Name: Medication Review 2
Creator: Abeer Aamir
Keywords: Ear Nose and Throat,Haematology, Communication, Medicine Optimisation

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By Abeer Aamir • July 01, 2026 • Last reviewed: 29/08/2026 •

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Summary Expert

In this scenario, you will be conducting a Structured Medication Review (SMR) for a patient taking numerous medications.

Please ensure that this scenario and mark scheme align with the most up-to-date guidelines from the UK NICE and the BNF resources.

You will need a Student Pharmacist and an Actor for this OSCE station.

Revision Topics

Be aware, this may reveal any answers!

Student Instructions

Actor Instructions

This may reveal scenario objectives!

You are Priya Nair (PREE-yah NAIR).

How to play this role:

You are cooperative and polite, but slightly embarrassed about raising the swallowing problem and worried you are wasting the pharmacist's time. You are mildly overwhelmed by how many tablets you take and are not confident what most of them are for.

Speak at a normal pace, but pause and sip water occasionally, particularly before longer answers. Your mouth is dry and talking is a little effortful.

You do not know the names of your medicines. If the student asks what a tablet is called, say: "I am sorry, I could not tell you the names. I know them by what they are for." e.g. "the one for my feet" or "the water tablet, is that the one you mean?"

Keep answers brief. Do not volunteer information you have not been asked for.

Patient details

Name: Priya Nair
Age: 71
Weight: 64 kg
Lives with your husband, who sometimes helps you with your tablets

Past medical history (give if asked)

High blood pressure
Irregular heartbeat: "Yes, I have an irregular heartbeat. I take a blood thinner for it."
Type 2 diabetes: "My sugars are reasonably well controlled, the doctor said."
Underactive thyroid: "Yes, I take a tablet for that every morning before I eat anything."
Nerve pain in the feet: "I was told it is from the diabetes. I take a small tablet at night for it."
Low iron: "My iron was low a while back. I have been on iron tablets for about a year now."

How you take your medicines (give if asked)

"In the morning I take my thyroid tablet first, before breakfast, and I take my iron tablet at the same time so I do not forget it."
"Then after breakfast I take my blood pressure one, my heart rate one, one for my diabetes, another for my diabetes, and my blood thinner."
"At night I take the other diabetes one, my blood thinner again, and the small one for my feet."
If asked about missed doses: "I try to take them all. Sometimes I miss the evening ones if I fall asleep early."
If asked about medication burden: "I do find it a lot, especially in the mornings when there are so many at once."
If asked about over the counter medicines: "I sometimes take something for my hay fever. It is the drowsy kind, in a yellow box. I cannot remember what it is called."
- If the student asks how often: "Most days through the summer. It has been quite bad this year."
If asked about herbal remedies, supplements or vitamins: "No, nothing like that."

Allergies

"None that I know of."

The swallowing problem

"I have been struggling to swallow my tablets for the past few months. My mouth feels very dry, especially in the mornings and at night."
If asked when it started: "It started a few months after I was put on the tablet for the pain in my feet."
If asked whether it is painful: "Not painful, just very dry. Sometimes it takes several sips of water to get them down. Occasionally one feels like it sticks."
If asked about swallowing food: "No, food is completely fine. It is only the tablets."
If asked about swallowing liquids: "No, liquid is completely fine. It is only the tablets."
If asked whether food ever sticks or comes back up: "No, never."
If asked about weight loss: "No, my weight has been the same."
If asked about pain on swallowing or a lump in the throat: "No, nothing like that."

Other symptoms (give if asked)

"I feel a bit groggy in the mornings sometimes."
Falls: "No falls, but I do feel a bit unsteady when I first get up."
Constipation: "Yes, actually. I have been quite constipated lately."
Dry eyes: "Now that you mention it, yes, they do feel gritty."
Urinary problems: "No, nothing like that."
Mood or memory: "I am fine. A bit tired, but nothing I would worry about."
Bleeding or bruising: "I bruise a little more easily than I used to, but nothing serious."
Black or dark stools, or blood: "No, nothing like that."
If asked whether anyone investigated why the iron was low: "I do not think so. They just started me on the tablets. Nobody has mentioned it since."
Teeth: "I still have my own teeth. I have not been to the dentist in about two years."

Lifestyle

Smoking: "No, never."
Alcohol: "I do not drink."
Exercise: "I try to walk a little each day, but the foot pain limits me."
Diet: "I eat reasonably well. Plenty of vegetables and lentils."

How to respond to the student's suggestions

If they explain one of your medicines is causing the dry mouth: "Oh. I had not connected the two at all."
If they suggest adjusting the night tablet for your feet: "I would be happy to try something else if that is what is causing it. The dry mouth is really bothering me."
If they suggest changing the hay fever medicine: "Oh, I did not realise that could be a problem too. I just take it when it is bad."
If they suggest taking the iron at a different time from the thyroid tablet, or stopping the iron: "Nobody told me that. Should I have been doing something differently?"
If they suggest a liquid or dispersible version of a tablet: "I did not know that was possible. That might help a lot, actually."
If they offer something for the dry mouth itself: "I would be happy to try that."

If the student has not raised the cause by roughly two thirds of the way through, prompt once:

"Do you think one of my tablets could be doing this?"

If the student has not offered a plan for the swallowing itself, prompt once:

"So what should I actually do about getting them down?"

Mark Scheme

Introduction

0 / 3

Introduces themselves, their role and the purpose of the medication review

+1

Confirms patient details: name and date of birth or age

+1

Establishes what matters to the patient and what she hopes to get from the review

+1

Medication History

0 / 8

Takes a full medication history and does not rely solely on the printed list

+1

Establishes exactly how and when she takes each medicine in practice, rather than as prescribed

+1

Elicits that the iron is taken at the same time as the levothyroxine, before breakfast

+1

Asks about over the counter, herbal and as required medicines and elicits the sedating antihistamine

+1

Establishes the frequency of antihistamine use

+1

Rather than accepting it as occasional

Assesses adherence non judgementally

+1

Elicits missed evening doses, particularly the second iron dose

Explores medication burden and the patient's own view of taking eight medicines

+1

And recognises the overall pill burden, particularly the morning cluster, as a problem in its own right

Checks for allergies

+1

Interpreting the Clinical Data

0 / 5

Reviews and correctly interprets the recent blood results

+1

Identifies that the haemoglobin and ferritin are now normal, indicating the iron deficiency has been corrected

+1

Identifies that the TSH is raised with a low normal free T4, indicating inadequate levothyroxine effect

+1

Connects the raised TSH to the co-administration of iron with levothyroxine rather than assuming a dose increase is needed

+1

Increasing the levothyroxine dose without correcting the timing risks over-replacement once the interaction is removed, which carries particular risk of atrial fibrillation deterioration and osteoporosis in an older patient.

Notes that renal function is adequate for the current apixaban and metformin doses

+1

Identifying Medication Related Problems

0 / 5

Correctly identifies amitriptyline as an anticholinergic cause of the dry mouth, and explains the mechanism

+1

Amitriptyline is a tricyclic with substantial antimuscarinic activity. Xerostomia is a recognised and common adverse effect, and the timeline fits the onset of symptoms.

Identifies the sedating antihistamine as a second anticholinergic contributor and recognises the additive anticholinergic burden

+1

Chlorphenamine is antimuscarinic and sedating. Taken most days alongside amitriptyline it compounds the dry mouth, constipation, grogginess and unsteadiness, and raises falls risk in a 71 year old.

Identifies the iron and levothyroxine interaction and explains that iron reduces levothyroxine absorption

+1

Ferrous salts chelate levothyroxine and markedly reduce its absorption. Doses should be separated by at least four hours.

Identifies iron as a contributor to the constipation

+1

Recognises that iron deficiency anaemia in a patient on an anticoagulant has not been investigated for a gastrointestinal source, and flags this for follow up

Unexplained iron deficiency anaemia in an older anticoagulated patient warrants investigation for occult gastrointestinal blood loss. Correcting the anaemia without establishing the cause leaves a potentially serious pathology unaddressed.

Agreeing the Plan

0 / 4

Discusses the proposed changes with the patient and seeks her agreement rather than instructing her

+1

Explains what each remaining medicine is for, addressing her stated uncertainty

+1

Agrees a clear follow-up plan with a timeframe, including repeat thyroid function and review of the neuropathic pain

+1

Offers written information or a revised medicines schedule for her to take away

+1

Safety Netting

0 / 3

Advises her to seek review if the foot pain worsens after the night tablet is reduced

+1

Advises her to seek urgent help if she develops difficulty swallowing food, food sticking, pain on swallowing or unexplained weight loss

+1

Failure to safety net appropriately is a patient safety concern and should result in a fail.

Advises her to report any bleeding, black stools or increased bruising, given her anticoagulation

+1

Communication and Professionalism

0 / 6

Uses open questions and allows the patient to speak without interruption

+1

Responds to her embarrassment about the swallowing problem with sensitivity, and does not make her feel she has wasted anyone's time

+1

Avoids jargon and adjusts explanations when she indicates she has not understood

+1

Checks patient understanding of the agreed plan

+1

Concludes the consultation well, summarising the plan and asking if she has further questions

+1

The student did not say anything that could harm the patient

+1

This includes but is not limited to increasing the levothyroxine dose without addressing the iron timing, stopping amitriptyline abruptly, recommending a sugar-containing product, implying medicines can be changed without prescriber involvement, missing the uninvestigated iron deficiency in an anticoagulated patient, or failing to act on red flag symptoms.

Time Management

0 / 1

Completed the scenario in time and achieved 70% of marks

+1

Referral Criteria

References

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Comments(0)

Medicine	Dose and frequency
Amitriptyline 10 mg tablet	One at night
Amlodipine 5 mg tablet	One daily
Apixaban 5 mg tablet	One twice daily
Bisoprolol 2.5 mg tablet	One daily
Ferrous sulfate 200 mg tablet	One tablet once daily
Levothyroxine 100 microgram tablet	One daily, on an empty stomach, 30 minutes before breakfast
Metformin 500 mg tablet	One twice daily
Sitagliptin 100 mg tablet	One daily

Test	Result	Reference range
Weight	64 kg
Blood pressure	128/76 mmHg
eGFR	68 mL/min/1.73m²	>60
Haemoglobin	131 g/L	115 to 165
Ferritin	92 micrograms/L	15 to 200
TSH	5.9 mU/L	0.4 to 4.0
Free T4	11.2 pmol/L	9.0 to 25.0
HbA1c	51 mmol/mol
Serum creatinine	78 micromol/L

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