IN-DEPTH NON-ACUTE CONSULTATION · 15 MINUTES + 5 MINUTES DISCUSSION
Twelve medicines and one set of priorities
Fictional Clinora training simulation. Source and safety audit completed after correction of the supplied Claude draft. Independent specialist validation of difficulty and scoring has not been performed. Not an official MRCP(UK) station, a validated pass prediction or patient-specific medical advice.
Learning objectives
- Distinguish disease burden from treatment burden.
- Elicit goals before proposing deprescribing.
- Identify reversible medicine-related harm without replacing one rigid list with another.
- Sequence changes and monitoring so benefit and harm can be attributed.
Candidate brief
Sheila lives alone and has had admissions with dizziness and a fall. She has diabetes, hypertension, CKD, osteoporosis, osteoarthritis and previous depression, and takes twelve regular medicines. Review the whole person, examine relevant risks and negotiate an individualised plan.
Rehearse aloud before revealing teaching material. Use 15 minutes for the encounter and five minutes for examiner questions 1, 2 and 6. The other questions are teaching extensions. In a real emergency, assessment and escalation take priority over any timer.
Patient encounter: Sheila Ridgway, 84
I have a shopping bag of tablets and do not feel better for any of them—but my daughter says I must not stop anything.
Only if asked: current harms
She has postural dizziness, one fall, daytime cognitive fog, dry mouth, blurred near vision and constipation. Pain remains 4/10 despite co-codamol and gabapentin. She has had nineteen healthcare appointments in a year.
Only if asked: medicines
Metformin MR 1 g twice daily, gliclazide 80 mg twice daily, amlodipine 10 mg, ramipril 5 mg, indapamide 2.5 mg, alendronate weekly, calcium/vitamin D, amitriptyline 25 mg nocte, co-codamol 30/500 two tablets four times daily, gabapentin 300 mg three times daily, aspirin 75 mg without documented vascular disease, omeprazole and PRN lactulose.
Goals, values and family
Her priority is to remain in her own home, think clearly and reduce appointments. Longevity is not her main objective. She has capacity and wants her daughter involved with permission, but does not want her preference described as ‘giving up’.
Function and support
She uses a stick, furniture-walks, shops online with neighbour support and manages medicines through a dosette box filled by her daughter. Ask about mood, cognition, continence, nutrition, vision, hearing, sleep and what help she would accept.
Examination: findings and interpretation
Ask permission, preserve dignity and describe what you would examine and why. Reveal the relevant findings only after doing so.
Postural and functional assessment
BP falls from 118/62 lying to 94/52 at three minutes standing with typical dizziness. Timed Up and Go is 19 seconds with a stick. She needs her arms to rise; there is no focal neurological deficit.
Medicine-burden findings
Dry mouth, mildly dilated pupils, constipation history and slowed responses support anticholinergic/sedative burden without proving a single culprit. Forearm bruising and no documented vascular indication increase concern about aspirin harm.
Frailty and capacity
Self-rated health is 4/10; weight is stable. She is orientated and able to understand, retain, use and weigh information and communicate a choice. Frailty does not remove autonomy.
Investigation cards
State your next action before opening each card. Later results are not information available at the start of the encounter.
Relevant results
HbA1c 48 mmol/mol, eGFR 38, sodium 131, potassium 3.4, haemoglobin 118 g/L and thyroid, B12, folate and liver tests unremarkable. The results strengthen concern about hypoglycaemia, diuretic/electrolyte effects and renal dosing; they do not generate a universal deprescribing list.
Records to reconcile
Confirm actual use, indications, adherence, over-the-counter medicines, renal dosing, prior fractures, duration of bisphosphonate therapy and whether aspirin has any undocumented secondary-prevention indication. Review discharge summaries and recent BP/glucose trends.
Worked consultation and clinical reasoning
Start with the outcome Sheila values
The goal is staying safely at home with clearer thinking and fewer burdens. Explain that optimisation can include stopping, reducing, substituting, starting a beneficial intervention or coordinating appointments. Her daughter advises; Sheila decides while she has capacity.
Prioritise immediate harm
First address symptomatic postural hypotension and sedative/anticholinergic burden. Review indapamide and the intensity of antihypertensive treatment; reassess amitriptyline, high-dose co-codamol and gabapentin against actual benefit, renal function, falls, cognition and constipation. Do not stop several centrally acting medicines abruptly or simultaneously.
Review preventive medicines rather than reflexively deleting them
Reassess gliclazide because HbA1c is low for this context and hypoglycaemia may be silent. Verify aspirin indication; absence of documented vascular disease is a reason to investigate, not proof by itself. Review alendronate duration and current fracture risk rather than declaring a fixed drug holiday. Check metformin dosing and tolerance with CKD.
Sequence, monitor and coordinate
Agree one or two reversible changes first, define the intended benefit, withdrawal risks, monitoring interval and restart threshold. Arrange falls/therapy and pain review, constipation treatment, medication support and a named coordinator. With Sheila’s consent, explain to her daughter that the plan is active harm reduction aligned with Sheila’s goals, not abandonment.
Examiner discussion
Five-minute subset: questions 1, 2 and 6. Give your answer first, then compare the reasoning.
1. Which drug would you stop first?
Reveal worked answer
There is no context-free answer. Immediate harms make postural and sedative contributors priorities, but verify indication, dependence and withdrawal risk. A sequential plan is safer and more interpretable than stopping everything plausible.
2. Does HbA1c 48 mean excellent control?
Reveal worked answer
It may represent overtreatment in an older person with frailty, CKD, falls and sulfonylurea exposure. Ask about unrecognised hypoglycaemia and agree an individual target rather than celebrating the number.
3. Can the daughter refuse deprescribing?
Reveal worked answer
Not for a capacitous adult. Sheila makes the decision. Invite the daughter with consent, acknowledge her fear and explain the monitoring and restart plan.
4. Would you stop aspirin?
Reveal worked answer
First confirm whether a vascular indication exists. If none is documented, reassess the balance of bleeding harm and benefit with Sheila rather than continuing by inertia.
5. Is a bisphosphonate holiday automatic after five years?
Reveal worked answer
No. Reassess fracture risk, treatment duration, adherence and adverse effects. Prior vertebral fracture may support continued therapy; the decision is individual and monitored.
6. What belongs in the written plan?
Reveal worked answer
Sheila’s goals, agreed changes, reason for each, monitoring, withdrawal/safety-net advice, restart thresholds, named ownership, family involvement preferences and follow-up coordination.
What changes if…?
Each variation changes the baseline case. Explain both what changes in management and what remains important.
She develops symptomatic glucose 2.8 mmol/L
Treat hypoglycaemia immediately and review gliclazide urgently. The event moves glycaemic de-intensification to the front of the sequence.
Records show a previous ischaemic stroke
Aspirin now has a secondary-prevention indication. Reassess bleeding risk but do not treat it as an unexplained legacy medicine.
She lacks capacity for this decision
Identify the specific impairment and decision, maximise communication, check any valid attorney or advance decision, and make a best-interests decision using known wishes and least-restrictive options. Family contributes evidence; it does not automatically consent.
Dizziness resolves after the first change
Document benefit and avoid assuming every other medicine must still be stopped. Continue the agreed review of burden and priorities at Sheila’s pace.
Case-specific reflection
Formative Clinora anchors, not official PACES marks. Identify one missed decision and one communication improvement, then repeat the encounter.
Goals
Strong: Elicits and uses Sheila’s priorities before changing medicines.
Incomplete: Asks what matters only after presenting a plan.
Unsafe: Lets the daughter’s preference replace Sheila’s decision.
Clinical judgement
Strong: Prioritises current harm and sequences reversible changes.
Incomplete: Produces a plausible stop-list without monitoring.
Unsafe: Stops several medicines abruptly.
Medicines reasoning
Strong: Verifies indication, benefit, harm, renal context and withdrawal risk.
Incomplete: Uses age alone as the rationale.
Unsafe: Assumes every guideline medicine must continue unchanged.
Coordination
Strong: Creates named ownership and a usable written plan.
Incomplete: Sends multiple new referrals without reducing burden.
Unsafe: Leaves no review or restart threshold.