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Probability diagnosis

Environmental hazards e.g. slipping, tripping

Postural hypotension

Postural instability e.g. knees, hips, Parkinson

Visual e.g. glaucoma, macular degeneration

Alcohol: acute or chronic

Medication esp. iatrogenic

Serious disorders not to be missed

Vascular:

  • Cerebral insufficiency incl. TIAs, stroke

  • Acute coronary syndromes

  • Cardiac arrhythmias e.g. sick sinus syndrome

  • Subdural or extradural haematoma

Infection:

  • Any systemic infection esp. sepsis

  • Any febrile illness

Tumour/cancer:

  • Cerebral tumour

Other:

  • Kidney failure

  • Head injury

  • Cognitive impairment e.g. dementia, delirium

  • Fluid and electrolyte disturbance

Pitfalls (often missed)

Parkinson disease—early onset

Peripheral neuropathy

Gait and foot disorders

Labyrinthine e.g. BPPV, labyrinthitis

Rarities:

  • Vitamin deficiency esp. Vit. D

  • Cerebellar degeneration

  • Post prandial hypotension

Masquerades checklist

Depression

Diabetes: hypoglycaemia; neuropathy

Drugs (many—see history)

Anaemia

Thyroid/other endocrine: Addison D, hypothyroid?

Spinal dysfunction esp. myelopathy

Urinary tract infection—nocturia

Is the patient trying to tell me something?

Highly likely, consider conversion reaction.

Key history

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.

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.

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.

Key examination

  • 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

Key investigations

First line:

  • urinalysis

  • blood sugar

  • pulse oximetry

  • FBE & ESR

  • U&E

  • ECG (or 24 hour monitor).

Consider others according to history and findings:

  • LFTs (γGT)

  • TFT

  • echocardiography

  • spinal X rays

  • CT or MRI if indicated

  • Doppler studies

Diagnostic tips

Consider ...

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