MD Acumen · PLAB 2 OSCE / CPSA course · free practice resources
Practice case P2-35 · Face-to-face · simulated patient
“I went down again in the kitchen” — an 82-year-old after another fall
An 82-year-old widower has been brought to the surgery by his daughter after a fall in his kitchen yesterday — his third this year. He was not hurt this time and says he is “fine”.
Reviewed and kept current
Station family: History, diagnosis and management · 8-minute station · 1 min 30 s reading · Last editorial review: 16 October 2026 · Next scheduled refresh: 11 April 2027.
Candidate instructions
Read this as you would outside the room
You have 1 minute 30 seconds to read, then 8 minutes. Candidates: everything below this section is folded away — leave it closed until you have finished the station.
| Information | |
|---|---|
| Your role | Foundation Year 2 doctor in a general practice. Your supervising GP and the practice clinical pharmacist are available; the community falls and frailty service accepts practice referrals. |
| Patient | Mr Bernard Hale, 82, retired joiner. His daughter Susan drove him in and is in the waiting room at his request. |
| Reason for appointment | Booked by his daughter: “Dad fell again yesterday — third time this year. Not hurt. Wants his tablets looked at.” |
| Records | Amlodipine 10 mg daily (hypertension); tamsulosin 400 micrograms daily (prostate); zopiclone 7.5 mg at night (repeat for three years); amitriptyline 25 mg at night (“back pain and sleep”, started last year). Colles’ fracture of the left wrist after a fall on the pavement 18 months ago; no bone health assessment recorded. Blood pressure 128/72 sitting six weeks ago. eGFR 58, normal sodium and blood count four months ago. Lives alone; widowed two years. Non-smoker. |
Your task
•
Take a focused history of the falls.
•
You may ask for examination findings; they will be read out to you.
•
Explain to Mr Hale what you think is causing the falls, and agree a plan with him.
Folded away
For the actor and the examiner
1 · Actor script — role player only
Candidates: do not open until you have consulted.
Persona and manner
- Bernard Hale, 82, retired joiner, widowed two years. You live alone in the house you bought in 1971; your daughter Susan lives twenty minutes away and visits most days. You have an allotment and two grandchildren you adore.
- Proud and understated — “I’m fine” is your answer to most things. You are more worried than you let on, and you are frightened of ending up “in a home”. You do not like being talked about as if you were not there.
Opening line — say this verbatim
- “I went down again in the kitchen yesterday, doctor. I’m not hurt. Susan made me come — she thinks it’s the tablets.”
Volunteer freely if given the space
- Yesterday morning: you got up from the table to put the kettle on, felt the room “swim”, and the next thing you were on the floor. You did not black out — “I knew where I was” — but you could not get up for about twenty minutes; you shuffled to the chair and pulled yourself up. Susan arrived at ten.
- This is the third fall this year: once in the bathroom at night in February (banged your hip), once at the allotment in May, and now this. The wrist fracture on the pavement was the year before.
- “I just need my tablets sorting. I’m rattling.”
Only if asked
- Each fall: all on standing up or soon after — from bed in the night, from kneeling at the allotment, from the table. Light-headed, the room swims, legs go. No chest pain, no palpitations, no warning other than the dizziness. You have never lost consciousness, never bitten your tongue or wet yourself, and nobody has seen you “go grey” or jerk. No weakness down one side, no speech trouble, no headache.
- The night-time falls: you get up two or three times a night to pass water (the prostate tablet helps a bit). You take the sleeping tablet at ten and feel “muzzy” when you get up in the night; it is the same tablet you were given when your wife died and “I can’t sleep without it”.
- The amitriptyline: Dr gave it for your back and to help you sleep; you are not sure it does much. Your mouth is dry and you are constipated.
- You take all the tablets in the morning except the two at night. No new medicines. You have not missed doses. You get your tablets in a blister pack from the chemist.
- Alcohol: a whisky at night, “a good one” — about a double. No more. You do not smoke.
- Eating: you have lost weight since your wife died — “she did the cooking”; mostly toast and soup; you have not weighed yourself. No trouble swallowing. Bowels: constipated. No blood.
- Eyes: you wear glasses for distance; the reading glasses are your wife’s. Last eye test — “a good few years”. You do not think you have cataracts; nobody has said.
- Feet: your toenails are hard to cut; you wear slippers in the house. Hearing: a bit deaf in the left ear.
- Home: a terraced house, stairs with one rail, bathroom upstairs, no grab rails; loose rug in the hall; you keep the heating low to save money. No alarm pendant — “Susan keeps on about it”.
- Driving: you still drive — short trips to the allotment and the supermarket — you have not had any dizziness while driving and have never fallen while out of the house except the pavement fall and the allotment. If asked whether you have had dizziness at the wheel: no.
- Memory: fine — you do the crossword. Mood: you miss your wife; some days are grey; you still enjoy the allotment and the grandchildren; nothing worse than that. Fear of falling: give this only if asked how the falls have affected you, or what you have stopped doing — or at the summary.
Impact on daily life — home and work (only if asked)
- You have stopped going to the allotment on your own since the May fall — Susan takes you on Sundays. You have stopped having a bath and “wash at the sink”.
- You sit more and do less; you have not been to the pub quiz for months. Your legs feel weaker than last year.
- Susan rings three times a day and has started talking about “somewhere with a warden”. You dread it. Money is tight on the pension.
Ideas, concerns and expectations
- Idea: “It’s the tablets — Susan read that the sleeping one makes you fall.”
- Concern: that you will break a hip like your neighbour did and never come home; that you will be “put in a home”; that the doctor will take your licence away.
- Expectation: the tablets sorted, and to be left in your own house.
Cues to deliver, timed
- Minute 2: “It’s always when I stand up. The room sort of swims.”
- Minute 4, if the doctor has not asked about night-time or the sleeping tablet: “It’s worse in the night. I’m like a drunk man going to the toilet.”
- Minute 6, if the doctor has not asked what you have stopped doing: “I don’t go up the allotment on my own any more. Susan won’t have it.”
If the doctor summarises and asks whether you want to add anything
- If fear of falling or the wrist fracture has not come up: “I didn’t say — I’m frightened of it now. I lie there at night thinking about it. And that wrist I broke on the pavement — nobody ever did anything about my bones after that. Should they have?”
- If both have: “Susan wants me in a home. I’d rather fall.”
How to respond to the doctor
- If the doctor explains that your blood pressure drops when you stand, that several of your tablets make that worse and make you unsteady, and proposes changing them one at a time with a plan to review: relieved — “That makes sense. Which one first?”
- If the doctor suggests stopping the sleeping tablet dead: alarmed — “I won’t sleep at all.” Accept a gradual reduction with an explanation.
- If the doctor mentions strength and balance classes or a physiotherapist: “I’m not sitting in a circle with a beach ball.” Soften if it is explained that it is about keeping you at the allotment and out of a home.
- If the doctor asks whether you would accept someone coming to look at the house (rails, the rug, the bathroom) and a pendant alarm: “If it keeps Susan quiet.”
- If the doctor asks whether Susan can be brought in to hear the plan: “Yes — but talk to me, not her.”
- If the doctor says nothing about your bones: ask at the summary.
- If the doctor says you must stop driving: upset — “That’s my independence gone.” If the doctor explains that nothing so far means you must stop or tell the DVLA, but that you must not drive if you feel dizzy or faint and that it will be reviewed: you accept.
- If jargon is used (“orthostatic hypotension”, “polypharmacy”, “FRAX”, “anticholinergic burden”): “You’ll have to put that in English.”
Do not
- Volunteer the fear of falling, the allotment, the bath, or the bone question unless asked about impact — or until invited to add anything (apart from the timed cues).
- Describe any blackout, chest pain, palpitations or weakness down one side — there were none.
- Agree to move out of your house.
Findings to give the candidate — only if asked for
If the candidate asks to examine you, or asks for observations or examination findings, read these out. Do not offer them otherwise. (Where a separate examiner is present, the examiner reads them.)
General: thin, alert, orientated; walks in slowly with a stick, slightly stooped, taking short steps; turns in several steps. Weight 62 kg, height 1.72 m, BMI 21. No injury. If only a “blood pressure” or a sitting reading is asked for: 138/78 sitting, pulse 68 (a single reading; the lying and standing readings are given only when asked for). Lying and standing blood pressure (if asked for — do it or read it out according to how it is requested): lying after 5 minutes 146/82, pulse 68 regular; standing at 1 minute 112/64 — he says “there it goes, the room’s swimming” — pulse 74; at 3 minutes 118/68, still a little light-headed. Cardiovascular: pulse regular, no murmur, no carotid bruit; ECG if requested — sinus rhythm 66, normal. Gait and balance: Timed Up and Go 19 seconds; cannot rise from the chair without using his arms; unsteady when turning; Romberg negative. Neurological: no focal deficit; mild loss of vibration sense at the ankles; reflexes present and symmetrical. Cognition: 4AT 0; recalls three words. Vision: wears distance glasses, last eye test “a few years ago”; reads the chart with glasses to 6/12. Feet: long toenails, worn slippers. Blood glucose 5.4 mmol/L if checked. Mood: if screened with two questions — low some days since his wife died, but still enjoys the allotment and his grandchildren.
2 · Examiner mark sheet — generic scheme plus the key facts for this case
Domain marks — with the key facts that earn a 4 at this station
| Domain (GMC wording) · key facts for this case | 1 | 2 | 3 | 4 | Score |
|---|---|---|---|---|---|
1 · Data gathering, technical and assessment skills
| ☐ | ☐ | ☐ | ☐ | /4 |
2 · Clinical management skills
| ☐ | ☐ | ☐ | ☐ | /4 |
3 · Interpersonal skills
| ☐ | ☐ | ☐ | ☐ | /4 |
| Station total | /12 |
Domain score (educational construct):
| Score | Descriptor |
|---|---|
| 1 | Unsatisfactory (did not achieve safe FY2 standard) |
| 2 | Borderline (just achieving minimum safe FY2 standard) |
| 3 | Satisfactory (competent and safe FY2 standard) |
| 4 | Good (exceeds FY2 standard) |
This 1–4 domain score and its descriptors are an Acumen educational construct: the GMC publishes the three marking domains and the four-mark maximum, but not the descriptors its examiners use, and it does not publish station mark sheets. See Legal & Regulatory.
Marks are 1 to 4 in each domain; the generic descriptor for each mark is on the mark scheme page, and the structure of the eight minutes is on the 8-minute station page. The full standard for this case is in section 3 and the GMC feedback statements, with examples from this case, are in section 4. The examination findings that the role player gives — only if the candidate asks for them — are at the end of section 1.
3 · Expanded station-specific marking standard — what earns 4, 3, 2 and 1 here
The top row is the full picture of what a competent FY2 could do at this station, including the working diagnosis with its justified differentials, the safety-net and the follow-up; lower rows describe how performance falls away. It is a debriefing aid, not a checklist to recite: nobody says every line in eight minutes, and a 4 is a judgement that the essentials — the italic key facts on the mark sheet — were done well, in plain language and at the patient’s pace. Acumen training standard — the GMC does not publish station mark sheets.
| Mark | Domain 1 · Data gathering, technical and assessment skills | Domain 2 · Clinical management skills | Domain 3 · Interpersonal skills |
|---|---|---|---|
| 4 |
|
|
|
| 3 | Falls, medicines and postural symptoms well characterised and the lying/standing blood pressure obtained; one of the 20 minutes he could not get up, alcohol, nutrition, vision and feet, driving or the fear of falling missing. | Correct diagnosis, medicines reviewed with a sensible order and the postural drop addressed, bone health and the falls service covered; one of the home assessment, alcohol and sleep, or the structured review date missing. | Warm and clear; one fear not addressed or the plan delivered a little quickly for a man of 82. |
| 2 | Hears “dizzy when I stand” and goes straight to the drug list; red flags screened only partly; examination findings not requested or lying/standing blood pressure not asked for; impact not explored. | Stops or changes several drugs at once with no review plan; or deals with the medicines but not the bones, the home or the strength and balance programme; or treats the sitting blood pressure as the problem and leaves amlodipine unchanged. | Pleasant but talks over him or to the examiner; the sleeping tablet removed without negotiation; the care-home fear unheard. |
| 1 | A medication list read back to him; little about the falls themselves; no examination findings requested. Or unsafe: does not establish whether he lost consciousness or screen for cardiac and neurological causes; or ignores that he could not get up and the symptomatic postural drop. | “Take care getting up” and a repeat prescription; no medication change; no referral; no safety-net. Or unsafe: stops zopiclone and amitriptyline abruptly without explanation; or adds another antihypertensive, a stronger hypnotic or an antihistamine for sleep; or tells him he must stop driving and must notify the DVLA on the basis of today’s findings; or dismisses the wrist fracture as irrelevant to his bones. | Patronising (“at your age”) or hurried; he stops contributing. Or unsafe: threatens him with a care home or the DVLA to force compliance, or dismisses his fear of falling. |
4 · GMC feedback statements — where underperformance was identified — with case-specific examples
A feedback statement marks where underperformance was identified in the consultation. With PLAB 2 results the GMC may attach any combination of the ten statements to a station — none, one or several. The right-hand column shows what each one looks like at this station. Record the statements that applied in the practice log.
| GMC feedback statement | Underperformance it signals (generic) | Case-specific examples |
|---|---|---|
| 1 · Consultation | Disorganised or unstructured consultation | Reads through the drug list before hearing what happened; no structure to the falls history; no summary before the plan. |
| 2 · Issues | Key issues or priorities not recognised | Treats it as a repeat-prescription review and does not recognise a recurrent faller with symptomatic postural hypotension, a previous fragility fracture and frailty who needs a comprehensive assessment. |
| 3 · Time | Poor time management | Spends five minutes on the prostate and the back pain; the lying and standing blood pressure, the bone question and the plan arrive in the last minute. |
| 4 · Findings | Abnormal findings or results, or their implications, not identified | Is told lying 146/82 and standing 112/64 with symptoms, Timed Up and Go 19 seconds and a Colles’ fracture after a fall from standing — and does not call any of them abnormal or connect them. |
| 5 · Examination | Physical examination or use of instruments not competent | Does not ask for lying and standing blood pressure, or asks for a single sitting reading; does not ask about gait, chair rise, vision, feet or cognition. |
| 6 · Diagnosis | Working diagnosis or differential diagnoses not correct | “You’re a bit unsteady” — no diagnosis; or blames age; cannot say why this is not syncope, a stroke or an arrhythmia; the bones never mentioned. |
| 7 · Management | Management plan not reflecting current best practice | Stops everything at once; or changes nothing; no referral to the falls service; no DXA; nothing about what to do if he falls again or feels faint at the wheel; no review date; Susan not involved. |
| 8 · Rapport | Rapport and sensitivity to the patient’s feelings and concerns not shown | Talks to the examiner or about him in the third person; patronises — “at your age, falls are to be expected”; or frightens him with the care home. |
| 9 · Listening | Verbal and non-verbal cues not used; poor active listening | Misses “It’s always when I stand up. The room sort of swims”, “I’m like a drunk man going to the toilet” and “I don’t go up the allotment on my own any more”; never invites him to add anything, so the fear of falling and the bone question are never heard. |
| 10 · Language | Language or explanations not understandable; understanding not checked | “You have orthostatic hypotension from polypharmacy and a high anticholinergic burden; I’ll calculate your FRAX and refer you for a DXA.” |
5 · Examiner points of fact and guidelines
Points of fact the examiner should have to hand
- NICE NG249 (Falls: assessment and prevention in older people and in people 50 and over at higher risk; published 29 April 2025 — replaced CG161): do not use falls risk prediction tools (1.1.1); in community settings ask people about any falls, when they present after a fall and opportunistically in routine appointments (1.1.2). Offer a comprehensive falls assessment and management to anyone who has fallen in the last year and is living with frailty, was injured and needed treatment, lost consciousness, could not get up independently, or has had two or more falls in the last year (1.1.3) — Mr Hale meets at least two (living with frailty; two or more falls in the last year).
- The comprehensive assessment (NG249 1.2.2) includes: alcohol; cardiovascular examination including a lying and standing blood pressure; cognition and mood; diet, fluid intake and weight loss; dizziness (Dix–Hallpike if rotational vertigo); footwear and feet; functional ability and concerns about falling; gait, balance, mobility and muscle strength; hearing; long-term conditions; medication review; neurological examination; osteoporosis risk assessment; urinary continence; and visual impairment. Risk factors identified are promptly addressed (1.2.3).
- Interventions (NG249 section 1.3): tailored to the person’s risk factors (1.3.1); consider a structured medication review to identify and adjust medicines that increase falls risk (1.3.2); for people taking psychotropic medicines, review them, discuss the increased falls risk and plan withdrawal as appropriate (1.3.3 — zopiclone and amitriptyline here); encourage NHS advice on vitamin D for bone and muscle health, although the evidence that it prevents falls is insufficient (1.3.4); offer a home hazard assessment and intervention using a validated tool, ideally by an occupational therapist (1.3.5–1.3.6); refer to ophthalmology if cataracts are impairing vision (1.3.7); investigate cardioinhibitory carotid sinus hypersensitivity and consider pacing if falls are unexplained (1.3.8); consider a falls prevention exercise programme that is professionally delivered, progressive, tailored, focused on balance, coordination, strength and power, and long enough to change behaviour (1.3.9–1.3.10); consider cognitive behavioural interventions for concerns about falling that strength and balance exercise has not helped (1.3.11).
- Lying and standing blood pressure (Royal College of Physicians, July 2025 procedure): first reading after lying for at least 5 minutes; second within the first minute of standing; third after 3 minutes standing; repeat if still falling; record symptoms. A positive result is a drop in systolic pressure of 20 mmHg or more (with or without symptoms), a standing systolic below 90 mmHg even if the drop is smaller, or a diastolic drop of 10 mmHg with symptoms (clinically much less significant). Use a manual sphygmomanometer if possible. His drop of 34 mmHg with symptoms is positive.
- STOPP/START version 3 (O’Mahony and colleagues, European Geriatric Medicine 2023; the criteria themselves are in the supplementary file): the falls section lists drugs that predictably increase falls risk in susceptible older people, including vasodilators in people with persistent postural hypotension, hypnotic Z-drugs (zopiclone) in people with recurrent falls and alpha-blockers in people with recurrent falls or orthostatic hypotension. Other criteria cover tricyclic antidepressants in people with falls, orthostatic hypotension, prostatism or constipation; Z-drugs for insomnia beyond 2 weeks; and two or more drugs with anticholinergic properties. START supports bone-protective treatment, and vitamin D, after a previous fragility fracture. (The BNF zopiclone monograph carries the same STOPP caution for older adults.)
- NICE NG259 (Osteoporosis: risk assessment; published 29 July 2026 — replaced CG146): assess fragility fracture risk in all people aged 50 and over, and women who have experienced the menopause, who have had a previous fragility fracture or who use systemic glucocorticoids (1.1.1); and consider assessing all men aged 75 and over, all women aged 65 and over, and people aged 50 to 74 with risk factors including a history of two or more falls in the last year, hip fracture in a first-degree relative (particularly if they were under 80), low BMI, smoking and alcohol over 14 units a week (1.1.2). A distal radius fracture after a fall from standing height is a fragility fracture; Mr Hale should have been assessed 18 months ago. NG259 1.3.1: use FRAX or QFracture (ages 40–90) with a full clinical assessment; 1.4.1: offer DXA directly (with or without a tool) to anyone with a single major osteoporotic fragility fracture in the last 2 years — his wrist fracture 18 months ago qualifies (NG259 defines major osteoporotic fractures as spine, hip, shoulder and wrist).
- Deprescribing safely: stop or reduce one drug at a time and review; taper hypnotics after long-term use (zopiclone after three years will cause rebound insomnia and withdrawal if stopped abruptly — NICE NG215 on medicines associated with dependence or withdrawal; the BNF advises gradual withdrawal); taper tricyclics over weeks; when stopping or reducing antihypertensives use home readings and the standing pressure as the guide — the target in a frail older person with postural symptoms is the standing pressure he can tolerate, not the sitting number (NICE NG136 asks clinicians to use clinical judgement for frailty and multimorbidity, and to measure standing pressure in people with postural symptoms). Mouth dryness and constipation here are anticholinergic effects of amitriptyline.
- Driving (DVLA, Assessing fitness to drive, November 2025 edition; Appendix D): a fall without loss of consciousness carries no DVLA standard. Postural (orthostatic) hypotension needs notification only if a doctor considers it relevant to driving — for example dizziness or presyncope at the wheel. By contrast, unexplained loss of consciousness (one episode) means no driving for 6 months and DVLA notification; reflex vasovagal syncope with a reliable prodrome that has not occurred while driving needs neither. Advise him not to drive if he feels faint or dizzy, record the advice, and review it as medicines change. Zopiclone and amitriptyline can also impair next-day driving, so tapering them helps his driving safety too. BNF zopiclone: for older adults start at 3.75 mg, increasing to 7.5 mg only if necessary, for up to 4 weeks — his 7.5 mg for three years is at the ceiling dose and far beyond licensed duration, so taper in steps per NG215.
- Frailty and getting up after a fall: the Clinical Frailty Scale (Rockwood) gives a shared language — he is around 5, mildly frail; the practice frailty register (GP contract) supports a medication review and a falls assessment. He could not get up for 20 minutes — not yet a “long lie”, which means on the floor for an hour or more and is associated with dehydration, pressure injury, rhabdomyolysis, pneumonia and death — a pendant alarm, a mobile phone in the pocket and “how to get up from the floor” taught by the physiotherapist are practical safety measures. Sarcopenia — low muscle strength and slow gait (Timed Up and Go over 12–15 seconds, inability to rise from a chair without arms) — responds to progressive resistance and balance training and to adequate protein.
- Alcohol and sleep: a nightly “double” is about 2 units (more if poured at home) — around 14 units a week, at the UK Chief Medical Officers’ lower-risk limit, and every night rather than spread out with drink-free days; it worsens postural hypotension, nocturia and sleep quality, and interacts with zopiclone and amitriptyline. Sleep hygiene, daytime light and activity, and treating nocturia are the alternatives to a hypnotic; bereavement-related insomnia is common and a brief psychological approach (CBT for insomnia) is first-line (NICE CKS Insomnia).
Where candidates lose marks at this station
- A sitting blood pressure of 128/72 taken as reassuring.
- Stopping zopiclone and amitriptyline on the same day.
- “Take care getting up” — and a repeat prescription.
- The Colles’ fracture never connected to his bones.
- Talking to Susan about him.
- “You’ll have to stop driving” on today’s findings.
Guidelines for this station
- NICE NG249 — Falls: assessment and prevention in older people and in people 50 and over at higher risk (2025)
- NICE NG259 — Osteoporosis: risk assessment (2026)
- Royal College of Physicians — Measurement of lying and standing blood pressure (July 2025, PDF)
- STOPP/START criteria for potentially inappropriate prescribing in older people: version 3 (European Geriatric Medicine, 2023; criteria in the supplementary file)
- NICE NG5 — Medicines optimisation (structured medication review)
- NICE NG215 — Medicines associated with dependence or withdrawal symptoms
- DVLA — Assessing fitness to drive: Appendix D, transient loss of consciousness
- DVLA — Assessing fitness to drive: a guide for medical professionals (November 2025)
6 · MLA content map tags for this case
| MLA content map | This station |
|---|---|
| Domain 1 · Areas of clinical practice | Medicine of the older adult · Cardiovascular |
| Domain 3 · Clinical and professional capabilities | History, examination and differential diagnosis · Safe prescribing · Chronic condition management plans · Complexity, uncertainty and prioritisation · Managing risk |
| Domain 5 · Patient presentations | Falls · Frailty · Dizziness |
| Domain 6 · Conditions | Orthostatic/ postural hypotension · Osteoporosis and fragility fractures · Sarcopenia/ frailty |
| Station family | History, diagnosis and management — History, diagnosis and management |
7 · My marks and reflection — practice log form
Record your three domain marks, your station total, the GMC feedback statements that applied (where underperformance was identified), and what you will keep and change. The form is already labelled with this case and its web address; a copy of your entry is emailed to you, so your practice log builds up in your inbox and can be downloaded.
Record my marks and reflection for P2-35
Revision link for this case: mdacumen.com/plab-2-osce/case-35-another-fall-at-home
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