You are an FY2 in acute medicine
Personal Details:
Name: Mary Peterson
Age: 75
Medical Record:
Past medical history: Stroke (1 year ago, good recovery), Hypertension, Hip replacement (2 years ago).
Regular medication: Amlodipine 10mg, Ramipril 10mg, Simvastatin 80mg, Aspirin 75mg.
Notes:
A 75-year-old woman was brought to the hospital after her fourth fall in recent months.
Notes from the emergency department:
Had a fall this morning. Felt unsteady on her feet and fell off.
She did not lose consciousness and had no specific symptoms before falling. She was unable to get up by herself. No chest pain or palpitation. No arms or legs weakness.
Examination in the emergency department: Mild weakness on the right arm and legs (long-standing since stroke), otherwise was unremarkable
Task:
1. Take a focused history of her falls.
2. Address her concerns and discuss the management plan
Opening Sentence: “Oh, Doctor, I’m so embarrassed to be here again. I just seem to be so unsteady on my feet these days.”
Open History (to give freely): “I was just walking from the kitchen to the living room, and my legs just seemed to give way. I didn’t trip over anything. I didn’t feel dizzy or black out. One minute I was walking, the next I was on the floor. This is the fourth time it’s happened.”
Cues to give: “My daughter had to help me up. I couldn’t get up on my own.”
ICE (Ideas, Concerns, Expectations):
Ideas: “I think I’m just getting old and clumsy.”
Concerns: “What if I fall again on my bad hip? I’m so scared of breaking it and having to go through all that surgery again. I’m becoming frightened to move around my own house.”
Expectation: “I want to know why I keep falling and what can be done to stop it.”
How to Act: You are a little frail but mentally sharp. You are anxious and have lost your confidence.
More History (only if asked): You have recovered well from your stroke, but have some mild residual weakness on one side. You live with your daughter, who is very supportive. You are able to manage your daily activities, but are becoming more hesitant. No symptoms of lightheadedness on standing.
Social History: Lives with daughter.
Questions to ask:
“So you don’t think it’s just old age?”
“What is a ‘falls clinic’?”
Examination findings: when the candidate verbalises the need for examination:
Observations stable, BP 130/80 (lying) 120/70 (standing), Spo2 98, HR 73, T 37
Chest clear, I+II+0, abdomen soft non tender, no bruise or wound
Intact neurological examination, apart from known mild weakness on the right upper arm and leg
History of the Falls (SPLATT):
Can you tell me about the most recent fall? What were you doing? (Symptoms before) Where did you fall? (Place) How did you land? Did you hit your head? (Landing) Did you lose consciousness or black out? (Loss of consciousness) What happened afterwards? Were you able to get up by yourself? (Activity after) When did it happen? (Time)
Review of Systems: Did you have any new weakness in your arms or legs? Any facial drooping? Any speech change?
Do you take any medication? Can we go through the list? (Drugs) How is your general health? Any problems with your breathing?
How is your eyesight and your hearing? (Eyes/Ears). Do you get lightheaded when you stand up from sitting?
How are you managing at home?
ICE (Ideas, Concerns, Expectations): What are your own thoughts about why you are falling? What is your biggest worry about these falls? What were you hoping we could do for you today?
Explain the situation, the likely diagnosis or DD:
Mary, it’s not embarrassing at all. Falling is a very common problem, and you’ve done the right thing by coming in to be checked over. It’s not something we should just put down to ‘getting old’. There are often many different factors that contribute, and our job is to try to unpick them to make you safer.
Addressing and answering the patient’s ICE:
Your biggest fear is falling and damaging the hip you had replaced. That is a very real and understandable worry. The fact that you are having recurrent falls and are unable to get up by yourself means we need to take this very seriously. The goal is to build up your strength and confidence again.
Next Steps:
There isn’t one single reason why you are falling. It’s likely a combination of things – the mild weakness from your stroke, your blood pressure medication, and perhaps a loss of muscle strength are all possible contributing factors. We need a team approach to this. I am going to refer you to the ‘Falls Clinic’, which is a specialist outpatient service for people in your exact situation.
Lifestyle Modifications/self-help measures:
At the falls clinic, you will be seen by a physiotherapist who will give you a personalised exercise programme to improve your balance and strength. This is the most effective thing we can do to prevent falls. An occupational therapist will also talk to you about making your home safer, for example, by removing trip hazards and installing grab rails.
While you are waiting for the clinic appointment, the physiotherapist here in the hospital will come to see you to teach you the correct technique for getting up from the floor, just in case you do have another fall. We can also give you information about a community alarm service, which is a pendant you can wear and press to get help if you fall and can’t get up.
We will see how you get on in the next day or two, and I will have a chat with my senior. If you are feeling better and more confident, then we can discharge you to continue having these exercises and support in the community. We will also write to your GP, who can continue monitoring you and see how you get on.
Addressing ideas, concerns, and expectations: Reframe falls from an inevitable part of ageing to a medical problem with solutions. Validate her fear of further injury.
The key management is a referral to the multi-disciplinary falls service. Explain the roles of the different team members (physio for strength and balance, OT for home assessment). Provide an interim safety plan (physio to teach getting up, community alarm).
What is scenario testing? This case tests the candidate’s knowledge of the multifactorial approach to managing falls in older adults. The focus is not on finding a single diagnosis but on initiating a holistic, multi-disciplinary management plan. The key is to demonstrate an understanding of the roles of physiotherapy, occupational therapy, and medication review.