What initial evaluation and management are required for a 60-year-old female patient with a history of Chronic Obstructive Pulmonary Disease (COPD), osteoarthritis, hyperlipidemia, Gastroesophageal Reflux Disease (GERD), Sjogren's syndrome, rheumatoid arthritis, and chronic depression who has fallen and hit her head and knee?

Initial Evaluation and Management for 60-Year-Old Female with Fall and Head/Knee Trauma

Order an urgent non-contrast CT head immediately, perform a comprehensive neurological assessment including Glasgow Coma Scale, obtain a 12-lead ECG, check orthostatic vital signs, and obtain knee radiographs. 1

Immediate Clinical Assessment

Neurological Evaluation:

• Assess airway, breathing, and circulation first, ensuring adequate oxygenation and blood pressure 1
• Perform rapid neurological examination with Glasgow Coma Scale scoring 1
• Check for signs of increased intracranial pressure: deteriorating consciousness, pupillary changes, or focal neurological deficits 1
• Perform serial neurological examinations every 15-30 minutes for the first 2 hours, then hourly for 4-12 hours 1

Cardiovascular Assessment:

• Measure orthostatic vital signs (blood pressure supine and standing) to assess for orthostatic hypotension, which is critical given her multiple comorbidities and fall risk 1
• Obtain 12-lead ECG to evaluate for arrhythmias, heart block, prolonged QT, Brugada pattern, or signs of ischemia 1
• Check troponin levels to evaluate for cardiac causes of syncope 1
• Institute continuous cardiac monitoring during evaluation 1

Imaging Studies

Head Imaging:

• Obtain urgent non-contrast CT head given her age >65 years, which is a high-risk feature even without altered mental status 1

Knee Imaging:

• Obtain knee radiographs (AP, lateral, and sunrise views) to evaluate for fracture, given her osteoarthritis and rheumatoid arthritis increase fracture risk 2

Cervical Spine:

• Consider CT cervical spine if she has neck pain, midline tenderness, or high-risk mechanism of fall 1

Laboratory Workup

Essential Labs:

• Complete blood count (assess for anemia, which occurs in 38-51% of patients with cardiovascular disease and is the 4th-5th most common comorbidity) 3
• Basic metabolic panel (evaluate for electrolyte abnormalities and assess kidney function, as chronic kidney disease is present in 30-45% of patients with heart disease) 3
• Troponin (cardiac evaluation) 1
• Blood glucose (given hyperlipidemia increases diabetes risk) 3

Critical Comorbidity Considerations

High-Risk Profile: This patient has multiple serious comorbidities that significantly increase morbidity and mortality risk. The combination of COPD, rheumatoid arthritis, and depression creates a particularly high-risk scenario 3, 4, 5:

• COPD patients with rheumatoid arthritis have threefold increased mortality regardless of which condition was diagnosed first 5
• COPD develops up to 68% more frequently in patients with RA compared to the general population 5
• Depression is present in 13-21% of COPD patients and is associated with elevated systemic inflammation (IL-6) 4
• Heart failure prevalence in COPD patients ranges from 20-70%, and 40% of mechanically ventilated COPD patients have left ventricular dysfunction 2

Medication Review:

• Review ALL current medications immediately, as polypharmacy significantly increases fall risk 6
• Pay particular attention to psychotropic medications for depression, which have consistent association with falls 6
• Avoid benzodiazepines despite their effectiveness for anxiety, as they significantly increase fall risk in older adults 6

Disposition Criteria

Admit if:

• Abnormal CT findings 1
• Persistent neurological symptoms 1
• Cardiac cause of syncope identified or suspected 1
• Unable to ambulate safely 1
• Significant knee injury requiring orthopedic consultation 2

Discharge with Close Follow-up if:

• Normal CT head 1
• Normal neurological examination 1
• Benign syncope cause identified 1
• Normal cardiac workup 1
• Able to ambulate safely (perform gait assessment before discharge) 1

Fall Prevention Before Discharge

Essential Interventions:

• Perform risk stratification and assessment tests for gait and balance 6
• Modify home environment by removing tripping hazards and improving lighting 6
• Evaluate and address vision problems and ensure appropriate footwear 6
• Arrange physical therapy referral for balance training exercises, which can reduce falls by up to 26% in high-risk individuals 6
• Consider Tai Chi programs for both anxiety and fall prevention 6

Follow-Up Plan

Early Follow-Up (<30 days):

• Schedule early follow-up within 30 days, which has been related to fewer exacerbation-related readmissions in COPD patients 2
• Review discharge therapy and make necessary medication adjustments 2
• Reassess fall risk and implement multifactorial intervention including medication review, exercise, and environmental modification 6

3-Month Follow-Up:

• Ensure return to stable state 2
• Review symptoms and perform spirometry to assess lung function 2
• Assess and optimize management of all comorbidities (COPD, osteoarthritis, rheumatoid arthritis, depression, GERD, Sjogren's syndrome, hyperlipidemia) 2

Critical Pitfalls to Avoid

• Do not prescribe benzodiazepines for anxiety without considering their significant impact on fall risk 6
• Do not focus only on the acute injury without addressing the underlying fall risk and multiple comorbidities 6
• Do not overlook cardiac causes of syncope in this high-risk patient with multiple cardiovascular risk factors 1
• Do not discharge without gait assessment and ensuring safe ambulation 1
• Do not fail to perform comprehensive medication review, especially psychotropic medications 6