We are excited to see so many of you join our FMEP courses. Several of you have requested we continue to post more practice SAMPs, so here you go!

SAMP

A 74-year-old man with a 3-year history of Parkinson’s disease presents to your family practice with 6 falls in the past 3 months. He reports intermittent lightheadedness when standing. His wife notes increasing forgetfulness over the past 6 months; she reports that he has forgotten to close the front door and is getting lost when they go on walks together. He has also recently started to report seeing rabbits running around the house. His wife is not sure what to make of these symptoms and thinks he is “seeing things.” Medications include levodopa-carbidopa, pramipexole, sertraline, and chlorthalidone.
On examination:
Supine BP: 140/85 mm Hg, HR 67
Standing BP (1 min): 118/72 mm Hg, HR 70
Standing BP (3 min): 112/70 mm Hg, HR 72
He does not report symptoms during the measurement. (8 points)

1. What is the most appropriate interpretation of this patient’s blood pressure findings? (1 point)
   1. Normal age-related variation
   2. Orthostatic hypotension requires symptoms for diagnosis
   3. Orthostatic hypotension, regardless of symptoms
   4. Dehydration is the only likely cause

   Answer: C

2. Which of the following is the MOST appropriate initial management step? (1 point)
   1. Start midodrine immediately
   2. Increase levodopa dose
   3. Review and adjust contributing medications
   4. Refer urgently to neurology

   Answer: C (Trap: always address reversible/medication causes first)

3. True or false: The presence of visual hallucinations and cognitive fluctuations suggests Lewy body dementia rather than typical Parkinson’s disease? (1 point)

   Answer: True

4. True or false: Dopamine agonists can worsen orthostatic hypotension. (1 point)

   Answer: True

5. This patient is at high risk for an atypical Parkinsonian syndrome. List three features in this case that support this concern. (3 points)

   Answer:
   Orthostatic hypotension
   Visual hallucinations
   Cognitive decline/fluctuations

6. The patient’s blood pressure drops on standing with only a minimal rise in heart rate. What is the most likely underlying mechanism causing his orthostatic hypotension? (1 point)

   Answer: Autonomic failure due to neurodegeneration affecting sympathetic nervous system pathways. This leads to impaired vasoconstriction and blunted compensatory tachycardia

Helpful CMAJ Resource:
https://www.cmaj.ca/content/198/12/E444