Others (In Murtagh)
Falls In The Elderly
Falls in the elderly are unintentional events in which an older adult comes to rest on the ground or a lower level, often resulting from the interplay of intrinsic factors (such as muscle weakness, impaired balance, polypharmacy, and cognitive decline) and extrinsic environmental hazards.
Murtagh Diagnostic Strategy
| Category | Diagnosis | Key Discriminator | Cantonese Question / Finding | Probability |
|---|---|---|---|---|
| Probability Diagnosis | Multifactorial / age-related falls (environmental + gait/balance impairment + polypharmacy) | Multiple minor risk factors, no single medical cause; > 65 y/o | 「你覺得係咪行路唔穩加上屋企環境嘅問題？」 | ~40% |
| Drug-related falls (sedatives, anti-HT, polypharmacy) | Temporal link to new/changed medication | 「你幾時開始食呢隻藥？同跌倒有冇時間上嘅關係？」 | ~15% | |
| Serious Not To Miss | Hip / vertebral fracture | Inability to weight-bear, bony tenderness, shortened & externally rotated leg | 「跌完之後行唔行到路？有冇痛到企唔到？」 | ~10% |
| Cardiac syncope (arrhythmia, aortic stenosis) | LOC, palpitations, exertional syncope, ejection systolic murmur | 「跌之前有冇暈低、心跳亂？」/ Auscultation: ejection systolic murmur at aortic area | ~5% | |
| Stroke / TIA | Focal neurological deficit, sudden onset | 「跌之前有冇手腳突然冇力、講嘢唔清楚？」 | ~3% | |
| Subdural haematoma (post-fall complication) | Headache, confusion, progressive deficit days after fall; on anticoagulant | 「跌完之後有冇頭痛、精神變差？食緊薄血丸？」 | ~2% | |
| Pitfalls | Postural hypotension | Symptoms on standing; BP drop ≥20/10 mmHg | Lying-to-standing BP: 「我幫你量下瞓低同企起身嘅血壓」 | ~15% |
| Peripheral neuropathy (esp. diabetic) | Stocking-pattern sensory loss, unsteadiness in dark | 「你對腳有冇痺、好似著咗襪咁嘅感覺？」 | ~10% | |
| Cervical spondylotic myelopathy | Spastic gait, hyperreflexia, neck pain | 「有冇條頸痛？行路有冇覺得對腳硬硬地？」 | ~2% | |
| Masquerades | Drugs (sedatives, anticholinergics, opioids) | Temporal association, polypharmacy | Review drug list using STOPP criteria [3] | ~15% |
| Diabetes (neuropathy, hypoglycaemia) | Known DM, hypo episodes, sensory loss in feet | 「你有冇糖尿？有冇試過血糖低頭暈？」 | ~10% | |
| Depression → psychomotor retardation, inattention | Low mood, loss of interest, poor concentration, social withdrawal | 「你心情點呀？有冇對嘢冇晒興趣？」 | ~10% | |
| Parkinson's disease | Bradykinesia, resting tremor, rigidity, shuffling gait [4] | 「你行路有冇越行越細步？手有冇震？」/ Exam: cogwheel rigidity, festinating gait | ~5% | |
| Anaemia | Fatigue, pallor, exertional dizziness | 「你有冇覺得特別攰、面色差？」 | ~3% | |
| Trying to Tell Me Something? | Fear of losing independence / being institutionalised | Reluctance to admit falls; family pressure to move to nursing home | 「你有冇擔心要搬去老人院？屋企人有冇俾壓力你？」 | ~20% |
| Social isolation / loneliness | Living alone, reduced social contact | 「你平時有冇朋友探你？會唔會覺得孤獨？」 | ~10% | |
| Elder abuse / neglect | Unexplained injuries, fearfulness, poor nutrition | 「你同屋企人相處點呀？有冇人對你唔好？」 | ~2% |
Clinical Test Game Plan
| Time | Task | Cantonese Key Phrases | Why It Scores Marks |
|---|---|---|---|
| 0:00–0:30 | Friendly opening, rapport, set agenda | 「你好呀，我係X醫生，今日由我同你傾下。請問我可以點樣稱呼你呀？」「你今日嚟睇醫生，最想傾啲咩呀？」 | Interpersonal marks: greeting, preferred name, open-ended opening |
| 0:30–1:30 | HPI: Falls history — circumstances, frequency, timing, mechanism, injuries, loss of consciousness, preceding symptoms | 「可唔可以同我講下你跌倒嗰陣嘅情況？」「跌之前有冇頭暈、眼前發黑、心跳快嘅情況？」「有冇撞親頭？有冇受傷流血？」 | Chief complaint & HPI accuracy; red-flag screening |
| 1:30–2:30 | Targeted systems review & risk factors — medications (sedatives, anti-HT, polypharmacy), vision, hearing, gait aids, home environment, alcohol, footwear | 「你而家食緊啲咩藥？有冇食安眠藥、血壓藥？」「你對眼睇嘢清唔清楚？」「屋企有冇啲地毯、門檻容易絆倒？」 | DDx discrimination; identifies modifiable risk factors |
| 2:30–3:30 | PMHx, FHx, Social Hx, Functional assessment — chronic diseases (DM, PD, stroke, osteoporosis), walking aids, ADLs, living situation, carer support | 「你平時行路使唔使用拐杖或者助行架？」「你自己一個住定係有人照顧？」「你日常自己煮飯、沖涼搞唔搞到？」 | Biopsychosocial completeness; functional impact |
| 3:30–4:30 | ICE + Hidden agenda — Ideas, Concerns, Expectations; ask "Why today?" | 「你自己覺得點解會跌？」(Idea) 「你最擔心嘅係咩呀？」(Concern) 「你今日嚟，最希望醫生可以幫到你啲咩？」(Expectation) 「點解揀今日嚟睇醫生呢？」(Hidden agenda) | Marks heavily weighted on ICE; hidden agenda often = fear of fracture, loss of independence, or pressure from family |
| 4:30–5:15 | Summarise & check understanding | 「等我總結返，你最近跌咗X次，冇暈低過，食緊呢幾隻藥，你最擔心係...，我有冇漏咗啲咩？」 | Interpersonal marks: summarising, inviting correction |
| 5:15–6:00 | Plan, safety net, close | 「我會安排幫你驗下血同埋做返身體檢查。如果你再跌倒、頭暈、或者企唔穩，記得即刻返嚟或者打999。」「你有冇嘢想問我？多謝你今日嚟。」 | Safety-net line; empathetic close |
- "Why today?" is critical. The patient may have come because: a family member is worried, they fear losing independence (e.g. being sent to a nursing home), they had a near-miss fall with an injury, or they are afraid of hip fracture.
- Ask: 「係咪有啲嘢令你特別擔心，所以今日先嚟睇醫生？」
| Domain | English Question | Cantonese Question | Why It Matters | If Positive Think of |
|---|---|---|---|---|
| Fall details | How many falls? When? Where? What were you doing? | 「你跌咗幾多次？喺邊度跌？嗰陣做緊咩？」 | Distinguishes mechanical vs medical cause | Recurrent → multifactorial assessment needed [1] |
| Mechanism | Did you trip/slip or did you just go down? | 「你係絆倒定係突然間腳軟跌低？」 | Trip = extrinsic; spontaneous = intrinsic | Spontaneous → syncope, postural hypotension, arrhythmia |
| LOC / Pre-syncope | Did you black out? Any dizziness, palpitations, chest pain before the fall? | 「跌之前有冇暈低、眼前發黑、心跳快、胸口痛？」 | Red flag: cardiac syncope | Arrhythmia, aortic stenosis, PE |
| Post-fall | Could you get up? How long on the floor? | 「跌完之後你自己起唔起到身？喺地下瞓咗幾耐？」 | "Long lie" → rhabdomyolysis, hypothermia, functional decline | > 1 hr on floor → urgent Ix |
| Injuries | Any fractures, head injury, bruising? | 「有冇撞親頭？有冇骨折、瘀傷？」 | Identifies complications | Subdural haematoma, fracture |
| Gait & balance | Any difficulty walking? Using aids? | 「行路穩唔穩？有冇用拐杖/助行架？」 | Gait and balance assessment is the single most important part of fall evaluation [1][2] | Parkinsonism, cerebellar disease, peripheral neuropathy |
| Vision | Any recent change in eyesight? | 「你睇嘢有冇差咗？幾時驗過眼？」 | Visual impairment is a major modifiable risk factor [2] | Cataracts, macular degeneration |
| Medications | What medications? Any new ones? Sedatives, BP drugs, pain meds? | 「你食緊啲咩藥？最近有冇轉過藥？有冇食安眠藥、止痛藥？」 | Polypharmacy (≥4 drugs) and psychotropic drugs are major modifiable fall risk factors [1][3] | Drug-related falls (benzodiazepines, anti-HT, opioids, anticholinergics) |
| Postural symptoms | Dizzy when standing up? | 「你起身企嗰陣有冇頭暈？」 | Postural hypotension | Anti-HT drugs, autonomic neuropathy (DM) |
| Alcohol | How much alcohol? | 「你有冇飲酒？飲幾多？」 | Alcohol → gait impairment, neuropathy | Alcohol-related falls |
| PMHx | DM, stroke, Parkinson's, heart disease, osteoporosis, arthritis? | 「你有冇糖尿病、中風、柏金遜、心臟病、骨質疏鬆、關節炎？」 | Each increases fall risk differently | DM → neuropathy; PD → postural instability; stroke → hemiparesis |
| Home environment | Stairs, rugs, lighting, bathroom grab bars? | 「屋企有冇樓梯？廁所有冇扶手？夜晚夠唔夠光？」 | Environmental hazards are modifiable [2] | Home modification referral |
| Fear of falling | Are you afraid of falling again? Avoiding activities? | 「你有冇驚再跌？有冇因為驚跌而唔敢出街？」 | Fear of falling → activity restriction → deconditioning → ↑falls (vicious cycle) [1] | Psychological problem for biopsychosocial |
| Functional status | Can you manage daily activities? Bathing, cooking, shopping? | 「你日常沖涼、煮飯、買嘢自己搞唔搞到？」 | ADL impairment = social problem | Need for carer/home help |
| Social | Who do you live with? Any carer? | 「你同邊個住？有冇人照顧你？」 | Assesses support network | Social isolation → delayed help after fall |
| Continence | Any rushing to toilet? Incontinence? | 「你有冇急住去廁所嘅情況？有冇漏尿？」 | Urgency incontinence → rushing → falls | Urge incontinence as contributing factor |
Case Report Form Answer Builder
- CC: Recurrent falls / a fall in a [age]-year-old [gender]
- HPI must capture:
- Number of falls, timing, location, activity at time
- Mechanism: trip/slip vs spontaneous
- Preceding symptoms: LOC, dizziness, palpitations, focal neurology
- Injuries sustained
- Ability to get up; duration on floor
- Current medications (especially sedatives, anti-HT, polypharmacy)
- Gait/balance baseline; use of walking aids
- Relevant PMHx (DM, PD, stroke, osteoporosis, arthritis, visual impairment)
- Likely RFC examples:
- "Patient fell at home yesterday and daughter is worried about recurrence"
- "Recurrent falls over past 3 months, now afraid to walk alone"
- "Fall with hip pain, worried about fracture"
- Best single answer: State the trigger event + the underlying concern, e.g. "Recurrent falls over the past 2 months causing fear of falling and functional decline, prompted to attend by concerned daughter."
| Component | Likely Content | Example Wording for CRF |
|---|---|---|
| Ideas | "I think it's just old age" / "Maybe my blood pressure pills" / "My legs are weak" | Patient attributes falls to aging and leg weakness. |
| Concerns | Fear of hip fracture; fear of losing independence; fear of nursing home; worry about burdening family | Patient is worried about breaking a hip and having to move to a nursing home. |
| Expectations | Wants medication review; wants referral for physiotherapy; wants reassurance; wants home assessment | Patient hopes for a check-up to find the cause and prevent further falls. |
- Multifactorial falls (environmental hazards + gait/balance impairment + polypharmacy/medication side effects) in the majority of FM station scenarios
- Minimum supporting evidence: Age > 65, ≥2 falls, identifiable risk factors (e.g. polypharmacy, impaired vision, environmental hazard), abnormal Timed Get Up and Go test [2]
- If the stem strongly suggests a single cause (e.g. clear syncope with LOC → cardiac cause; classic tremor + shuffling → PD), shift the most likely diagnosis accordingly
| DDx | Key Discriminator |
|---|---|
| 1. Postural (orthostatic) hypotension | Symptoms on standing; BP drop ≥20 systolic / ≥10 diastolic on lying-to-standing |
| 2. Cardiac syncope (arrhythmia / aortic stenosis) | LOC, palpitations, exertional symptoms, murmur |
| 3. Parkinson's disease | Resting tremor, bradykinesia, rigidity, shuffling gait |
(Adjust based on the specific case stem — e.g. if DM is prominent, substitute diabetic peripheral neuropathy)
| Domain | Problem |
|---|---|
| Biological | Polypharmacy contributing to falls risk; osteoporosis increasing fracture risk |
| Psychological | Fear of falling leading to activity avoidance and deconditioning; possible depression |
| Social | Loss of functional independence (difficulty with ADLs); social isolation if living alone; carer burden on family |
| Diagnosis/DDx | Best Supporting Physical Sign | How to Elicit | Why It Supports This Diagnosis |
|---|---|---|---|
| Multifactorial falls (most likely Dx) | Timed Get Up and Go (TUG) test abnormal | Ask patient to stand from chair without using arms, walk 3m, turn, walk back, sit down. Time it. Abnormal if > 12 seconds or unsteady [2] | Demonstrates impaired gait and balance — the strongest predictor of future falls [1] |
| Postural hypotension | Orthostatic BP drop ≥20/10 mmHg | Measure BP lying (after 5 min supine) then standing (at 1 and 3 min) | Confirms orthostatic hypotension as fall mechanism |
| Cardiac syncope (aortic stenosis) | Ejection systolic murmur, loudest at aortic area, radiating to carotids | Auscultate with diaphragm at right 2nd intercostal space; patient sitting forward | Suggests aortic stenosis causing exertional syncope |
| Parkinson's disease | Cogwheel rigidity at wrist | Passively flex/extend patient's wrist while they perform contralateral hand movement (Froment's manoeuvre) [4] | Cardinal sign of PD; supports diagnosis when combined with bradykinesia and tremor |
| Peripheral neuropathy | Reduced sensation to monofilament/vibration in stocking distribution | 10g monofilament on plantar foot; 128Hz tuning fork on great toe | Loss of proprioception → sensory ataxia → falls |
Exam Discriminators and Traps
Must-Not-Miss Red Flags — Urgent Referral
- LOC / true syncope → ECG, consider Holter, echocardiogram; refer cardiology if cardiac cause suspected
- New focal neurological deficit → suspect stroke/TIA → urgent CT brain, refer A&E
- Head injury on anticoagulant → urgent CT brain to rule out subdural/extradural haematoma
- Inability to weight-bear after fall → X-ray hip/spine → suspect fracture
- Progressive confusion after fall → consider subdural haematoma (especially if on warfarin/DOAC)
- Unexplained injuries / signs of abuse → safeguarding referral
| Trap | How to Avoid |
|---|---|
| Forgetting to ask about medications (especially sedatives, anti-HT) | Always do a drug history — polypharmacy (≥4 drugs) is one of the most important modifiable risk factors [1][3] |
| Not distinguishing mechanical fall from syncope | Always ask about LOC, preceding symptoms |
| Ignoring postural BP | This is a key physical sign and commonly tested |
| Forgetting ICE | Allocate specific time; use exact phrases |
| Writing only biological problems in biopsychosocial | Must include psychological (fear of falling, depression) and social (isolation, ADL limitation, carer burden) |
| Not asking about home environment | Environmental modification is a key evidence-based intervention [2] |
| Missing the hidden agenda | Ask "Why today?" — often family pressure or a recent scary near-miss |
From GC slides [1][5]: A Comprehensive Geriatric Assessment (CGA) approach is essential for falls — assess medical, functional, psychological, and social domains simultaneously. Falls are rarely due to a single cause.
- Safety net (say to patient): 「如果你再跌倒、頭暈、暈低、或者企唔穩行唔到路，記得即刻打999或者去急症室。」
- Brief management plan to mention if asked:
High Yield Summary
What to ASK: Fall circumstances (mechanism, LOC, preceding Sx), medications (sedatives/anti-HT/polypharmacy), vision, gait/balance, home environment, PMHx (DM/PD/stroke/osteoporosis), functional status, fear of falling, ICE, and "Why today?"
What to WRITE: CC = recurrent falls in elderly; Most likely Dx = multifactorial falls; Best physical sign = Timed Get Up and Go test or orthostatic BP; DDx = postural hypotension, cardiac syncope, Parkinson's disease; Biopsychosocial = polypharmacy (Bio), fear of falling (Psych), loss of independence/social isolation (Social).
What NOT TO MISS: LOC (→ cardiac syncope), head injury on anticoagulant (→ SDH), new focal neurology (→ stroke), medication review (STOPP criteria), and the hidden agenda (fear of nursing home / loss of independence).
Active Recall - Family Medicine Clinical Test
[1] Lecture slides: The Patient Who Falls - Tinetti ME 2010 (JAMA).pdf [2] Lecture slides: Management of Falls in Older Persons - Moncada LV 2011 (AAFP).pdf [3] Lecture slides: GC 079 (supp-2)STOPP-START-V3.pdf [4] Senior notes: Ryan Ho Neurology.pdf (Parkinson's disease section, p119-122) [5] Lecture slides: GC 038. Comprehensive geriatric assessment and rehabilitation in older people.pdf [6] Lecture slides: GC 031. Back pain in an elderly woman_osteoporosis and related fractures.pdf [7] Senior notes: Ryan Ho Fundamentals.pdf (Elderly patients history checklist, p7) [8] Senior notes: Maksim Medicine Notes.pdf (Geriatrics section, p113) [9] Lecture slides: GC 054. Frailty in the older people.pdf [10] Lecture slides: GC 037. Common neurological problems in older people.pdf
Facial Pain
Facial pain is an unpleasant sensory experience localized to the face, arising from neurological, vascular, musculoskeletal, or sinus-related etiologies such as trigeminal neuralgia, temporomandibular disorders, or sinusitis.
Fits, Faints And Funny Turns
Fits, faints, and funny turns is a clinical umbrella term for transient episodes of altered consciousness or awareness, encompassing seizures, syncope, and other paroxysmal events that require systematic differentiation to identify their underlying neurological, cardiac, or metabolic cause.