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GP Interaction 10

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GP Interaction 10
By Jitesh Arora • February 28, 2024 • Last reviewed: 24/09/24 •




Summary

In this scenario, a GP trainee seeks guidance from a pharmacist regarding a patient with type 2 diabetes and resistant hypertension. The pharmacist will conduct a thorough assessment and make recommendations for the next steps in medical management based on the patient’s history, symptoms, medications, contraindications, and interactions. 

 

Please ensure that this scenario and mark scheme align with the most up-to-date UK NICE guidelines and the BNF when using it for your OSCE assessment. 

 

A student pharmacist and an actor playing the role of a trainee doctor are required. 

Revision Topics
Be aware, this may reveal any answers!

Hypertension 

Student Instructions

You are a pharmacist. A GP trainee has come to you for advice regarding a 60-year-old female patient with type 2 diabetes and resistant hypertension. Your task is to gather all necessary information through questioning the GP trainee and make a recommendation for the next steps in medical management. 

 

To do  

  1. Gather essential patient details, including medical history, current medications, allergies, and lifestyle factors relevant to the scenario 

  1. Offer clear, evidence-based advice to the GP on potential next steps, including management options or further diagnostic testing. 

 

You have 10 minutes.
You have access to the BNF. 

Actor AI 🤖 (Beta)
Actor Instructions

You are GP Trainee Bob Smith (Bob, Smith). 


Opening Statement: “I have a patient, a 60-year-old female with type 2 diabetes, who has resistant hypertension. I was hoping you would be able to provide some advice on what the next steps would be in terms of medical management” 

 

Patient Information:
Provide information when prompted. 

  • Patient demographics:  

    • "Patient demographics are - Joanne Roberts (Jo-anne, Rob-urts), 60 years old, female, Caucasian, BMI 24.5." 

  • Past medical history: 

    • "Past medical history includes type 2 diabetes and resistant hypertension – she is at stage 2." 

    • "She has never experienced any complications of her stage 2 hypertension, including malignant hypertension." 

  •  Current signs and symptoms:  

    • “None.” 

  • Medication history: 

    • “Metformin 500 mg Tablets – One tablet twice daily.” 

    • “Ramipril 10 mg tablet - once daily. This is the max dose.” 

    • “Amlodipine 10 mg once daily. This is the max dose.” 

    • “Indapamide 2.5 mg tablets once daily – again, the max dose.” 

    • “Patient has never been put on any other antihypertensive medications in the past.” 

    • “Patient sometimes takes paracetamol over the counter if she experiences a headache when required.” 

  • Allergies 

    • “None.” 

  • Lifestyle:  

    • “Patient is retired. They are an avid gardener.” 

    • “They are a non-smoker; a non-drinker and they say they eat a balanced diet.” 

 

If the pharmacist asks: 

  • "Her average BP readings are 165/109, which have been consistent both at the surgery and at home." 

  • "Her latest HbA1c is 45 mmol/mol, indicating well-controlled diabetes." 

  • "Her QRISK score is 9%  

  • “The patient has very good compliance with their medications and has never missed a dose.” 

  • “Patient has not experienced any side effects of their medication.” 

  • "No relevant family history"

 

Mark Scheme

 

Introduction 
0 / 3
Introduce yourself as the community pharmacist with an appropriate greeting
+1
Confirms they are speaking about the correct patient (I.e. Name and DOB)
+1
Confirms prescriber identity
+1
Symptoms 
0 / 1
Checks current signs and symptoms
+1
Symptoms relating to hypertension may include headaches, dizziness, vision problems, or chest pain. Malignant hypertension symptoms may involve severe, rapidly increasing blood pressure with signs of end-organ damage.
Medical History 
0 / 5
Confirms medication history including dose, frequency, indication, including any over-the-counter products and herbal remedies
+1
Confirms the prescriber has checked the patient's adherence to their medication
+1
Checks for allergies and clarifies reactions
+1
Checks for any relevant past medical history.
+1
Check for any relevant family history.
+1
Management and Advice 
0 / 2
Lifestyle and non-pharmacological approach:
Confirm the patient’s lifestyle factors, such as smoking, alcohol consumption or exercise
+1
Determines if the patient been educated on non-pharmacological approaches to blood pressure management 
+1
e.g. Salt reduction, weight management or regular physical activity.
Recommendation 
0 / 4
Providing a recommendation:
Recognise that the patient is already on the maximum dose of their antihypertensive medications
+1
Advise the GP trainee to perform a U&E blood test to check the serum potassium level and renal function
+1
Spirolactone is a potassium sparing diuretic. A significant amount of the drug is excreted in urine and can increase potassium levels. It is also contraindicated in patients with significant renal impairment.
Advise the GP trainee to consider starting the patient on a potassium-sparing diuretic such as spironolactone if the potassium comes back less than or equal to 4.5 mmol/L
+1
States to consider an alpha blocker (e.g. doxazosin) / beta-blocker (e.g. atenolol) if the potassium comes back more than 4.5 mmol/L
+1
The student should be able to back up their recommendation through a suitable guideline (e.g. NICE).
Communication 
0 / 6
Uses appropriate language for the person and situation.
+1
Uses volume, tone, pace, and emphasis appropriately, and gives time to ask questions.
+1
Knowledge and understanding of the topic are apparent.
+1
The conversation is structured and flows well.
+1
Concludes well, helping with further questions.
+1
The student did not say anything that could harm the patient  
+1
This includes but is not limited to, providing incorrect information or medication, misdiagnosing conditions, neglecting to inquire about allergies, making incorrect referrals, or failing to act on red-flag symptoms.
Time Management
0 / 1
Completed the scenario in time and achieved 70% of marks
+1
 

Any criteria marked in red must be met to pass this station.  




Referral Criteria

Referral Criteria for Hypertension 

 
Refer to Accident & Emergency (A&E) if: 

  • Extremely high blood pressure (hypertensive crisis): Blood pressure readings of 180/120 mmHg or higher with symptoms such as severe headache, chest pain, shortness of breath, or vision changes could indicate a hypertensive crisis, requiring immediate medical attention. 

  • Signs of stroke or transient ischemic attack (TIA): Sudden onset of numbness or weakness, especially on one side of the body, confusion, trouble speaking or understanding speech, trouble seeing in one or both eyes or difficulty walking could suggest a stroke. Immediate referral to A&E is required. 

  • Severe chest painthat may suggest a heart attack: If a patient experiences chest pain or discomfort that feels like pressure, squeezing, or fullness, it could indicate a heart attack requiring emergency care. 

  • Symptoms of organ damage associated with high blood pressure, such as acute kidney failure (e.g., reduced urine output, confusion, or swelling), require immediate medical intervention. 

 

Refer for an Urgent GP Appointment if: 

  • Consistently high blood pressure readings: If a patient has consistently high blood pressure readings over multiple checks, an urgent GP appointment is needed to start or adjust treatment. 

  • Elevated blood pressure readings with additional risk factors: Patients with high-normal blood pressure and additional cardiovascular risk factors (e.g., diabetes, smoking, family history of heart disease) require an urgent evaluation. 

  • Symptoms of hypertension-related complications, such as persistent severe headaches, visual changes, or nosebleeds, may indicate poorly controlled blood pressure needing urgent review. 

  • A sudden drop in blood pressure (hypotension)with symptoms like dizziness, fainting, or confusion: Could indicate a serious condition like shock, requiring urgent evaluation. 

 

Refer for a Routine GP Appointment if: 

  • Mildly elevated blood pressure readings(e.g., 130-139/85-89 mmHg): If a patient consistently has mildly elevated blood pressure readings, a routine GP appointment is warranted to monitor and discuss potential lifestyle changes or medications. 

  • Regular monitoring for patients with chronic conditions(e.g., diabetes, chronic kidney disease) that predispose them to hypertension: Routine appointments are needed to manage and monitor blood pressure effectively. 

References

 

 

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