An 82 years old man was brought to the ED by EMS after a fall.

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Vital signs are “normal”. The patient fell while trying to go to the bathroom during the night. He can’t explain why he fell but is adamant that he did not hit his head on the nightstand corner on the way down and could not get up by himself. He could not get up by himself and was too heavy for his wife to lift. He has pain in his right leg but feels “fine” at the moment apart from a mild headache.

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Physical exam findings are notable for a GCS 14 (disoriented day and month). He has no signs of visible head trauma but some pain to his neck. He had normal heart and lung sounds. There are no other signs of injury on your assessment.

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His past medical history is significant for coronary artery disease, congestive heart failure with reduced ejection fraction (EF 45%), hypertension, dyslipidemia, BPH.

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