Structured history of a fall: before, during and after
A structured history of a fall looks at the events before, during and after it, and the lead-up is the best clue to the cause.
Remember
Ask first what the patient was doing immediately before the fall, and about any warning symptoms, because the lead-up helps to separate a trip from a medical cause.
When a patient has fallen, the history begins with understanding how and why it happened. A falls history is organised around five themes: who, when, where, what and how. The what theme tells the story of the event itself, divided into before, during and after.
The "before" part is where the cause usually hides. Ask what the patient was doing immediately beforehand, and whether they stood up suddenly, tripped or slipped. Then ask about warning symptoms: light-headedness (a sense of being about to faint), dizziness, seeing lights, chest pain or headache. Palpitations (an awareness of the heartbeat) suggest an arrhythmia (an abnormal heart rhythm).
A mechanical fall is a trip or slip with an outside cause, and the person stays conscious until they land. In syncope (a faint: a brief loss of consciousness from reduced blood flow to the brain), people often cannot recall the moments before it. Standing up suddenly raises the possibility of orthostatic hypotension (a fall in blood pressure on standing).
The "during" part asks whether consciousness was lost (which can be hard to judge). Loss of bladder control, tongue biting or shaking can suggest a seizure but are not diagnostic on their own. Identify injuries too, particularly a knock to the head or a fracture. The "after" part asks how long recovery took, whether the patient could get up without help, and about confusion, weakness or numbness.
Patients may be unable to remember the event, so a collateral history (an account from anyone who saw it or knows the patient) is valuable. Injuries, time on the floor and treatment describe consequences and do not explain the fall. Even a mechanical fall needs thought: the cause of the trip, such as a visual problem or a hazard in the home, should be dealt with.
Key facts
- Five themes
- who, when, where, what and how organise the history of a fall.
- The what step
- the story of the event is divided into before, during and after the fall.
- Before
- ask what the patient was doing, then about light-headedness (a sense of being about to faint), dizziness, seeing lights, chest pain, headache, a trip or a slip.
- During
- ask whether consciousness was lost, and about incontinence (loss of bladder control), tongue biting or shaking, which can suggest a seizure but are not diagnostic on their own.
- After
- ask how long it took to regain consciousness, whether the patient could get up without help, and about confusion, weakness or numbness.
- Mechanical clue
- a clear recollection of tripping over a hazard, with consciousness kept until the fall, fits a mechanical fall.
- Medical clue
- loss of consciousness before the fall suggests syncope or another medical cause.
Exam traps
- How long the patient remained on the ground does not explain the cause, because it describes a consequence of the fall, not what caused it.
- Past medical history of chronic conditions does not come first, because it is best read in the light of how the fall happened.
- Whether the fall happened indoors or outdoors is not the focus of the "what" step, because it belongs to the "where" step, which looks for hazards.
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