What is the best course of action for a 60-year-old female with a history of Chronic Obstructive Pulmonary Disease (COPD), osteoarthritis, hyperlipidemia, Gastroesophageal Reflux Disease (GERD), Sjögren’s syndrome, rheumatoid arthritis, and chronic depression, who presents with head and knee injuries, dizziness, and orthostatic hypotension after a fall?

Emergency Department Evaluation and Admission Strongly Recommended

This patient requires immediate emergency department evaluation and hospital admission given her significant head trauma with ongoing symptoms, orthostatic hypotension with documented dizziness, multiple high-risk comorbidities, and inability to ensure safety—her decision to leave against medical advice represents a dangerous clinical situation that warrants urgent reconsideration.

Critical Risk Factors Present

This 60-year-old patient demonstrates multiple concerning features that mandate emergency evaluation:

Head Trauma in High-Risk Patient

• Ground-level falls in adults ≥60 years carry substantial risk for severe intracranial injury and mortality, with ground-level falls accounting for 34.6% of all trauma deaths in patients ≥65 years 1
• Her significant head trauma (golf ball-sized hematoma, periorbital bruising, 7/10 pain) requires urgent imaging evaluation 1
• Patients with head injury and orthostatic symptoms are at high risk for rapid deterioration and require comprehensive evaluation including CT head and cardiac workup 1

Documented Orthostatic Hypotension with Symptoms

• Her orthostatic vital signs are markedly abnormal: repeat standing BP dropped to 106/68 from lying 127/73, with concurrent symptomatic dizziness 1
• Orthostatic hypotension assessment is a critical component of fall evaluation, and positive findings mandate further workup 1, 2
• Occult hypotension (decreased perfusion not evident by standard vital signs) is present in 42% of older adults with "normal" vital signs and represents a significant mortality risk 1

Multiple High-Risk Comorbidities

• Rheumatoid arthritis patients have a 1.99-fold increased risk of COPD and significantly worse outcomes when both conditions coexist 3, 4
• Her combination of RA, Sjögren's syndrome, COPD, and depression creates a high-risk profile for complications 5, 6
• Depression is independently associated with 1.48 times higher odds of frequent exacerbations in COPD patients 6

Required Emergency Department Evaluation

Immediate Diagnostic Testing

The following tests should be obtained urgently:

• EKG is mandatory to evaluate for cardiac causes of syncope/near-syncope, particularly given her cardiovascular risk factors and the association between falls and cardiac disorders 1, 2
• CT head without contrast is indicated given significant head trauma, ongoing symptoms, and age >60 years—this population has 9.7% critical finding rate on CT head after falls 7
• Complete blood count and basic metabolic panel to assess for anemia, electrolyte abnormalities, or other metabolic causes 1
• Orthostatic vital signs should be repeated in controlled ED environment with continuous monitoring 1, 2

Comprehensive Fall Assessment

A structured evaluation must address 1, 2:

• Detailed history: Loss of consciousness, prodromal symptoms, time on ground, medication review (particularly focusing on vasodilators, diuretics, antipsychotics, sedative/hypnotics)
• Complete head-to-toe examination for occult injuries beyond the obvious head and knee trauma
• Neurological assessment with attention to neuropathies, proximal motor strength, and cognitive status
• Gait assessment using "Get Up and Go" test prior to any discharge consideration

Admission Criteria Met

This patient meets multiple criteria for hospital admission 1, 2:

• Inability to ensure patient safety (documented by orthostatic hypotension with symptoms)
• Significant head trauma requiring observation for potential delayed intracranial hemorrhage
• Unresolved cause of fall with high recurrence risk
• Multiple comorbidities requiring interdisciplinary management
• Failed safety assessment (symptomatic with position changes)

Interdisciplinary Care Required

• Hospitalist/orthogeriatrics consultation for medical optimization and fall risk stratification 1
• Physical and occupational therapy evaluation for all admitted patients after falls 1, 2
• Medication reconciliation with focus on deprescribing high-risk medications contributing to fall risk 1

Critical Pitfalls in This Case

The AMA Discharge Represents Serious Risk

• Financial concerns should never preclude necessary emergency evaluation when life-threatening conditions are possible
• The patient's stated plan to "go to ER if needed" demonstrates inadequate understanding of her immediate risk
• Delayed presentation after intracranial hemorrhage significantly worsens outcomes

Inadequate Risk Assessment

• SBP <110 mmHg represents shock in adults >65 years, and her documented drop to 106/68 meets this threshold 1
• Her repeat dizziness "this morning" indicates ongoing instability and high risk for recurrent falls
• Ground-level falls in patients >60 years should trigger the same concern as high-energy trauma in younger patients 1

Immediate Actions if Patient Reconsiders

If the patient can be contacted and convinced to return:

1. Arrange immediate EMS transport back to ED (do not allow self-transport given orthostatic symptoms) 1
2. Expedite CT head and cardiac evaluation upon arrival 1, 7
3. Initiate fall precautions including bed alarms, frequent monitoring, and assistance with all transfers 1
4. Consult interdisciplinary team (hospitalist, PT/OT, pharmacy) for comprehensive fall prevention program 1, 2

Outpatient Management Only if ED Evaluation Completed

If the patient absolutely refuses ED evaluation despite counseling, the minimum acceptable plan requires:

• Urgent primary care follow-up within 24 hours with repeat orthostatic vital signs 2
• Home safety assessment by occupational therapy with direct intervention 1, 2
• Medication review focusing on elimination of high-risk medications (particularly any sedatives, antipsychotics, or multiple antihypertensives) 1
• Physical therapy referral for gait/balance assessment and exercise prescription 1, 2
• Strict fall precautions at home including removal of throw rugs, adequate lighting, use of assistive devices, and 24-hour supervision 1, 2
• Clear return precautions for worsening headache, confusion, weakness, recurrent dizziness, or any fall 2

However, this outpatient approach is suboptimal and carries substantial risk given her presentation—hospital admission remains the standard of care 1, 2.