CASE INFORMATION

Case ID: PH-014
Case Name: John Peterson
Age: 72 years
Gender: Male
Indigenous Status: Non-Indigenous
Year: 2025
ICPC-2 Codes: K89 – Postural Hypotension

COMPETENCY OUTCOMES

Competency Domain	Competency Element
1. Communication and Consultation Skills	1.1 Engages the patient to understand concerns, ideas, and expectations 1.2 Provides clear explanations tailored to the patient’s level of health literacy 1.4 Uses effective consultation techniques, including active listening and empathy
2. Clinical Information Gathering and Interpretation	2.1 Takes a thorough history to assess dizziness and postural symptoms 2.2 Identifies red flags requiring urgent investigation
3. Diagnosis, Decision-Making and Reasoning	3.1 Develops a differential diagnosis for postural hypotension 3.2 Determines appropriate investigations based on history and risk factors
4. Clinical Management and Therapeutic Reasoning	4.1 Develops an evidence-based management plan 4.2 Provides pharmacological and non-pharmacological treatment options
5. Preventive and Population Health	5.1 Discusses lifestyle modifications and fall prevention strategies
6. Professionalism	6.1 Maintains patient confidentiality and demonstrates ethical practice
7. General Practice Systems and Regulatory Requirements	7.1 Ensures appropriate follow-up, documentation, and specialist referrals
9. Managing Uncertainty	9.1 Provides reassurance and safety-netting when the diagnosis is unclear
10. Identifying and Managing the Patient with Significant Illness	10.1 Recognises when postural hypotension is secondary to a more serious underlying condition

CASE FEATURES

Elderly male presenting with dizziness and near-falls upon standing.
Exploring potential causes, including medication effects, autonomic dysfunction, dehydration, and cardiovascular causes.
Assessing risk factors for falls and fractures.
Balancing reassurance with appropriate investigation and management.
Providing non-pharmacological and pharmacological strategies to manage postural hypotension.

INSTRUCTIONS

You have 15 minutes to complete the tasks for this case.

You should treat this consultation as if it is face-to-face.

You are not required to perform an examination.

A patient record summary is provided for your information.

Perform the following tasks:

Take an appropriate history.
Outline the differential diagnosis and key investigations required.
Address the patient’s concerns.
Develop a safe and patient-centred management plan.

SCENARIO

John Peterson, a 72-year-old retired teacher, presents with episodes of dizziness and light-headedness when standing up from sitting or lying down over the past few months. He reports one near-fall last week, where he felt like he was going to faint but managed to sit down in time.

He is concerned about falling and whether his medications could be causing this.

PATIENT RECORD SUMMARY

Patient Details

Name: John Peterson
Age: 72
Gender: Male
Gender Assigned at Birth: Male
Indigenous Status: Non-Indigenous

Allergies and Adverse Reactions

No known drug allergies

Medications

Perindopril 5mg daily (for hypertension)
Metformin 500mg BD (for type 2 diabetes)
Tamsulosin 0.4mg daily (for benign prostatic hyperplasia)

Past History

Hypertension (diagnosed 8 years ago)
Type 2 diabetes (diagnosed 5 years ago)
Benign prostatic hyperplasia (BPH) (diagnosed 2 years ago)
Mild osteoarthritis

Social History

Retired high school teacher.
Drinks 1-2 glasses of wine on weekends.

Family History

No family history of neurodegenerative disorders.
Father had a stroke at age 78.

Smoking

Quit smoking 15 years ago, previously smoked 10 pack-years.

Alcohol

Drinks 1-2 standard drinks per week.

Vaccination and Preventative Activities

Up to date with vaccinations.
Last health check was 1 year ago.

ROLE PLAYER INSTRUCTIONS

Just like a consultation with a doctor, the candidate will ask you a series of questions.
The OPENING LINE is always to be said exactly as written. This is the only part of the script
which will be the same for all candidates. Where the candidate goes after the opening line is
up to them.

The remainder of the information is to be given based on the questions asked by the
candidate.

The information in the following script are core pieces of information. The core pieces of
information will not necessarily follow the order in the script but should be given when cued
by the candidate’s question.

GENERAL INFORMATION can be given relatively freely. After the opening line, most
candidates will ask an open question like “Can you tell me more about that?” You can provide
the GENERAL INFORMATION in response to that sort of question.

SPECIFIC INFORMATION should only be given when the candidate asks a relevant question.
Candidates don’t need to ask for all the information in the SPECIFIC INFORMATION section,
but all the relevant information is given there should they want to.

Each line or dot point in the SPECIFIC INFORMATION section is an appropriate chunk of
information which can be provided to the candidate when asked a relevant question.

Do not give extra information than asked.

Do not provide details which are not given in the information chunks (i.e.: do not elaborate
or ad-lib).

If the candidate asks a question that is not given in the script, the best way to respond is with
a generic response indicating there is no problem. For example:

Candidate: “How many hours do you sleep?”
Response: “I’m sleeping fine.” / “I don’t have any concerns about my sleep.”

The case may have specific QUESTIONS to ask the candidate. You can start asking the
QUESTIONS if the candidate asks about your ideas or concerns or questions.

Ask the other questions in a conversational way. You do not need to ask all the questions. The
aim should be to ask most of the questions but without interrupting the candidate.

The Patient Record Summary is also included. This is not part of the script but is included for
your general information.

If you need help in understanding any of the medical information in the script, ask the College
examiner who will be with you, and they can help to explain the terms or the conditions.

ROLE-PLAYER SCRIPT

Opening Line

“Doctor, I’ve been feeling dizzy when I stand up lately, and I almost fell last week. Could it be my blood pressure tablets?”

General Information

Your name is John Peterson, and you are 72 years old.
You are a retired high school teacher, living at home with your wife.
You are generally independent in your daily activities.
You walk most days, but you have been avoiding walks lately due to fear of falling.

Specific Information

(Reveal only when asked directly)

Background Information

You had a routine health check last year, and everything was normal except for your blood pressure and diabetes, which are managed with medications.
You don’t recall having these dizziness episodes before, and this is the first time you have had a near-fall.
For the past few months, you have noticed dizziness and light-headedness when standing up.
The dizziness is brief (a few seconds) and happens mostly in the morning.
It also sometimes happens after meals or after standing for a long time.
You had a near-fall last week, where you suddenly felt weak and had to grab onto the chair to stop from falling.
You feel fine when sitting or lying down.
You don’t feel light-headed all the time, only when changing positions.

Symptoms and Triggers

The dizziness is not spinning (not like vertigo), but rather a feeling of light-headedness or faintness.
It improves when you sit down again.
You have no chest pain, palpitations, or breathlessness.
You sometimes feel weak after long walks.
You notice it more in the morning and sometimes after meals.

Medication and Fluid Intake

You take perindopril for high blood pressure, which was well-controlled at your last check-up.
You take tamsulosin for an enlarged prostate, which you started about a year ago.
You take metformin for diabetes, but your blood sugar levels have always been stable.
You do not drink much water—only 3-4 glasses per day.
You have not missed meals and do not have low blood sugar episodes.

Concerns and Expectations

You are worried about falling and getting injured.
You want to know if your blood pressure medications are causing this.
You are concerned about whether this is a sign of something serious, like a stroke or Parkinson’s disease.
You want to know if you need tests or a scan.
You want to keep your independence and stay active but are worried about your balance.

Red Flag Symptoms (Reveal only when asked directly)

No fainting or blackouts.
No headaches, blurred vision, or hearing problems.
No slurred speech, facial droop, or limb weakness.
No tremors, stiffness, or slowing of movement.

Emotional Cues & Body Language

You appear concerned but not panicked.
If the doctor is vague or avoids answering directly, you will ask:
- “Could this be something serious, like a stroke?”
If the doctor suggests waiting before changing medications, you may ask:
- “But what if I fall in the meantime?”
If the doctor explains things well and gives a clear plan, you will feel reassured and motivated to follow their advice.

Questions for the Candidate

(Ask these naturally throughout the consultation.)

“Could this be a stroke or something serious?”
“Is this because of my blood pressure medication?”
“What can I do to stop feeling dizzy when I stand up?”
“Do I need tests or scans for this?”
“Should I stop my medications or change them?”
“Am I at risk of falling, and how can I prevent it?”
“Would drinking more water help?”
“Should I avoid walking outside alone?”

Key Behaviours & Approach

You are worried about falling and want practical solutions.
If the doctor only talks about medications and doesn’t discuss lifestyle changes, you will ask:
- “Is there anything I can do apart from changing my pills?”
If the doctor mentions dehydration, you may say:
- “I never thought about that. How much water should I drink?”
If the doctor explains everything well and offers reassurance, you will feel more confident in managing the condition.

Additional Context for the Role-Player

You want to maintain independence and are afraid of falling.
You trust medical advice but want clear explanations and a structured plan.
You are open to lifestyle modifications but need specific instructions.
You do not want unnecessary tests or procedures, but you don’t want to ignore a serious condition either.

Role-Player Summary

This case assesses the candidate’s ability to:

Take a structured history, identifying causes of postural hypotension.
Provide a differential diagnosis, considering medications, dehydration, autonomic dysfunction, and cardiovascular causes.
Offer appropriate management, including medication review, fluid intake advice, and lifestyle modifications.
Reassure the patient while ensuring appropriate follow-up.
Discuss fall prevention strategies, improving patient safety and confidence.

THE COMPETENT CANDIDATE

The competent candidate should be able to:

Task 1: Take an appropriate history from the patient, considering possible causes and risk factors for postural hypotension.

The competent candidate should:

Elicit a detailed symptom history, including onset, duration, frequency, and triggers of dizziness.
Clarify symptom characteristics, asking about:
- Timing (e.g., on standing, after meals, in the morning).
- Duration (brief or persistent episodes).
- Associated symptoms (palpitations, chest pain, blurred vision, falls).
Assess medication history, identifying antihypertensives, diuretics, or vasodilators (e.g., tamsulosin).
Explore lifestyle factors, including fluid intake, alcohol use, diet, and recent illness.
Screen for falls risk, asking about previous falls, use of walking aids, and fear of falling.
Assess cardiovascular and neurological red flags, such as syncope, persistent weakness, or neurological deficits.
Address patient concerns, particularly about stroke, Parkinson’s disease, and loss of independence.

Task 2: Formulate a differential diagnosis and explain it to the patient.

The competent candidate should:

Explain that postural hypotension (orthostatic hypotension) is the most likely diagnosis, given symptoms and risk factors.
Discuss other possible causes, including:
- Medication-related hypotension – due to perindopril and tamsulosin.
- Dehydration – from low fluid intake or heat exposure.
- Autonomic dysfunction – possible in diabetes or Parkinson’s disease.
- Cardiac causes – arrhythmias or aortic stenosis (less likely).
- Anaemia or blood loss – if there were fatigue, pallor, or history of GI bleeding.
Reassure the patient that a stroke is unlikely, as symptoms are positional and brief, without focal neurological signs.
Explain that further tests may be needed to confirm the cause.

Task 3: Address the patient’s concerns, including fall risk, long-term management, and potential medication adjustments.

The competent candidate should:

Reassure the patient that postural hypotension is common in older adults and often manageable.
Explain that falls prevention is key, as postural hypotension increases the risk of injury.
Discuss potential medication adjustments, including:
- Reviewing perindopril dosage if blood pressure is too low.
- Considering alternatives to tamsulosin, which can worsen hypotension.
Provide education on symptom management, including:
- Standing up slowly and avoiding sudden postural changes.
- Drinking more fluids and ensuring adequate salt intake (unless contraindicated).
- Wearing compression stockings if indicated.
- Avoiding alcohol and heavy meals that worsen hypotension.
Provide clear instructions on when to seek medical attention, such as if symptoms worsen, lead to falls, or become unpredictable.

Task 4: Develop an initial management plan, including investigations, lifestyle modifications, and follow-up.

The competent candidate should:

Confirm the diagnosis with lying and standing blood pressure readings (drop of ≥20 mmHg systolic or ≥10 mmHg diastolic).
Consider additional tests, such as:
- ECG to rule out arrhythmias.
- FBC and iron studies if anaemia is suspected.
- Electrolytes and renal function to assess for dehydration or medication effects.
- Autonomic function tests if neurogenic causes are suspected.
Review medications, considering:
- Adjusting antihypertensives if needed.
- Trialling an alternative to tamsulosin if worsening symptoms.
Provide non-pharmacological management, including:
- Increasing water intake to at least 1.5-2 litres per day.
- Encouraging slow position changes and isometric exercises (e.g., leg crossing when standing up).
- Recommending physiotherapy if gait stability is a concern.
Arrange follow-up in 2-4 weeks to assess response to interventions.

SUMMARY OF A COMPETENT ANSWER

Takes a structured history, assessing medications, symptoms, fall risk, and red flags.
Provides a clear differential diagnosis, explaining why postural hypotension is likely.
Addresses patient concerns empathetically, particularly about stroke, medication side effects, and independence.
Develops an evidence-based management plan, balancing lifestyle changes, medication review, and monitoring.
Ensures appropriate safety-netting, advising when to return if symptoms worsen.

PITFALLS

Failing to assess for red flags, such as neurological symptoms or cardiac causes.
Overlooking medication side effects, particularly tamsulosin and antihypertensives.
Not providing falls prevention advice, missing an opportunity to reduce risk of injury.
Over-relying on medications, instead of encouraging lifestyle changes first.
Not scheduling follow-up, leaving the patient uncertain about management.

REFERENCES

MARKING

Each competency area is assessed on the following scale from 0 to 3.

☐ Competency NOT demonstrated
☐ Competency NOT CLEARLY demonstrated
☐ Competency SATISFACTORILY demonstrated
☐ Competency FULLY demonstrated

1. Communication and Consultation Skills

1.1 Communication is appropriate to the patient’s concerns and sociocultural context.
1.2 Engages the patient to gather information about symptoms, concerns, and expectations.
1.4 Communicates effectively in routine and difficult situations.

2. Clinical Information Gathering and Interpretation

2.1 Elicits a comprehensive history, including medication review and risk factors.
2.2 Orders appropriate investigations, balancing clinical suspicion and patient safety.

3. Diagnosis, Decision-Making and Reasoning

3.1 Develops a structured differential diagnosis, prioritising postural hypotension, medication effects, and neurological causes.
3.2 Identifies indications for medication review or further testing.

4. Clinical Management and Therapeutic Reasoning

4.1 Develops a structured, evidence-based treatment plan, incorporating medication review and lifestyle interventions.
4.2 Provides pharmacological and non-pharmacological treatment options, ensuring a patient-centred approach.

5. Preventive and Population Health

5.1 Discusses fall prevention strategies, including hydration, standing techniques, and physiotherapy.

6. Professionalism

6.1 Maintains confidentiality and ethical decision-making.

7. General Practice Systems and Regulatory Requirements

7.1 Ensures accurate documentation and appropriate follow-up.

9. Managing Uncertainty

9.1 Provides reassurance and safety-netting, ensuring the patient understands when to seek further medical care.

10. Identifying and Managing the Patient with Significant Illness

10.1 Recognises features suggestive of serious disease requiring escalation.

Competency at Fellowship Level

☐ CLEARLY BELOW STANDARD
☐ BELOW EXPECTED STANDARD
☐ BORDERLINE
☐ AT EXPECTED STANDARD
☐ ABOVE STANDARD