SAQ question is now on the new format, shown below
[SAQ 1: Geriatrics (syncope)]
A 71-year-old patient was cooking with his daughter in the kitchen when suddenly, the patient collapsed onto the kitchen floor. The patient takes amlodipine and ramipril for hypertension and topical ibuprofen gel for ongoing knee pain.
Q1. The daughter read about seizures causing falls and is worried if his father had a seizure. What 4 specific questions in the history would you want to ask to enquire about seizure related falls
[2 marks] [each for 0.5 marks]
Was there any tongue biting?
Was there any epilepsy aura: smells, tastes, or deja vu before the event?
Any tonic clonic activity?
Did the event last more than 5 minutes?
Was there a prolonged post-ictal period?
Did the head turn or was there any abnormal limb positions?
Q2. To assess the prodrome features prior to the syncopal episode, what questions would you want to ask in the history?
[2 marks] [each for 0.5 marks]
Did the patient feel hot, clammy, or sweating
Did their vision go blurry or dark
Was there any dizziness
Were there any associated headaches
Q3. From the history, seizure is ruled out. Name 4 investigations that should be taken and give a reasoning for why they are important.
[4 marks] [each for 0.5 marks]
ECG - assess for arrhythmias or long QT syndromes
Bloods - FBC (anaemia), electrolytes (hyper/hypokalaemia can cause arrhythmias), blood glucose (hypoglycaemia) and for baseline in case any medications are prescribed
Urine dipstick - UTI in elderly can cause delirium which can contribute to falls
Evidence of: absent P waves, irregularly irregular rhythm, rhythm is not sinus
Q5. The daughter describes that the patient has felt similar palpitations in the last 5 days. The patient is haemodynamically stable. Describe a management plan for the patient.
[2 marks] [each for 1 mark]
Rate control - beta blocker such as atenolol, diltiazem CCB (caution in heart failure), digoxin (sedentary)
Rhythm control - cardioversion or long-term rhythm control
Delayed cardioversion - as A.fib has been present for more than 48 hours and stable. Treat with electrical cardioversion and Anti coagulate for at least 3 weeks
Q6. After a few weeks, the daughter arrives with his father again in A&E as the patient has had another fall when he was getting up from bed. Basic observations are: HR 89, BP 110/70, Temperature: 37.5, Oxygen saturations: 96%. ECG shows sinus rhythm. Urine dipstick is clear. State the underlying diagnosis and describe what examination can be done and what the findings are for a positive test.
[1 mark] [each for 0.5 marks]
Orthostatic hypotension.
Lying and standing BP.
Q7. You later see the patient on the ward, and he starts to cry. After further discussion, he discloses that unfortunately he lost his wife a few months ago. Because of this, he has found it hard to eat and drink. Name the 5 stages of grief and describe what stage the patient is experiencing.
[1 mark]
Denial
Anger
Bargaining
Depression
Acceptance
Q8. Describe 4 management options for the patient’s low blood pressure according to the biopsychosocial medical model.
[4 marks] [each for 0.5 marks]
Evaluate polypharmacy using STOPP START tool
Drug: fludrocortisone, midodrine
Compression stockings
Conservative: get up slowly, use carpets and rugs
Occupational assessment to assess any hazards
Strength balance training - regular exercises
Sight tests
Q9. Unfortunately, the patient has another fall, and this time fractured his hip. What tool should be used to assess the fall risk?
[1 mark] [each for 1 mark]
FRAX tool
Q10. You decide to do a DEXA scan. What is the Z score and T score?
[2 marks] [each for 1 mark]
T score: number of SD the patient is from an average healthy young patient
Z score: number of SD the patient's bone density adjusted for age, sex, and ethnicity
Q11. What is the diagnosis and medical management?
[2 marks] [each for 1 mark]
Osteoporosis.
This can be managed with: Adcal, bisphosphonates. Bisphosphonates can cause side effects such as reflux and osteonecrosis of the jaw.
SAQ question is now on the new format, shown below
[SAQ 1: Geriatrics (syncope)] A 71-year-old patient was cooking with his daughter in the kitchen when suddenly, the patient collapsed onto the kitchen floor. The patient takes amlodipine and ramipril for hypertension and topical ibuprofen gel for ongoing knee pain.
Q1. The daughter read about seizures causing falls and is worried if his father had a seizure. What 4 specific questions in the history would you want to ask to enquire about seizure related falls [2 marks] [each for 0.5 marks]
Q2. To assess the prodrome features prior to the syncopal episode, what questions would you want to ask in the history? [2 marks] [each for 0.5 marks]
Q3. From the history, seizure is ruled out. Name 4 investigations that should be taken and give a reasoning for why they are important. [4 marks] [each for 0.5 marks]
Q4. An ECG is completed. Give 2 features of the ECG and describe the underlying diagnoses. [2 marks] [each for 1 mark] image: https://litfl.com/wp-content/uploads/2018/08/ECG-Atrial-Fibrillation-coarse-flutter-waves-2-2.jpg
Q5. The daughter describes that the patient has felt similar palpitations in the last 5 days. The patient is haemodynamically stable. Describe a management plan for the patient. [2 marks] [each for 1 mark]
Q6. After a few weeks, the daughter arrives with his father again in A&E as the patient has had another fall when he was getting up from bed. Basic observations are: HR 89, BP 110/70, Temperature: 37.5, Oxygen saturations: 96%. ECG shows sinus rhythm. Urine dipstick is clear. State the underlying diagnosis and describe what examination can be done and what the findings are for a positive test. [1 mark] [each for 0.5 marks]
Q7. You later see the patient on the ward, and he starts to cry. After further discussion, he discloses that unfortunately he lost his wife a few months ago. Because of this, he has found it hard to eat and drink. Name the 5 stages of grief and describe what stage the patient is experiencing. [1 mark]
Q8. Describe 4 management options for the patient’s low blood pressure according to the biopsychosocial medical model. [4 marks] [each for 0.5 marks]
Q9. Unfortunately, the patient has another fall, and this time fractured his hip. What tool should be used to assess the fall risk? [1 mark] [each for 1 mark]
Q10. You decide to do a DEXA scan. What is the Z score and T score? [2 marks] [each for 1 mark]
Q11. What is the diagnosis and medical management? [2 marks] [each for 1 mark]