OPIC SBA & SAQs

Question 1

Define acute confusion , dementia and delirium

Answer 1

Acute confusion = acute deficit in thinking, short-term memory and orientation with reduced awareness

Dementia = chronic deficit in thinking, memory and/or personality

Delirium = acute onset confusion with hallucinations or illusions

Question 2

Give 3 common causes of dementia and describe the underlying pathology

Answer 2

Alzheimer’s disease (about 50%) Degeneration of the cerebral cortex, with cortical atrophy, neurofibrillary tangles, and amyloid plaque formation

Vascular dementia (about 25%)
Brain damage due to cerebrovascular disease: either major stroke, multiple infarcts or chronic changes in smaller vessels (subcortical dementia)

Dementia with Lewy bodies (about 15%)
Deposition of abnormal protein within neurons in the brain stem and neocortex

Question 3

How you would adapt your history taking/information giving for a patient with cognitive impairment?

Answer 3

• Allow for extra time
• Arrange appointment at beginning/end of day to make sure it is quiet or consider a home visit
• Draw pictures or write if needed
• Use simple terms, speak slowly, low pitch
• Collateral history

Question 4

Stuart is a 57 year old lorry driver who presents with a 6 month history of slowness of gait and difficulty with writing. Fine hand movements are poor. In the past he has seen a urologist with urgency of micturition and occasional incontinence. He is taking sildenafil and an inhaler for asthma.

On examination there is slowness of gait, facial hypomimia and cogwheel rigidity in all 4 limbs.

He is started on co careldopa but, when seen 4 months later, is not significantly improved. The dosage is therefore increased. 3 months later he is still no better.

What does this suggest and what might be the reason for this?

Answer 4

Alternative diagnosis e.g. MSA

OR

Could suggest that his PD is so advanced that he no longer has enough doperminergic neurones to be stimulated to release dopamine therefore no substrate for co-careldopa to work on.

Question 5

What is meant by on/off fluctuations in patients who are taking levodopa preparations and why do they occur?

Answer 5

The “on-off” phenomenon in Parkinson’s disease refers to a switch between mobility and immobility in levodopa-treated patients, which occurs as an end-of-dose or “wearing off” worsening of motor function

Question 6

What is the Comprehensive Geriatric Assessment? List advantages and disadvantages of using this approach

Answer 6

A multidimensional interdisciplinary diagnostic process focused on determining a frail elderly person’s medical, psychological and functional capability in order to develop a plan for treatment and follow-up.

Advantages:
* NNT 17 to avoid one death at 6 months
* people more likely to remain active with lower levels of dependency compared to standard treatment of presenting complaint

Disadvantages:
* only seems to be effective when the whole multidisciplinary team are involved which can be trciky to facilitate

Question 7

What are the main reasons the elderly are more prone to drug toxicity?

Answer 7

• redcued renal function (MAIN REASON)
• decreased body size, altered body composition (more fat, less water)
• drug interactions due to polypharmacy

Question 8

Which medications should be used with particular care in the elderly?

Answer 8

• NSAIDs
• opioids
• anticholinergics
• antipsychotics
• benzos
• SSRIs

Question 9

Why should co-prescribing NSAIDs and ACE inhibitors be avoided?

Answer 9

Both nephrotoxic- can cause AKI

Question 10

Outline findings from the history, examination and investigation of vasovagal syncope

Answer 10

Hx: Onset in seconds; precipitated by fear, stress, pain or standing

Ex: Possible postural drop, otherwise normal.

Ix: No abnormal findings

Question 11

Outline findings from the history, examination and investigation of cardiac syncope

Answer 11

Hx: Sudden onset and recovery. Chest pain,
palpitations and/or shortness of breath.

Ex: Fast, slow or irregular pulse.

Ix: Arrhythmia or MI on ECG; raised cardiac markers.

Question 12

Outline findings from the history, examination and investigation of a neurological cause of fall

Answer 12

Hx: Rapid onset, headache, decreased GCS,
weakness, altered sensation

Ex: Focal neurology, persistently abnormal GCS.

Ix:CVA or intracranial haemorrhage on CT.
Check glucose!

Question 13

Outline findings from the history, examination and investigation of a seizure

Answer 13

Hx: Possible aura, no memory of fall.
Abnormal limb movements, tongue biting, incontinence, post-ictal phase.

Ex: Drowsy, injuries, possible Todd’s paralysis, but could also be normal examination.

Ix: Initial investigations often normal, may have raised prolactin (check glucose).

Question 14

4 questions should an Advanced
Care Plan address?

Answer 14

At this time in your life, what is important to you?

What elements of care are important to you and what WOULD you like to happen in future?

What would you NOT want to happen? Is there anything that you worry about happening?

Who would speak for you - your nominated spokesperson or Lasting Power of Attorney?

Question 15

Give 3 barriers to carers accessing support

Answer 15

A lack of information

Reluctance to use services because of a sense of duty

Restrictions in service use due to cost or lack of availability

Question 16

Give 3 questions that you might use as part of a spiritual history

Answer 16

What support do you have? Do you have people you can talk to?

What is your greatest worry?

What would be the most helpful thing for you? What do we need to know about you to give you the best care?

What gives your life meaning?

Where do you get your strength from?

Is religion or faith important to you?

Question 17

Mr Lang is 83-year-old with a known diagnosis of vascular dementia. His wife died three years ago and he was unable to cope alone at home.

His dementia has worsened. In particular, it affects his speech: he has expressive dysphasia with obvious word-finding problems. Nevertheless, it is felt that he can understand most things said to him. The GP is called in because Mr Lang looks unwell.

Mr Lang complies with an examination and the GP confirms that he has a chest infection.

What legal and ethical factors must the GP consider when developing a management plan for this patient?

Answer 17

GMC guidance on consent: patients and doctors making decisions together (GMC 2008)

Capacity to consent both to examination and to treatment for his chest infection and to
regular analgesia for his pain, despite his communication difficulties

Keeping a written record of the consultation and of the decisions that were made

Mental Capacity Act

Question 18

What 3 factors are assessed as part of the MUST score?

Answer 18

Question 19

What should you do for patients who score as high risk on the MUST score?

Answer 19

Refer to Dietician

Provide first line dietary advice: ‘Food First’ approach
-Provide 2 homemade high calorie drinks a day
-Provide high calorie/ high protein fortified diet
-Provide 2 nourishing snacks a day in between
meals

Re-weigh weekly

Document action taken

Question 20

What is the inverse care law?

Answer 20

those who need care the most are the least likely to receive it

Question 21

A 73 year old man presents to A&E after a fall. You treat a head wound and perform a full medication review. He has a postural drop on assessment. Which one of these medications has most likely contributed to the fall ?
1. Codeine
2. Digoxin
3. Ramipril
4. Carbamazepine
5. Sertraline

Answer 21

3. Ramipril

Question 22

A 87 year old gentleman is having repeated falls. As part of the assessment you conduct a medication review.

Which one of these drugs does NOT contribute to an increased falls risk?

1. Candesartan
2. Chlorpheniramine
3. Fludrocortisone
4. Amitriptyline
5. Zopiclone

Answer 22

3. Fludrocortisone

Question 23

A 82 year old woman comes to the GP complaining of involuntary leakage of urine while coughing and laughing. She also has urgency. Her symptoms have been present for 6 months. What is the most useful test?

1. Urinary dipstick
2. HbA1c
3. Bloods including FBC and U&Es
4. Post void bladder scan
5. Cystoscopy

Answer 23

4. Post void bladder scan

Question 24

Where do fragility fractures most commonly occur?

Answer 24

spine (vertebrae), hip (proximal femur) and wrist (distal radius)

Question 25

Define osteoporosis

Answer 25

syndrome associated with low bone mass and micro architectural deterioration of bone tissue with increased risk of fractures

Question 26

An elderly patient presents with an unexplained fall. On investigation they have a low Hb. Which of these medications may have contributed to the fall?

1. Codeine
2. Digoxin
3. Ramipril
4. Carbamazepine
5. Sertraline

Answer 26

5. Sertraline - increases risk of GI bleed

Question 27

What is the definition of postural hypotension?

Answer 27

Drop in blood pressure of >20 mmHg systolic or > 10 mm Hg diastolic

Question 28

How would you direct a patient to take thier oral bisphosphonates?

Answer 28

empty stomach, NBM 30 mins after, 240ml of water, upright for 30 mins

Question 29

Why may you operate on a patient with a fracture despite them having reduced mobility?

Answer 29

To ensure pain control and reduce opioid requirements
To allow good nursing care
To allow sitting out
To allow chance to regain function

Question 30

A 88 year old male presents to A&E after a witnessed fall in a nursing home. He sustained a head injury during the fall. On examination his GCS is 15/15 and carers report there is no change in his mental state.
He has not vomited or had a seizure since the event. There was no LOC and he can give a full account of tripping and landing. He is normally anticoagulated for AF with warfarin and his INR is within target range on admission to hospital.

What in the history warrants a head CT and in what time frame should it be completed?

Answer 30

Warfarin treatment alone, CT within 8 hours (if not other red flag sxs)

Question 31

A 92-year-old lady with severe Alzheimer’s dementia can no longer recognise her daughter and her behaviour has begun to fuctuate signifcantly. She has recently lost signifcant weight and it has become impossible to ensure adequate intake through meals alone.

Which one of these options is appropriate?
1. Insert long term PEG
2. Replace toast with fortisip at breakfast to make up
calories
3. Hand feed blended normal foods
4. Give top-up feeds by NG tube once a week
5. Stop consumption of sugary food and replace with high fat foods

Answer 31

3. hand feed blended normal food

Question 32

What do you need to consider when thinking about feed options for patients with dementia?

Answer 32

Swallowing
Chewing
Mouth care
Thirst sensation/hunger sensation
Risk of aspiration

Question 33

72year old female, background of multiple previous strokes, now hoist transfer with QDS POC. Admitted with SOB and
cough. She is treated for a right CAP, hypoactive delirium, and urinary retention secondary to constipation.

How many risk factors does she have for pressure sores?

Answer 33

4 - older age, female, hoist transfer, right CAP