Pharmacy — Referral to GP for Polypharmacy Review in an Elderly Patient
A community pharmacist refers an 81-year-old man to his GP after an annual medication use review identifies three concerns in a twelve-medication regimen: a likely NSAID-related renal decline, a potentially unnecessary proton-pump inhibitor, and a duplicate beta-blocker indication. The proficient challenge is to prioritise the three concerns clearly within the word limit, while cutting the stable long-term medications that require no immediate action.
Letter type
Referral
Write to
General Practitioner
Target length
200–230 words
The case notes
Patient: Mr Harold Barker, 81 years old; annual MUR (Medication Use Review) conducted today
Medication list (12 items): Aspirin 75 mg, bisoprolol 5 mg, amlodipine 5 mg, ramipril 5 mg, furosemide 40 mg, spironolactone 25 mg, atorvastatin 40 mg, omeprazole 20 mg (since 2019, original indication not documented), ibuprofen 400 mg TDS (ongoing for knee OA, self-purchased), co-codamol 30/500 (prescribed), metformin 500 mg, gliclazide 80 mg
Renal concern: eGFR 38 (last 3 months: eGFR was 51 then 44); decline correlating with ibuprofen use; ramipril and metformin both renal-dose sensitive
Duplicate concern: Bisoprolol prescribed for rate control in AF; also listed under heart failure — one indication, but documented separately by two prescribers; risk of double-dose if repeat prescriptions are not co-ordinated
Omeprazole concern: Started 2019 — no documented indication; patient cannot recall why; not on ibuprofen at the time of initiation
Reported side effects: Muscle aching for 6 weeks — not yet reported to GP; taking atorvastatin (myopathy risk)
Not a concern (stable): Aspirin, amlodipine, furosemide, spironolactone, gliclazide — all within appropriate dose ranges, no recent changes
Task: Write a referral letter to the GP, Dr Claire Forde, identifying the three most clinically important medication concerns and requesting a structured review.
Writing task
Write a referral letter to the GP, Dr Claire Forde, identifying the three most clinically important medication concerns and requesting a structured review.
What to include, what to cut
The hardest mark to win is selection. The same case notes contain decision-relevant facts and distractors. Here is what an examiner expects to see in a Grade B letter for this scenario, and what should be left out.
Include
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The ibuprofen-related eGFR decline and the downstream risk to ramipril and metformin dosing
The highest-priority concern: ongoing NSAID use in an 81-year-old with declining eGFR and two renal-sensitive medicines is an acute patient-safety risk, not a routine review item.
-
Six weeks of muscle aching on atorvastatin — not yet reported to GP
New, unreported symptom with a known association to the statin. The GP does not know about this; the pharmacist's report is the only route to action.
-
Omeprazole without a documented indication since 2019
Long-term PPI without indication is a deprescribing opportunity. It earns its place because it is an actionable finding from the review — not a chronic stable medication.
Leave out
-
Aspirin, amlodipine, furosemide, spironolactone and gliclazide
Documented as stable with appropriate doses. Listing all twelve medications wastes the word count and buries the three concerns. The GP holds the full medication record.
-
Detailed pharmacological explanation of statin myopathy
State that muscle aching is a recognised side effect of statins and that CK testing may be warranted; one line. The GP knows the mechanism.
Criterion in focus · Conciseness & Clarity
A polypharmacy referral letter is won or lost on prioritisation. With twelve medications and five potential observations, the proficient task is to select the three that require GP action now, state them in order of urgency, and cut the rest. A letter that lists every medication fails Conciseness & Clarity even if every fact is accurate.
Now write the letter — and find out what is blocking your Grade B
Write a 200–230 words referral letter from these notes, paste it into the free checker for an instant read, then submit it for a human grade against all six criteria. Dr Mariam's team returns line-by-line feedback, from $12.