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An 88 year old woman is living alone in her own home. She has a history of diabetes, diabetic retinopathy and congestive heart failure. Her medications include 80mg of furosemide daily, metoprolol 25 mg orally twice daily, lisinopril 5 mg daily and aspirin 81 mg daily. She does not complain of any cardiopulmonary symptoms currently. She has recently suffered two falls in her home. One occurred in the bathroom and the other occurred in the kitchen. Your history taking in regards to this patient must include all of the following EXCEPT:
A. Ask questions about her home environment (e.g. lighting, footwear, pets, rugs)
B. Further questioning about circumstances and possible symptoms prior to her falls
C. Medication review to assess adherence to her prescribed medication regimen
D. Questions as to whether she has any suspected reasons for her falls
E. Whether she has experienced any similar episodes while driving
B. Further questioning about circumstancesand possible symptoms prior to her falls
Answer: E. Whether she has experienced any similar episodes while driving. There are many questions that are relevant to ask to investigate falls in older adults. Questions assessing both the patient and the environment all may yield information. While the question of whether the patient has experienced any similar episodes while driving may give you clues as to whether the patient has fallen due to a seizure or perhaps a cardiac or neurologic etiology, it is non-specific. It is also difficult to “fall” – a decrease in position from one level to the next – while seated.
Your physical examination in regards to this patient’s falls would include all of the following EXCEPT:
A. Auscultation of the lungs
B. Blood pressure measurements in both the supine and standing positions
C. Examination of the feet
D. Get Up and Go Test for gait and balance evaluation
E. Ophthalmologic examination
Answer: A. Auscultation of the lungs. Falls in older adults are often multifactorial. In this patient specifically, risk factors for falls include orthostatic hypotension due to dehydration from diuretics and decreased blood pressure from beta blockers as well as possible hypotensive blood pressure decreases posturally due to diabetic complications. A foot exam is important given the possibility of diabetic neuropathy and possible unrecognized ulcerations /sores on the feet. An eye exam may be helpful given her retinopathy or other unknown eye conditions. A gait and balance evaluation is helpful in demonstrating how these (and other factors) interact to produce a safer/less safe balance and gait. A pulmonary exam may be indicated to assess for heart failure as a contributor to falls, however, as the patient is asymptomatic in this regard, the other exam components may produce a greater diagnostic yield.