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Probability diagnosis

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Environmental hazards e.g. slipping, tripping

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Postural hypotension

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Postural instability e.g. knees, hips, Parkinson

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Visual e.g. glaucoma, macular degeneration

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Alcohol: acute or chronic

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Medication esp. iatrogenic

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Serious disorders not to be missed

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Vascular:

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  • Cerebral insufficiency incl. TIAs, stroke

  • Acute coronary syndromes

  • Cardiac arrhythmias e.g. sick sinus syndrome

  • Subdural or extradural haematoma

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Infection:

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  • Any systemic infection esp. sepsis

  • Any febrile illness

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Tumour/cancer:

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  • Cerebral tumour

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Other:

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  • Kidney failure

  • Head injury

  • Cognitive impairment e.g. dementia, delirium

  • Fluid and electrolyte disturbance

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Pitfalls (often missed)

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Parkinson disease—early onset

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Peripheral neuropathy

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Gait and foot disorders

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Labyrinthine e.g. BPPV, labyrinthitis

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Rarities:

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  • Vitamin deficiency esp. Vit. D

  • Cerebellar degeneration

  • Post prandial hypotension

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Masquerades checklist

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Depression

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Diabetes: hypoglycaemia; neuropathy

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Drugs (many—see history)

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Anaemia

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Thyroid/other endocrine: Addison D, hypothyroid?

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Spinal dysfunction esp. myelopathy

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Urinary tract infection—nocturia

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Is the patient trying to tell me something?

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Highly likely, consider conversion reaction.

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Key history

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A careful history is required including an interview with family members and any witnesses to the fall. Investigate the onset, environment and circumstances of the fall.

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Consider seizure and loss of consciousness, and situational factors such as rushing to bathroom, climbing stairs or ladder. Incl. accounts of any witnesses to the fall.

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Questions should incl. any premonitory or associated symptoms e.g. vertigo, lightheadedness, palpitations, chest pain dyspnoea, visual disturbance, possible unusual or disturbed behaviour. Gather past and recent medical history incl. diabetes, hypertension, cerebrovascular disease; as well as a drug history, esp. alcohol or illicit drugs, prescription agents esp. sedatives antidepressants, hypotensives, hypoglycaemics, antipsychotics, diuretics, NSAIDs. Check thyroid status.

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Key examination

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  • General features: appearance of patient incl. central cyanosis, hydration status, vital signs incl. pulse, BP (supine and standing) and temperature

  • Look for and exclude obvious extrinsic causes of falls

  • Comprehensive CVS examination

  • Examine ears, eyes, oral cavity, head and neck, spine, extremities esp. feet

  • Neurological examination including muscle features, sensation, coordination, balance and gait

  • Mini mental state examination

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Key investigations

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First line:

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  • urinalysis

  • blood sugar

  • pulse oximetry

  • FBE & ESR

  • U&E

  • ECG (or 24 hour monitor).

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Consider others according to history and findings:

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  • LFTs (γGT)

  • TFT

  • echocardiography

  • spinal X rays

  • CT or MRI if indicated

  • Doppler studies

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Diagnostic tips

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Consider ...

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