Station 49

Fred Callaway

Age: 77 years old male

Examiner

Station List
Doctor
Patient
Full Case

Marking Scheme

Data Gathering and Diagnosis

  • Ask which medications are included in the blister pack and clarify which may have been double-dosed
  • Ask if the patient has reported any new or current symptoms
  • Ask about gastrointestinal symptoms such as nausea, abdominal pain, or upset stomach (as all medications are taken orally)
  • Ask about any bruising or bleeding, including in the urine or from the back passage (possible side effect of Clopidogrel)
  • Ask about dizziness or recent falls (possible side effects of Ramipril or Tamsulosin)
  • Ask about muscle cramps or aches (possible side effect of Atorvastatin)
  • Ask about headaches (known side effect of Tamsulosin)
  • Ask about onset and duration of memory problems
  • Ask about any recent changes in personality or behaviour
  • Ask about any gait abnormalities and whether the patient uses a walking aid, bed bound or requires support with mobility. 
  • Ask about any gait abnormalities and whether the patient uses a walking aid, bed bound or require support with mobility. Also explore associated symptoms such as tremors and urinary incontinence, which could suggest conditions like normal pressure hydrocephalus or Parkinson’s disease.
  • Ask about his nutritional status — whether he is eating and drinking well, and who is responsible for his shopping and meal preparation
  • Ask about bowel habits and whether the patient is experiencing any problems
  • Ask about lifestyle factors, particularly alcohol intake and smoking history
  • Ask about mood, including signs of low mood or emotional changes
  • Ask about the patient’s home setup, including who lives with him, whether he has a next of kin (NOK) or lasting power of attorney (LPA)
  • Ask how often carers attend and what support they provide
  • Ask if the nurse has performed recent observations and check for abnormal vitals, including blood pressure, heart rate, and oxygen saturation.
  • Give likely diagnosis of possible early dementia with accidental medication overdose

Example of explanation to patient​

Thanks so much for your call, Alice, and for your thorough assessment. Based on what you’ve described, particularly the concern about a possible accidental overdose and the carer-reported memory issues, I agree with you that Mr Callaway may be showing early signs of cognitive decline or dementia. I’ll arrange to assess him in person and refer him to the memory clinic for a formal cognitive assessment.

In terms of investigations, I won’t repeat his recent blood tests as they were normal last week, but I will arrange additional screening for reversible causes of confusion, including checking his B12, folate, and ferritin levels.

I’ll also get in touch with his son, Fred Junior, to explain what’s going on and ensure he’s aware of the concerns about medication safety and cognition.

Given this situation, I’ll refer him to the frailty or occupational therapy team to assess whether his care needs should be increased. In the meantime, it would be helpful if the carers could be provided with clear written instructions on how and when to give his medications. If they’re trained and happy to help administer them, great. If not, I’ll request short-term support from your team to assist with daily medication administration, if that would be alright with you. 

As he is currently well and has not shown any worrying symptoms and given that the medications involved are not typically harmful in cases of minor accidental double dosing, I would be happy for him to resume his usual medications from tomorrow. However, the carers and his son, should be advised to monitor him closely for any new signs such as bruising, bleeding, muscle cramps, dizziness, or confusion. If anything changes, they should contact us or seek emergency medical attention immediately

Management

Management

  • Offer to assess the patient in person for possible cognitive decline and early dementia.
  • Arrange further blood tests as part of a confusion screen, including B12, folate, and ferritin; no need to repeat FBC, U&Es, CRP, or LFTs as they were done a week ago and were normal.
  • Offer to contact the next of kin (Fred Junior) to inform him about the situation and concerns around medication safety and possible cognitive impairment.
  • Refer the patient to the memory clinic for further cognitive assessment.
  • Refer to the frailty team or occupational therapy team to carry out a home visit and assess whether the patient’s care needs should be increased. In the meantime, advise that the current carers be provided with clear written instructions regarding the patient’s medication and asked to assist with administration if they are trained and comfortable doing so. If the carers are not trained or are unwilling to administer medication, request support from the district nursing team to provide daily medication administration visits, especially as the patient is on once-daily medications, which may be manageable in the short term. 
  • Reassure that his regular medications can be resumed the following day, as the medications involved are not typically harmful in the event of minor accidental double dosing, and the patient is currently asymptomatic. However, carers should monitor for any concerning symptoms and seek medical advice if they arise
  • Advise that carers and next of kin can be provided with clear written instructions not only on potential side effects to watch for. They should be asked to monitor for any new symptoms such as bleeding, bruising, muscle cramps, abdominal discomfort, dizziness, or seizures, and seek urgent medical attention if any of these occur. In addition, the next of kin should be encouraged to check in regularly, by phone if not in person, and escalate any concerns promptly to healthcare services.
  • If unsure about the safety of continuing medications after overdose, advise that you will consult TOXBASE (www.toxbase.org) and BNF, and that you will call the nurse back with further guidance. 
  • Note that according to NICE guidance, patients who exceed the daily dose of two or more cardio-toxic agents (e.g. beta blockers, calcium channel blockers) should be referred for hospital assessment—though this does not apply here, awareness is important.
  • Offer practical safety measures such as a falls alarm due to his history of falls and mobility issues.
  • Thank the district nurse for her detailed assessment and for escalating concerns appropriately.

Learning point from this station: ​

In general practice, it is not uncommon to encounter cases where patients, particularly older adults or those with cognitive difficulties, accidentally take an extra dose of their regular medication. In many instances, this does not require hospital admission, especially if the medication is not known to be significantly harmful in small overdoses and the patient remains well.

When assessing such situations, clinicians should consider:

  • The drug’s usual indication, maximum recommended dose, known side effects, and potential toxicity
  • The patient’s comorbidities, especially liver or kidney dysfunction, which may affect drug clearance
  • Age, home environment, and the level of support available for medication management
  • Drug interactions and risk of cumulative adverse effects
  • Ensure the overdose was genuinely accidental by exploring the intent behind the ingestion. Always ask if the patient has had any thoughts of self-harm or suicide.

If there is any doubt, clinicians should consult trusted resourcessuch as the British National Formulary (BNF) or TOXBASE and seek senior or specialist advice where needed, for example, from an on-call medical team or via UK Medicines Information (UKMI).

Admission for Overdose or Poisoning

Admit patients who have taken an overdose or poisoning with any of the following:

  • The patient has exceeded the therapeutic dose of two or more potentially cardiotoxic medications (such as beta blockers, calcium channel blockers. digoxin)
  • There is any indication of intentional overdose or self-poisoning, regardless of the quantity taken (this is because patients who self-poison may not accurately recall what or how much they ingested, making community-based risk assessment unreliable).
  • The patient is symptomatic following ingestion or exposure to any drug or toxin
  • The ingested drug or substance is unknown
  • The patient has taken any delayed-action medication, even if currently asymptomatic. Examples of delayed-action medicines include aspirin, iron, paracetamol, tricyclic antidepressants, co-phenotrope, and any modified-release drug or preparation.
Further Reading