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You are an FY2 doctor working at a GP surgery. A patient enters to see you. Colin Oscopy is a 50-year-old gentleman who has presented following a fall last week. It is the first time that this has happened. He has type 2 diabetes, controlled by his diet. He is concerned that his fall is due to diabetes, and would like to discuss this today. He also states he has had palpitations for the last week.

His medications include: Aspirin Propanolol Simvastatin Ramipril Please take a history and perform an appropriate examination, focussing on the patient’s concerns.

HPC: You are Colin Oscopy, a 50-year-old gentleman who has presented following a fall last week. It is the first time that this has happened. You have type 2 diabetes, controlled by your diet. Over the past few months you have developed a chest pain. This comes on with exertion and occasionally spreads down both arms. The pain is dull in nature. You have also noticed palpitations for the last week. These have started to come on with exertion.

ICE: When asked specifically about concerns, you are very worried about your diabetes and think a ‘hypo’ caused the fall. Your father died from type 1 Diabetes when you were young and you are convinced that this will also happen to you.

PMH: Type 2 Diabetes, high cholesterol, hypertension, Rheumatoid Arthritis

DH: Aspirin, Propanolol, Simvastatin, Ramipril, and Methotrexate You are not allergic to anything you know of

SH: You live with your wife and three children. Your son has recently qualified as a junior doctor in Leeds. You don’t drink alcohol but used to smoke cigarettes, starting when you were 16.

FH: Your Dad had Type 1 Diabetes; heart disease runs in your maternal family.

The student should demonstrate a good falls history, and include questions specific to assessing for cardiovascular causes of falls. A cardiovascular examination should be performed and you should feedback that a systolic murmur can be heard on auscultation.

The student’s differential diagnosis should sound something like:

My differential diagnosis would be a l fall, secondary to a cardiovascular cause: specifically Aortic Stenosis. This is due to Colin’s history of palpitations and angina, in addition to a systolic murmur on examination. I would also want to rule out other causes such as syncope and arrhythmia. Example questions for discussion may include:

  • How would you investigate this patient?
  • How would you manage this patient?I
  • What are the typical symptoms in Aortic Stenosis?
  • What ECG and CXR findings would you expect to find in severe AS? -How could Colin’s medications have contributed to his fall? -What are the side effects of methotrexate?