Geriatrics Station 2

Setting:

You are a junior doctor working in A&E. The patient presents after being found on the floor at home by his wife.

Name: Steven Oluwole

Tasks:

1. Take a history from the patient.

2. Give your preferred diagnosis to the examiner.

3. Explain the diagnosis to the patient.

4. Give your initial management plan to the examiner.

You are not required to examine the patient.

Briefing

Diagnosis: Orthostatic hypotension presenting as a fall

You are Steven Oluwole (Age: 82)
You have presented to the Emergency Department after being found on the floor at home by your wife.

Appearance and Behaviour

Aim to look slightly anxious, especially when talking about your wife being left at home and your heart condition.

Opening statement

“I think I fell over, my wife found me on the floor”

Information to Give Freely

You had been sitting on the sofa watching TV for about an hour. You stood up to get some water and suddenly felt very dizzy. You woke up on the floor but you were a bit in shock with what had happened and had a headache so you didn’t try to get up by yourself.

Presenting Complaint

Before the fall:

What were you doing? - You had just stood up, you weren’t moving

Do you normally wear glasses/use any walking aids? - No

What do you mean by dizzy - You felt lightheaded, the room wasn’t spinning

Any other pre-syncopal symptoms - No

During the fall:

Do you remember falling - No (ie you did lose consciousness)

How long were you unconscious for - a few minutes or less, the TV was still on ads when you woke up

Did you manage to break your fall - No

Did you hit your head? - You think so, there’s some pain at the back of your head and you can feel a bump

Was it witnessed? - No, your wife was out at the time

After the fall:

Limb jerking/incontinence/post-ictal state - None and you returned to baseline very quickly

Confusion - None as far as you’re aware

Vomiting - Yes, vomited twice since waking up (about 2 hours ago)

Able to mobilise independently after fall - No, stayed on the floor (mainly because you were in shock rather than any weakness etc)

Length of lie - About an hour, waiting for wife to return

Any MSK pain? - Only your head hurts

Past Medical History

Prev episodes - No previous falls or loss of consciousness
Other conditions - Left-sided heart failure - you’ve been experiencing some breathlessness but mainly on exertion. You were started on a new water tablet for this only a few days ago.
Previous surgeries - No

Drug History

Prescribed - Bisoprolol and Ramipril for the last year. Furosemide started this week.
OTC - Nil
Allergies - Nil

Family History

Nil significant

Social History

Smoking - Smoked 15 a day for 10 years, have now stopped
Alcohol - Half a glass of red wine every Saturday and Sunday
Home -

Type of house - 2 floor house

Stairs - yes, no stair lift but normally manage alright

ADLs - can get around quite well usually, have become more breathless on exertion recently hence furosemide prescription
Mobilisation - No problems or walking aids
Job - Used to be a joiner, now retired
Baseline - Feel well in yourself both mentally and physically. Your wife and yourself help each other as needed and both enjoy gardening and watching game shows together.

Systems Review

General/red flags - NO fevers, NO weight loss, NO night sweats
Neuro - NO stroke symptoms or visual changes
ENT - Dizziness present but NO true vertigo, NO tinnitus, NO hearing loss
Resp - Mild breathlessness present as above. NO infective symptoms.
Cardio - Nil
GI - Vomitted as above
Urinary - Nil
MSK - Nil

Ideas / Concerns / Expectation

Ideas - “Could it be to do with my heart?”
Concerns - You don’t want to have to stay in hospital and leave your wife alone”
Expectations - “Could you check my head as it’s quite painful”

Discussion / Questions

The candidate will explain that the diuretic you were started on may have caused the fall. If they state that it was a medication without further clarification you should ask “Which medication?”.