Fall
HISTORY:
Fall ago
Event: ,
Preceded by:
Associated injuries: , , , , ,
Level of consciousness after the fall:
Assistance required to get up:
Fall witnessed:
Other elements:
EXAM:
General appearance:
Vital signs: , BP , HR , RR , SpO2 %, Temp °
Head:
Neck:
Heart: ,
Lungs: ,
Abdomen: , , ,
Skin:
Extremities: , , cap refill , pulses ,
Musculoskeletal: joints ,
Cervical spine: on , range of motion
Shoulder: : on , range of motion
Elbow: : on , range of motion
Wrist: : on , range of motion
Hand: : on , range of motion
Lumbar spine: on , range of motion
Hip: : on , range of motion
Knee: : on , range of motion
Ankle: : on , range of motion
Foot: : on , range of motion
Neurologic: cranial nerves , strength , sensation , reflexes , cerebellar function , gait
Mental status: , , speech , mood , thought process , , judgment
ASSESSMENT:
DDx:
Trauma from the fall: , , , , , ,
PLAN:
- Blood work: , , , , , , , , ,
- Urinalysis
- ECG
- Chest X-ray
- Orthostatic blood pressure measurements
- Bone density test
- Vision test
- Physical therapy
- Occupational therapy
- Home safety evaluation
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- Referral to fall prevention program
- Referral to geriatrician
- Follow-up in
- Return if falls continue or if new symptoms develop such as dizziness, weakness, or confusio