[##]-year-old [male/female] presents with history
and exam consistent with likely mechanical fall [with soft tissue abrasions] without
evidence of significant intracranial injury at this time.
Initial considerations in this patient
included intracranial hemorrhages including subarachnoid, subdural epidural
hemorrhages, brain contusions, delayed intracranial hemorrhages, cervical spine
fractures and dislocations, spinal cord injuries, musculoskeletal injuries, syncope
from cardiac etiologies including dysrhythmia and other neurologic etiologies
including cerebrovascular accident (CVA) and transient ischemic attack (TIA),
and fall syndromes (history of recurrent falls) among others.
Patient presented after [## hours] after a fall
[at home/assisted living facility/public place] described by the
[patient/bystanders] as “[tripping/stumbling/etc.]” consistent with likely
mechanical fall (non-syncopal fall from standing). A 12-lead EKG was obtained with [no evidence
of dysrhythmia, ischemia or infarction/atrial fibrillation without evidence of
rapid ventricular response/describe finding].
The patient [reported/denied] current use of anticoagulants [specifically
Warfarin (Coumadin)/Rivaroxaban (Xarelto)/Apixaban (Eliquis)/Dabigatran
(Pradaxa)/Enoxaparin (Lovenox)/but did report use of anti-platelet agent (aspirin/Plavix)]. Patient was noted to have a neurological exam
with [no evidence of focal deficits/other].
CT scans of the head [and cervical spine] were obtained with no evidence
of significant intracranial hemorrhage [and no evidence of acute spinal
injuries].
The patient [and family] were questioned on
fall history with [no report of frequent/prior falls/report of prior episodes
and discussion of the importance of close follow up with primary care provider
to discuss what can be done to decrease fall risk]. A gait assessment was performed in the ED
[with mobility device/cane/walker] and [noted to be unremarkable/notable for
slow, unsteady gait]. The patient lives
[alone/with family] and was noted to have [a family member/friend who is able
to check up on them over the next several days/no family or friends who are
able to check up on them consistently on discharge].
Prior to discharge, we discussed return precautions,
specifically emphasizing the signs of delayed intracranial hemorrhage, and
close follow up with primary care provider in the next [2-3 days/week] to
discuss ways to decrease fall risk [and consideration of whether the benefits
of anticoagulation outweigh the risks, and the patient [and family]
demonstrated understanding and agreement with this plan.
[Due to concern for delayed hemorrhage in a patient
who remains a fall risk and has limited social support, we discussed admission for
observation and consideration of repeat CT scans with the patient [and family]. We discussed admission with [Dr.
Name/admitting hospitalist] who evaluated the patient in the ED, and agreed
with planned admission.]
https://gempodcast.com/2018/11/09/retiring-the-term-mechanical-fall-for-older-patients/
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