Introduction
- Wash hands (and don PPE if needed)
- Introduce yourself (name and role)
- Confirm patient’s name and DOB
- Explain that you’d like to take a history from them
- Gain consent to continue
- Ask if patient in any pain before continuing
Presenting complaint
- Start with open questions: “How can I help today?”
- Allow patient to talk and ask 1/2 more follow up open questions
History of complaint
| WHO | Who has seen you fall? | Ensure adequate collateral history including addressing the when, where, what and why. |
| WHEN | When did you fall? | What time of day? What were they doing at the time? - Looking upwards (vertebrobasilar insufficiency) - Getting up from bed (postural hypotension) |
| WHERE | Where did you fall? | In the house, or outside? |
| WHAT | What happened before/during and after the fall? | Before - Was there any warning? - Was there any dizziness/chest pain or palpitations? During - Was there any incontinence or tongue biting? (indicating seizure activity) - Was there any loss of consciousness? - Was the patient pale/flushed? (may indicate vasovagal attack) - Did the patient injure themselves? - What part of the body had the first contact with the floor? After - What happened after the fall? - Was the patient able to get themselves up off the floor? - How long did it take them? - Was the patient able to resume normal activities afterwards? - Was there any confusion after the event? (head injury) - Was there any weakness or speech difficulty after the event? (e.g. stroke/TIA) |
| WHY | Why do you think you fell? | May have tripped over a rug or started a new medication |
| HOW | How many times have you fallen over the last 6 months? | Allows you to gauge the severity of the problem |
Systems review
| General | - Fatigue - Weight loss |
| Cardiovascular | - Chest pain - Palpitations - Check pulse, BP murmurs |
| Respiratory | - Shortness of breath - Cough - Listen to chest. |
| Neurological | - Loss of consciousness - Seizures - Motor or sensory disturbance - Neurological exam ( cranial nerve) |
| Genitourinary | - Incontinence - Urgency - Dysuria |
| Gastrointestinal | - Abdominal pain - Diarrhoea - Constipation |
| Musculoskeletal | - Joint pain - Muscle weakness |
Past Medical History
| General | - Visual/hearing impairment - Diabetes - Anaemia |
| Cardiovascular | - Cardiovascular disease - Arrhythmias |
| Respiratory | - COPD |
| Neurological | - Parkinson’s disease - Peripheral neuropathy - Stroke - Dementia |
| Genitourinary | - Recurrent urinary tract infection - Incontinence |
| Gastrointestinal | - Diverticulitis - Chronic diarrhoea - Alcoholic liver disease |
| Musculoskeletal | - Arthritis - Chronic pain - Fractures |
| ENT | - Vertigo/labyrinthitis - Check tympanic membranes are intact |
Medications
Some medications increase the chance of
- Beta-blockers (bradycardia)
- Diabetic medications (Hypoglycaemia)
- Antihypertensives (hypotension)
- Benzodiazepines (sedation)
- Antibiotics (intercurrent infection)
Social history and support
General social context
- Check accommodation, who they live with
- What tasks they can do independently
- Any carers
Smoking
- How much per day
- Or when did they quit & how much they smoked before they quit
Alcohol
- What they drink how frequently and how much
Diet and food intake
- How much fluid are they drinking
- What type of diet do they eat - toast and biscuits?
Closing the consultation
Summarise the key points back to the patient.
Ask the patient if they have any questions or concerns that have not been addressed.
Thank the patient for their time.
Dispose of PPE appropriately and wash your hands.