A 68-year old gentleman is seen for follow up. He has recently been diagnosed with heart failure. His echocardiogram shows a reduced ejection fraction. On reviewing his medications you can see that he has been taking atenolol going back many years for hypertension.
Which of the following beta blockers would you recommend he switches to in order to enhance his heart failure treatment?
A 75-year-old man presents with a short history of increasing confusion.
Preceding this, he fell three weeks ago in the bathroom. In the afternoon he was examined by his GP and he was alert with a normal physical examination. The patient has a history of hypertension for which he takes bendroflumethiazide.
Three weeks later the patient was visited at home because the dazed state had returned. He is afebrile, has a pulse of 80 per minute regular and blood pressure of 152/86 mmHg. His response to questions is slightly slowed, he is disoriented in time and there is some deficit in recent memory.
The patient moves slowly, but muscle strength is preserved. Neurologic examination shows slight hyperactivity of the tendon reflexes on the right. Plantar responses are unclear because of bilateral withdrawal. That gives him a GCS score of 14.
Which of the following would be the most appropriate next investigation for this man?
A 70-year-old man is referred with a three month history of progressive disorientation and falls.
Four weeks beforehand, he locked his wife out of their house, claiming that she was trying to steal his clothes. He had also telephoned the police in the middle of night, claiming that he could see men hiding under his bed.
On examination, his face is expressionless, his speech is quiet and monotonic. There are no cranial nerve palsies, otherwise. Increased tone is present in all four limbs, with a slow festinant gait. Reflexes, power and sensation are all normal.
Halfway through your examination he tells you that he is leaving the room, because of the lobsters coming through the window. Unfortunately, therefore, formal cognitive testing and basic investigations cannot be performed.
Based on this evidence, what is the most likely diagnosis?
A 93-year-old patient of yours wants to make an advanced decision but his family are not sure that he fully understands what he is doing. You have to assess his competence.
Which of the following statements about competence is correct?
During a new patient consultation for an 82-year-old man who has recently joined the practice, you observe that he is significantly underweight and suspect that he may be malnourished. As per NICE guidelines, what is the BMI threshold for diagnosing malnutrition?
Barbara is a 78-year-old woman who lives alone and manages most activities of daily living independently. Her GP wants to assess her frailty with a view to identifying the need for extra support.
Which of the below is most useful for that assessment?
A 26-year-old female who is obese visits her GP complaining of headaches and blurred vision. Upon examination, the GP notes bilateral blurring of the optic discs but no other neurological signs. The patient’s blood pressure is 130/74 and she has no fever. What is the probable underlying diagnosis?
A senior, delicate lady is admitted to the nearby nursing home following a stroke. How can her risk of developing a pressure ulcer be evaluated appropriately?
John is a 91 year old man with severe dementia. He has been relatively stable over the past two years with a gradual decline in cognition. The nursing home contacts you to report that he has been exhibiting more aggressive behavior, including swearing and hitting staff, over the past month and requests a review. What would be the most suitable approach to managing this situation?
A 33-year-old presents for review after experiencing a ‘collapse’ while at a concert. She reports feeling overheated and nauseous when she stood up to dance. Shortly after, she felt herself losing consciousness and fell to the ground. Her partner observed some twitching in her arms, but there was no evidence of tongue biting or urinary incontinence. She quickly regained consciousness and continued to enjoy the concert. On examination today, there are no neurological abnormalities. What advice should be given regarding driving?