help involved and more hands on the scene because, you know, this can have so if someone's got c spine tenderness, this is gonna have potentially some important consequences when we're thinking about airway, but also the spine. So do we just check c spine? No, we don't just check for your spine. We also check thoracic and lumbar spine as well. Anastasia has jumped the gun a bit. She's on the ball, she knows what's going on. Um We also wanna have a think about uh the skull and, and limbs as well. So what I like to do is check the spine first. If the spine's all, ok, there's no tenderness, then I'll ask them to move all four limbs. If they're able to, if there's no tenderness of their spine, they're able to move all four limbs and their G CS is ok. So if they're not confused and their consciousness and talking to me, then I can sort of start to feel a bit less worried that there might be something a bit more serious at play. That's a bit out of my uh level of competence. So that's just the kind of really quick trauma survey that I do. But it's important that I do that when I go and see them cos then that's gonna dictate how quickly I need to escalate things. However, if you do a trauma survey there's no spinal tenderness, they're able to move all four limbs. There's no kind of obvious neurological deficit. Then we can start thinking about getting a bit more of a history, do a full a toy at that point. And again, think about investigations and management and getting this patient into a more comfortable position as well. So once we've ruled out any serious in injuries, then we can start thinking about immobilizing an important thing to be aware of is CT head guidelines. Does anyone know where we can access guidelines for who should get a CT head in these kind of instances? So there's a really, really useful flow chart on uh on nice CT S. So part of the nice guidance, there's a beautifully laid out very, very clear flow chart on who needs a CT head following a fall. And um and how quickly they need that CT head as well. So I don't think, no, I haven't got a copy of I should have had the foresight to look it up, but um and get a copy of it for the slide, but it's, it's very easy to look up and it's something that I've bookmarked on my phone for when I'm on call, when I'm a bit tired when my memory is not quite working as it should be. And uh I just need to access it quickly. So I've, I've got it, it, screenshot it on my phone. It's something that I'd recommend you do for not just CT head guidelines because it's something that you're probably gonna have to be looking at quite frequently, but I've done it for local hospital guidelines as well. It's just a quite a handy tip for on calls for when you're an, um, an F one that's fairly busy and a little bit stressed. Um, but essentially it's a G CS under 15 on initial, um, initial man, um, initial assessment after the fall, I think it's G CS of less than 13 after two hours after the fall. Um There are some other, there are some other um just look up the guidelines. I was hoping to be able to recite it from memory, but uh I rely on the screenshot a bit too much apparently. But then, yeah, as er fri has pointed out, um if the patient's on anticoagulation, that will also uh mean that they'll need to get a CT head regardless of whether they've got any other symptoms. So that's kind of a brief overview of falls. It's quite a complicated subject. There's a lot of body systems at play that we need to think about when we're assessing someone who's coming to A&E with a fall. Um But hopefully this has given you AAA bit of a, a bit of a structure that you might use going forward, but ultimately, you'll find your own way of, of assessing people that works for you and ways of remembering things um that work for you as well. So this is by no means uh you should do, this is just a way to think about falls. Uh That's a, a bit more holistic and we've also talked a little bit about um something that's again, you'll be bleeped about quite frequently, a common reason to be bleeped, which is inpatient falls as well. Um And first steps to take and how to prioritize as well. So thank you for listening. Uh Welcome any questions from the audience at this point. Similarly, my email is there. If you have any questions about um fy one, anything at all, feel free to drop me an email, but thank you for listening. Thank you, Angus. That was a little talk. And since nobody has any questions, I suppose we're ready to um end this session. But everybody please be kind enough to complete the feedback form that I will re uh release at the end and then after you complete it, you will receive your certificate. Thank you very much, everybody. Thank you, Angus. Well, you're welcome. Thank you again, everyone for listening.