Fall
Age: years old
Gender:
HISTORY:
Presents for a fall that occurred ago
Occurred
Event surrouding the fall:
Preceded by ,
Injury sustained: , , , , ,
Level of consciousness after the fall:
Assistance required to get up:
Fall witnessed by someone:
Associated symptoms: *Try using right-click for negatives*
, , , ,
Contributing factors:
no history of: , , , , , , , ,
no use of: , , , , , , ,
EXAM:
General appearance: ,
Vital signs: , BP , HR , RR , SpO2 %, Temp °
Head: , scalp
Neck: , , , c-spine
Heart: , ,
Lungs: , ,
Abdomen: , , , , bowel sounds , ,
Skin: on
Extremities: , , cap refill sec, 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 , , judgment
ASSESSMENT:
DDx: accidental fall due to environmental factors, syncope, muscle weakness, balance disorder, vestibular dysfunction, neurological condition, medication side effect (e.g., sedatives, antihypertensives), orthostatic hypotension, cardiac event (e.g., arrhythmia, myocardial infarction), vision impairment, cognitive impairment, gait abnormality, footwear or walking aid issues, home hazards, alcohol intoxication, dehydration, electrolyte imbalance, seizure, osteoarthritis, infection leading to weakness, peripheral neuropathy, cerebrovascular accident (stroke), transient ischemic attack (TIA), delirium
Trauma from the fall: , , , , , ,
PLAN:
Investigations:
- Blood work: , , , , , , , , ,
- Urinalysis
- ECG
- Chest X-ray
- Orthostatic blood pressure measurements
- Bone density test
- Vision test
Treatments:
- Physical therapy
- Occupational therapy
- Home safety evaluation
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Further care:
- 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 confusion
HISTORY: Associated symptoms: EXAM: ASSESSMENT: PLAN: