Big BMW COE

Mnemonic Details History Taking Physical Examination Investigations Tools Management

Big Balance • Giddiness Falls a/w low light settings Visual acuity (Snellens chart), HbA1c, Vit B12, Folate, KIV VDRL 6-minute walk test, 5x sit to stand test EYE/ENT review
• Vestibular dysfunction Giddiness Cataracts, Visual fields (Glaucoma vs MRI Brain contrasted/stroke Timed Up and Go Test, xqFunctional reach PT: Balance training eg Taichi, elastic band
• Cerebellar dysfunction AMD) protocol, MRI IAM assessment Vestibular PT
• Visual impairment Otoscopy Retinal photography Berg Balance Scale, Balance Evaluation Systems Test Low vision OT
• Proprioceptive/sensory loss (Peripheral neuropathy) HINTS test, Dix-Hallpike, Rhomberg’s Audiogram (BESTest) Mobility aid prescription
• Postural instability: PD and Parkinson plus syndromes test Performance-Oriented Mobility Assessment KIV Antidepressants (fear of falling) –Trial of low dose
esp PSP) Full neuro + PD + Gait exam Short Physical Performance Battery Escitalopram 2.5mg ON x 2-6 weeks, stop when better
• Cervical myelopathy Foot exam (injuries, ulcers, Falls Efficacy Scale – International (Fear of falling) –
• Fear of falling deformities) Validated for Chinese + Malay, Cut off 14 or more

B BP • Postural Hypotension
• Hypovolemia including BGIT
• Dysautonomia (DM, PD, MSA, GBS)
• Endocrine (Adrenal insuff, hypothyroid)
• Situational
• Post-prandial, Post-micturition
• Carotid sinus hypersensitivity (when
hanging clothes, shaving, neck massage)
• Exertional -> LV outlet obstruction (eg AS)
• Acute Hypotension
• AMI, PE, Arrhythmias, Valve rupture,
Myxoma
• BGIT
Falls a/w postural changes,
post meal
Pre syncopal symptoms of
lightheadedness, clamminess,
dizziness, chest discomfort,
palpitations
Endocrine screen
Postural BP assessment + BP
measurement 1h after meal
Fluid status
Pallor
CVM exam: Murmur, irregular pulse,
pulses parvus et tardus
Abdo exam: Succussion splash, DRE
Full neuro + PD + Gait exam
FBC, RP Postural BP management:
TFT, 8am cortisol, short synacthen • Non pharm: Hydration (2 glasses before getting out
test of bed), TED stockings/abdo binders, recovery
ECG, Holter, TTE maneuvers, lying upright to sleep
Anemia panel • Pharm:Midodrine/Fludrocort
Implantable loop recorders Post micturition: Sit down to pee
CTPA Post prandial: Low carb diet, small meals, lie down after
Electrophysiological tests meals, adjust BP meds
Tilt table test Heart failure management (AHA/ACC/HFSA 2022 GDMT)
Ambulatory BP monitoring KIV CVM/GAS mx for acute life-threatening causes

M Medication • Sedatives, Antipsychotics Medication history BP monitoring with Drug levels if indicated e.g. digoxin, AGS Beers Criteria (2023) Med recon: SIRE (Symptoms, Indications, Risks, EOL)
• Less so: Antihypertensives Alcohol/Intoxicant history antihypertensives withheld valproate (over/underdosing) STOPP-START, STOPP- Frail, STOPP Fall Avoid sedatives if possible (non-pharm mx of insomnia,
• Medications with anticholinergic side effects CAGE questionnaire Medication Appropriateness Index alternative analgesia)
• Polypharmacy AEC, ACB Alcohol cessation counselling
• Alcohol/illicit drug use Potentially Inappropriate Medications

W Weakness • Acute: Stroke, Seizure Onset and progression of Full neuro + PD + Gait exam CT Brain/MRI Brain w MRC scale Acute stroke management
• Subacute: Infection (abscess/meningo-encephalitis), weakness Carotid bruit + pulse + CVM exam contrast/stroke protocol Mini nutritional assessment Optimise seizure control
GBS, MS flare, MG flare Video of seizure if present Spinal: structural deformity eg XR spine KIV MRI spine EWGSOP/ AWGS Sarcopenia definition and severity Rehabilitation: acute vs subacute vs
• Chronic: Associated numbness/ cortical kyphoscoliosis, step deformity, NCS/EMG assessment outpatient/community (Focused on resistance exercises)
• Degenerative spinal disease signs tenderness DEXA/CT limbs for muscle mass Mobility aid prescription
• Peripheral neuropathy Back pain/radicular pain Calf circumference Nutrition: Supplements if needed, High protein intake
• Sarcopenia Nutritional history Hand grip strength (1.5g/kg/day)
• Foot drop Physical activity at baseline KIV POD review

C Cognition • Poor safety awareness Cognitive history Full neuro + PD +Gait exam CT Brain/ MRI Brain dementia MMSE/MoCA Sleep, exercise, diet, cognitive stimulating activities
• Poor understanding of physical limitations Presence of carer supervision protocol GDS Cognitive enhancers, antidepressants
• Depression and carer stress Neuropsychiatric Assessment FAB Caregiver education and training

O Others • Pain CVM, Respi, Abdo, Skin, ENT exam Capillary blood glucose Analgesia
• Bone: Fracture, Foot deformities (Key points: Palpable bladder, sacral Inflammatory markers Optimise DM control
• Joint: Arthritis wounds/ other pressure injuries, RP, Ca/Mg/PO Replace electrolytes
• Muscle: Myositis, contusion atrophic vaginitis) XR of relevant joints Treat underlying infection
• Hypoglycemia, electrolyte imbalances PVRU CK (if muscle tenderness/ rapid Urge/stress incont +/- BPH mx, KIV URO
• Infections GALS examination muscular weakness with wasting) PT review
• Urinary problems: Urgency, incontinence from BPH/GUSM POD review

E Environment • Lighting Social history including home Saving Inventory-Revised (SIR) Preferred footwear: Thin mid sole (to feel the ground),
• Flooring environment and footwear Hoarding Rating Scale (HRS) good heel grip, closed cap
• Steps/stairs Screen for hoarding OT Home assessment
• Footwear tendencies Home care services, Hoarding clearance
PSY for hoarding disorder mx
HDB EASE programme

Bone health screening: Complications:

Vit D, RP (for CrCl) CT Brain if head injury
BMD XR of affected joint/bones
FRAX score CK for long lie, RP for rhabdo
Dental clearance
Definitions History Taking
• Fall: A sudden, unintentional change in position causing an individual to land at • Purpose
a lower level (either on an object or on the floor) other than as a consequence • Elicit contributing factors: Precipitating vs Predisposing, Intrinsic vs Extrinsic
of overwhelming external force • Assess for complications
• Recurrent falls: 2 or more falls in a year • SPLATT Mnemonic
• HPB definition: 2 falls in 6 months • Symptoms experienced
• Long lie: Inability to get up from a fallen position, usually on the floor or • Should include pre-fall, during fall, and post fall
ground, for more than an hour. • Previous falls, and resultant complications including fear of falling
• Location of the fall
• Activity at the time of the fall (eg relationship to posture, cough, micturition, meals,
Examination medications)
• Time of day the fall occurred
• Trauma associated with the fall: Physical and psychological
• PMHx
• Neurological: Stroke disease, Parkinson's disease, Seizures, Cognitive impairment
• Heart disease: Heart failure, arrhythmias, valvular diseases, outflow obstruction
• Osteoporosis
• Endocrinological: Adrenal insufficiency, TCM use, hypothyroidism
• Depression
• Premorbid
• Function: Ambulatory status, need for walking aids, activities of daily living (bADLs,
iADLs)
• Social history: Family support, presence of identified carer, home environment,
smoking/alcohol
• Premorbid personality: Values independence, resistant of aids

Complications
• Fractures
• Head injury: Cephalohaematoma, SDH, SAH
• Skin lacerations, facial injuries
• Complications of long lie e.g. rhabdomyolysis
• Fear of falling