Cases/Metabolic Problems and Endocrinology

Daughter Worried Her Mother Keeps Having Hypos — Free SCA Practice Case

Daughter worried her mother keeps having hypos

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12:00

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Data Gathering

History, ICE & Diagnosis

Clinical Management

Diagnosis, Plan & Decisions

Safety Net

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Materials for Candidate

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Patient Profile

Full Name

Hyacinth Brissett

Age

78 years

Consultation Type

Telephone

Situation

Telephone Consultation. Her daughter has asked to speak to a doctor.

Reason for Encounter

"I'm ringing about my mum. She's had two funny turns this month, all sweaty and muddled."

Medical Records

●PMH: Type 2 diabetes (12 years). Hypertension. CKD stage 3a. Knee osteoarthritis. Drives.
●Medications: Gliclazide 80 mg twice daily. Metformin 500 mg twice daily. Ramipril 5 mg. Atorvastatin 20 mg.
●Allergies: NKDA.
●Social: Lives alone.

Recent Notes

●Diabetes review, 5 weeks ago: HbA1c 41 mmol/mol (5.9%), previously 49. eGFR 49 (58 a year ago). Weight 63.1 kg (67.0 kg).

Patient Script

For the friend playing the patient role

Character Overview: You are Yvette Shaw, 51, a branch administrator at a plumbing wholesaler, ringing about your mother, Hyacinth Brissett, 78. You are on your lunch break in a quiet corner of the works yard. You live a 25 minute bus ride from your mum, you do not drive, and you ring her most mornings and do her big shop on Saturdays. You are warm, quick talking and practical, and underneath frightened and guilty.

Your mum is widowed (your dad, Cyril), proud, private and independent, and hates fuss. She has driven for over fifty years. You know she has diabetes and takes tablets but not their names or doses. She calls the episodes her "wobbles". You do not know whether her sugar went too high or too low, and you never say "hypo", "hypoglycaemia" or "dementia" unless the doctor asks what you are afraid of. Your mum knows you are ringing: she said "Go on then, if it makes you happy", but she is cross with you.

Opening Sentence: "Hello, doctor, thanks for ringing. It's about my mum, Hyacinth Brissett. She's seventy eight and she's had two funny turns this month, all sweaty and muddled, and I'm really worried about her."

History if Asked (Data Gathering Phase)

●The first turn: "Two Saturdays ago. I went round about half past eleven to take her shopping. She was at the kitchen table, drenched, grey and clammy, and not making sense. She called me Pearl, her sister. I made her a glass of squash and she couldn't hold it, so I held it to her mouth. About twenty minutes later she was herself again and hardly remembered it."
●The second turn: "Five days ago. Mr Tran next door popped round about eleven with a parcel and found her on the back step, sweating and mumbling. He gave her orange juice and a biscuit and stayed with her, then rang me at work. By the time I got there she'd come round but looked wiped out. She said she'd been busy and forgot to eat."
●Detail of both turns (if asked): Both late morning, so she was up and about, and nothing at night as far as you know. She could not sort it out herself: someone else gave the drink. Before the first one she said she felt shaky, her heart thumped and her fingers tingled, then it went fuzzy. Recovery took about twenty minutes after the sugary drink.
●Milder ones (if asked): "Last night she finally admitted there've been four or five mornings in the last few weeks when she's gone shaky and hot, had a biscuit and it passed. She didn't want to worry me."
●Tablets and meals (if asked): "She's up at seven, takes her tablets with a cup of tea and half a slice of toast, then she's off out. Often no proper meal till two or three. She says she isn't hungry in the day. Her tablets are in a days box and nothing has changed in years."
●Eating and weight (if asked): "She's eaten much less since her new top teeth about six months ago. They rub, so it's soup, porridge and soft toast. Her clothes are hanging off her. The nurse said she'd lost a few kilos." Asked about blood, cough, pain or night sweats: "No, nothing like that. She's well otherwise."
●Alcohol, new medicines, meter (if asked): Hardly any alcohol. No antibiotics or new medicines. No home glucose meter.
●Her recent check (if asked): "About five weeks ago. The nurse said her sugar number was the best it's ever been. She came out so proud."
●Driving (if asked): "She drives most days: the shop and post office in the mornings, church on Sundays, and over to my aunt Pearl's on Thursdays, about twenty minutes each way." If asked about the car or near misses: "Now you say it, last Saturday I noticed a fresh scrape down the wing. She said the gatepost jumped out at her." On the day of the second turn: "Mr Tran said her car was back on the drive about ten, so she'd been out to the shop an hour before he found her."
●How she is now (if asked): "She sounded fine at lunchtime and has had some porridge. She's home alone; Mr Tran said he'd pop in this afternoon. She says it's just her sugar playing up."

Ideas, Concerns, Expectations

Gating note: Yvette does not raise any of the following herself. Each part comes out only when the doctor asks what she thinks is going on, what is worrying her or what she is hoping for.

●Ideas: She thinks the sugar has gone wrong because her mum hasn't been eating, but cannot square that with "the best ever". Quietly she wonders about a stroke or her memory. "Her mum had dementia, and when Mum was talking rubbish I thought, here we go."
●Concerns: Her mum being alone when it happens. "What if nobody finds her?" Then the driving: "If she goes like that at the wheel she could kill someone's child." She feels guilty: "I should have made her come in after the first one." She dreads being the villain: "If I say anything about the car she'll never forgive me."
●Expectations: The tablets sorted so it cannot happen again, someone ringing her mum today, and a doctor telling her mum about the car. "It's got to come from you, not me."

If Asked: Medical History and Medications

Gating note: Yvette answers plainly. She knows only what her mum has told her and what she has seen.

●Diabetes and tablets: "Type 2, about twelve years, tablets only. Two sorts, the same two morning and evening with meals. I don't know the names. Not changed that I know of."
●Kidneys and other illness: "The nurse said her kidneys are a bit tired." No heart trouble, stroke or fainting. No falls, her knees ache but she's steady. These are the first episodes ever.
●Memory (if asked): "Always been sharp. She does her crossword every day." Her own mother had dementia in her eighties. No allergies.

Social History and Lifestyle Impact

●Her mum's life: Lives alone in her own house, cooks for herself, goes to a church group on weekday mornings. She hates being a burden.
●Support (if asked): Brother Garfield is in Leeds, so it is Yvette and Mr Tran next door. Pearl is 82 and does not drive. Church friends would do lifts but she hates asking. The bus stop is up a hill and her knees are bad.
●Yvette: Works 8 till 5, left early for the second turn. "I'm exhausted with worry. We had a row on Sunday and she put the phone down on me."

If Asked: Associated Symptoms

Gating note: Brief, natural answers from what Yvette saw or was told.

●Stroke, fit or other causes: Face straight, arms fine; mumbling but not slurred. No fit, no passing out, no wetting herself, no bang to the head, no fall (she was sitting). No chest pain. No temperature or water infection symptoms, no vomiting or diarrhoea, no extra thirst.
●Mood and sleep: Not low, sleeps fine.
●If asked to check her mum's sugar or pulse: "I'm at work and not with her, and she's got no meter. I could go round after work or ask Mr Tran."

Responses to Management (The Negotiation Phase)

●
If the doctor asks whether her mum knows about the call, or says they cannot discuss her:
- ●Reaction: If asked: "Yes, she knows. She was short with me but she said I could." If refused: hurt and sharp, "I've been the one who found her. Can I at least tell you what happened?" She settles when told she will be listened to and the doctor will speak to her mum for the decisions.
●
If the doctor explains the cause or the plan for the tablets:
- ●Reaction: Confused about the result: "The nurse said it was the best ever. How can too good be bad?" She settles when told the number suits someone on no risky tablet and her mum needs a safer, higher target. Guilty: "Has she been taking too many?" Reassured to hear she took them as prescribed but needs less now. About stopping or cutting a tablet: "Won't her sugar go sky high? She's so proud of her number." Settles if told it is planned, she will be checked and a bit higher is safe.
●
If the doctor talks about a stroke or her memory:
- ●Reaction: "So it's not her memory? Are you sure? Will it come back?" Wants an honest answer, settles with sweating and quick recovery pointing to low sugar, and that confusion when her sugar is normal means her mum should be seen again.
●
If the doctor explains what to do if it happens again:
- ●Reaction: Practical: "What do I give her? How much? What if she won't take it, or can't swallow? When do I ring 999?" To vague advice such as "ring if she gets worse": "Worse how? When exactly do I ring 999?" She tries it back, first slipping with "I'd give her tea and wait to see", and accepts correction.
●
If the doctor advises her mum to stop driving and tell the DVLA:
- ●Reaction: Dismayed then practical: "She'll go mad. She won't stop because I say so. Can you tell her, and tell the DVLA yourself so it doesn't come from me?" Settles when told it is her mum's legal duty and the doctor will speak to her today. If told to take her keys: "I can't. It's her car." If told she can drive if she eats first: "She'll take that as permission." Asked about the licence: "Will they take it off her for good?" wants an honest answer. Asked how her mum will get about: "Church, the shop, my aunt's? I work all week." Relieved by delivered shopping, church lifts, community transport or taxis.
●
If the doctor arranges follow up:
- ●Reaction: "Yes, please ring her today, I'll tell her to expect you." Will tell her not to take the tablet if asked. A meter: "She'll say she can't be bothered. Can the nurse show her?" Teeth: "Would a dietitian help? I'll get her to the dentist." Asks "Is her diabetes getting worse?"

Mark Scheme

Domain 1: Data Gathering and Diagnosis

0 / 16 indicators checked+0−0

Positive (0/8)

Negative (0/8)

Domain 2: Clinical Management and Medical Complexity

0 / 22 indicators checked+0−0

Positive (0/11)

Negative (0/11)

Domain 3: Relating to Others

0 / 12 indicators checked+0−0

Positive (0/6)

Negative (0/6)

Clinical Learning Points

The Core Dilemma and the Model Plan

●Hyacinth, 78, takes gliclazide 80 mg twice daily and metformin 500 mg twice daily. Her daughter has found her sweaty, grey and confused twice in a fortnight, and each time someone else had to give her sugar. Her HbA1c (glycated haemoglobin) is 41 mmol/mol (5.9%) and the nurse called it her best ever.
●The diagnosis is not in doubt. This station is about overtreatment: a number that looks excellent in someone on a hypoglycaemia causing tablet, with falling kidney function, weight loss and poor intake, is a warning.
●Model plan: take a focused history of both episodes, exclude other causes, recognise severe hypoglycaemia caused by gliclazide, stop it that day and agree a less strict target, arrange glucose checks and an early review, give first aid and 999 advice, tell her to stop driving and notify DVLA, speak to Hyacinth herself the same day, and keep Yvette's role manageable.
●Acceptable alternatives: reducing gliclazide substantially (at least halving) to the lowest effective dose, provided the reasons are given, glucose is monitored, a review is booked within one to two weeks and there is a plan to stop it after any further episode. Metformin may be continued, changed to modified release or stopped if the reasoning is sound.

Recognising Severe Hypoglycaemia

●Hypoglycaemia is usually a glucose below 4 mmol/L. Typical symptoms are sweating, shaking, a thumping heart, tingling, blurred vision and confusion. For driving, a severe episode is one needing another person's help, and both of Hyacinth's qualify.
●Fast recovery after sugar supports the diagnosis. Sulfonylureas and insulin are the usual causes; metformin alone does not cause it, so it is not the drug to blame.
●Sudden confusion still needs a few seconds of exclusion questions: face, arm or speech symptoms, a fit or collapse, a fall, chest pain, infection and alcohol.
●An HbA1c averages about three months and says nothing about swings, and a low value can also reflect kidney decline or weight loss.

Why Long Standing Tablets Became Too Much

●Gliclazide risk rises with skipped or irregular meals, poor intake, renal impairment, alcohol and interacting drugs. Hyacinth takes it with tea and half a slice of toast, eats little since her dentures, has lost about 4 kg in a year and her eGFR has fallen from 58 to 49.
●The BNF says sulfonylureas should be used with care in mild to moderate renal impairment, at the lowest dose that controls glucose, and that gliclazide can be used if necessary with careful glucose monitoring.
●Ask what has changed, as the regimen has not. Interactions to check in other patients include clarithromycin, sulfamethoxazole, fluoroquinolones, fibrates and miconazole. None applies to Hyacinth.

Individualised Targets in Older People

●NICE NG28 advises agreeing an individual HbA1c target (suggested 53 mmol/mol, 7.0%, for people on a medicine associated with hypoglycaemia) and considering relaxing it for older or frailer people where tight control carries a high risk from hypoglycaemia. NG28 gives no number for a relaxed target, so none is required.
●Hyacinth is below even the standard target and is having hypoglycaemia, so "maintain it" does not apply. Her age, kidney disease, weight loss and recurrent severe episodes all support a less strict target, agreed with her.

The Treatment Decision

●Stop gliclazide now. Every risk factor persists, her HbA1c is far below any sensible target and she has had two severe episodes. Do not wait for the next review.
●Reducing it substantially is also acceptable on the terms in section 1. Do not swap to another sulfonylurea, and do not add a replacement today, as an HbA1c of 41 needs no more drugs.
●Metformin: the BNF advises avoiding it if eGFR is below 30 and reducing the dose in moderate impairment, and NICE CKS suggests reviewing the dose if eGFR falls below 45. At an eGFR of 49, 500 mg twice daily is appropriate with a recheck, and NG28 allows modified release. Stopping it as well is reasonable if appetite and weight keep falling, with monitoring.
●If glucose later rises above her agreed target, NG28 suggests a DPP4 (dipeptidyl peptidase 4) inhibitor for frail adults, or an SGLT2 (sodium glucose cotransporter 2) inhibitor otherwise if there is no risk of volume depletion. Doses are renally adjusted, so check the BNF.

Monitoring, Follow Up and the Cause

●NG28 supports self monitoring where there is evidence of hypoglycaemia. Offer a meter and short term testing when she feels odd and before lunch for a couple of weeks. A reading below 4 mmol/L is treated as a hypo.
●Review within one to two weeks (a pragmatic interval, not a guideline figure) with readings, weight, urea, electrolytes and eGFR, and recheck HbA1c in about three months. A rise after stopping is expected and acceptable within her target.
●Treat the cause: dentist review of the dentures, regular small meals, dietetic input if weight keeps falling. Weight loss with bleeding, cough or pain needs investigation, not assumption.
●Refer to the specialist diabetes team if episodes continue after stopping the drug or she cannot recognise warning symptoms.

First Aid and When to Call 999

●If she can swallow, give fast acting sugar such as a small glass of fruit juice, a sugary drink or about five glucose tablets, check after 10 to 15 minutes if a meter is available, repeat if still below 4 mmol/L, then give something starchy such as biscuits, a sandwich or the next meal.
●If she is drowsy, unresponsive, cannot swallow safely or has a fit, give nothing by mouth, put her in the recovery position and call 999. She has no glucagon.
●Low sugar can return after initial recovery, so anyone with an episode should eat properly, have someone nearby for a few hours and tell the practice the same day. "Ring if she gets worse" is not adequate; say exactly what to give and when to ring.

Driving

●DVLA (Assessing fitness to drive: diabetes, updated 7 November 2025) defines severe hypoglycaemia as needing another person's help. A Group 1 driver on a sulfonylurea may drive without notifying only if they have awareness, have not had two or more severe awake episodes in 12 months (with the latest over 3 months ago) and are under regular review.
●Hyacinth fails that test, so the model advice is to stop driving now and notify DVLA herself. DVLA then makes medical enquiries, and nobody can promise whether the licence is kept.
●The guidance does not say what happens when the sulfonylurea is stopped after the episodes. Telling her to stop driving now and taking DVLA medical adviser advice on whether she must notify also passes (GMC guidance, paragraph 5), provided she is told not to drive meanwhile.
●"Eat first" or "carry glucose" is not a safe answer. If she keeps driving, the GMC says make every effort to persuade her, then tell the DVLA medical adviser if others are at risk, telling her first and in writing afterwards.

Confidentiality, Capacity and Yvette

●You can always listen to a relative. Sharing Hyacinth's results, medicines and plans needs her agreement, so ask early whether she knows about the call and is happy. Here she has agreed reluctantly, which is enough to discuss the problem, but decisions about her medicines and driving belong to her and should be made with her directly.
●The Mental Capacity Act 2005 presumes capacity. Brief confusion during a low sugar is not a reason to doubt it. There is no lasting power of attorney, so Yvette cannot decide for her and there is no best interests process.
●Do not make Yvette the enforcer: do not ask her to take the keys, and offer to speak to Hyacinth. Plan transport (delivered shopping, church lifts, community transport, taxis).
●Answer the memory worry honestly: sweating with quick recovery after sugar fits low glucose, and confusion with a normal glucose would need another look. Explain "best ever" without blaming the nurse. Agree a realistic role for Yvette and ask her to repeat what she would do.

Common Mistakes in This Station

●Treating an HbA1c of 41 as good control to protect.
●Blaming metformin, stopping it and leaving gliclazide unchanged, or only advising regular meals.
●Swapping to another sulfonylurea or adding a drug.
●Missing that the episodes were severe, or not asking about driving.
●Allowing driving if she eats first, or leaving Yvette to report her or take the keys.
●Refusing to listen to Yvette, or sharing details without asking whether Hyacinth agrees.
●Vague safety netting instead of what to give and when to ring 999.
●Ignoring the dentures, weight loss and kidney function, or leaving the change to the next review instead of speaking to Hyacinth that day.

Mapped to the RCGP curriculum topic: Metabolic Problems and Endocrinology.

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