Cases/Prescribing

Burning Chest Pain After Starting A Bone-protection Tablet — Free SCA Practice Case

Woman with burning chest pain after starting a bone-protection tablet

Station Timer

12:00

Golden Minute

Initial Introduction

•Introduce yourself

•Ask an open question — "How can I help you today?"

•Listen — don't interrupt

•Catch early cues

Data Gathering

History, ICE & Diagnosis

Clinical Management

Diagnosis, Plan & Decisions

Safety Net

Follow-up & Close

12:00

Golden Minute

Materials for Candidate

Please review before starting the consultation

Patient Profile

Full Name

Dorothy Vale

Age

77 years

Consultation Type

Video

Age

Situation

Video Consultation, booked to discuss endoscopy results.

Reason for Encounter

"I've had the camera test and I'd like to go through the results, please."

Medical Records

●PMH: Hypertension.
●Medications: Amlodipine 5 mg OD. Alendronic acid 70 mg once weekly (Mondays). Adcal D3 chewable, one tablet twice daily.
●Allergies: NKDA.
●Consultation 8 months ago: Patient requested treatment for osteoporosis due to concerns about fracture risk, triggered after a friend sustained a fracture and subsequently died following hospital admission. Assessment: FRAX score — green zone, indicating low fracture risk. Plan: "Discussion held regarding low fracture risk; however, the patient preferred to commence treatment. Alendronic acid 70 mg weekly started alongside Adcal D3. Counselled on correct administration, side effects, and advised dental check."
●Consultation 3 weeks ago: Six weeks of worsening retrosternal burning chest pain. Examination: epigastric tenderness, no peritonism. BP 120/70, pulse 76, temperature 36.2 °C, BMI 24.5. Impression: suspected oesophagitis, likely bisphosphonate-related. Plan: refer for upper GI endoscopy.
●Upper GI endoscopy report (3 days ago): "Oesophagus: distal oesophagitis with erythema and superficial erosions, consistent with Los Angeles Grade B oesophagitis. No stricture or Barrett's change. Stomach: normal. Duodenum: normal. Recommendations: start proton pump inhibitor therapy; review suitability of ongoing oral alendronic acid and reinforce correct administration. Impression: moderate erosive oesophagitis, likely secondary to alendronic acid."

Patient Script

For the friend playing the patient role

Character Overview: You are Dorothy, 77, widowed and living alone but independent. About eight months ago your best friend fractured her hip, was admitted to hospital, developed a clot on her lung and died. It shook you badly and you became frightened of breaking a bone. You went to the surgery and asked to be put on something for your bones. The doctor did a risk score and told you your risk was low, but you insisted you wanted treatment anyway, and he started alendronic acid. For the last couple of months you have had burning pain behind the breastbone — worse after meals, worse lying down, and worst at night, sometimes waking you. Gaviscon did not help. You had a camera test three days ago and have booked to discuss the results. If asked how you take the tablet, you will admit you take it with your morning tea and then usually go back to bed for half an hour — you did not realise this mattered. You are frightened of stopping the tablet because of your friend, and you will need genuine reassurance about your fracture risk before you will accept stopping it.

Opening Sentence: "Hello Doctor. I've come about the camera test I had a few days ago. They didn't really tell me anything at the hospital — they said my own doctor would go through it. I've been getting this awful burning behind my breastbone. What did it show?"

History if Asked (Data Gathering Phase)

●The pain: "A burning, right behind my breastbone. Worse after I eat, worse when I lie down, and worst at night — it's been waking me up."
●Duration: "A couple of months now, and it's been getting worse rather than better."
●What she's tried: "Gaviscon. It didn't touch it."
●Why she's on the tablet: "My best friend broke her hip, went into hospital, got a clot on her lung and died. It terrified me. I went and asked to be put on something for my bones."
●What she was told at the time: "He did some sort of score and said my risk was low. But I wanted something anyway. So he started me on it."
●How she takes it — if asked: "I take it on a Monday with my morning cup of tea, and then I usually go back to bed for half an hour before I get up properly." (Incorrect administration.)
●Her fear: "I'm frightened of coming off it. I don't want to end up like my friend."

ICE — Ideas, Concerns, Expectations

The patient does not volunteer this information unprompted. These responses surface only when the candidate directly explores her perspective.

●Ideas: Dorothy has not connected the tablet with the burning pain. "I hadn't linked the two at all. I thought it was just indigestion coming on with age."
●Concerns: Her dominant concern is fracturing a hip and dying like her friend; she is now also worried about what the camera test found. "My real fear is breaking a hip and that being the end of me. And now I'm worried about what they found."
●Expectations: She expects the results explained and something to settle the burning — but she expects to stay on the bone tablet. "Tell me what they found and give me something for this burning. But I want to keep taking my bone tablet."

If Asked — Symptom, Administration, Red-Flag, and Bone-Health Screen

The patient answers these only when directly asked.

●If asked how she takes the alendronic acid — key: "With my morning tea, and then I go back to bed for half an hour or so." (Should be: with plain water, on an empty stomach, remaining upright for at least 30 minutes.)
●If asked about dysphagia (food sticking) or odynophagia (pain on swallowing): "No, nothing sticks and it doesn't hurt to swallow."
●If asked about weight loss, vomiting, or vomiting blood, or black stools: "No weight loss, I haven't been sick, and no blood or black stools."
●If asked about appetite: "My appetite is fine."
●If asked about previous fractures — key to fracture-risk assessment: "No, I've never broken a bone."
●If asked about falls or unsteadiness: "No falls. I'm steady on my feet."
●If asked about family history of hip fracture or osteoporosis: "Not that I know of."
●If asked about smoking, alcohol, steroids, or early menopause: "I've never smoked, I hardly drink, I've never had steroids. My change was at about 52."
●If asked about whether she has had a bone density (DEXA) scan: "No, I've never had a scan of my bones."
●If asked about dental health and dental checks: "I go to the dentist every six months. My teeth are fine."
●If asked about diet, calcium, vitamin D, and exercise: "I eat well, plenty of dairy. I walk to the shops most days."
●If asked about other medication that could contribute to reflux: "Just the amlodipine and the calcium tablets." (Amlodipine can worsen reflux.)
●If asked about what she understands the camera test showed: "Nothing — they said my own doctor would explain it."

Responses to Management (The Negotiation Phase)

●If the Doctor explains the endoscopy result: "So it's inflammation and little ulcers in my gullet. Is that serious? Is it cancer?" (The tested point is explaining the result clearly and addressing the unspoken cancer fear — the report shows no stricture and no Barrett's.)
●If the Doctor explains the tablet caused it: "The bone tablet caused this? I had no idea a tablet could do that." (The tested point is explaining bisphosphonate-related oesophagitis.)
●If the Doctor asks how she takes it and identifies the error: "With my tea and then back to bed — was that wrong? Nobody ever explained it like that to me." (The tested point is identifying incorrect administration as a contributing factor.)
●If the Doctor recommends stopping the alendronic acid — the negotiation: "Stop it altogether? But my bones… I'm frightened of ending up like my friend." (The tested point is negotiating cessation by addressing the fear, not simply instructing.)
●If the Doctor revisits the original prescribing decision honestly — key: "So you're telling me I probably didn't need it in the first place? That my risk was low all along?" (The tested point is revisiting a prescribing decision made against the evidence, honestly and without blaming the colleague.)
●If the Doctor offers a proton pump inhibitor and reflux advice: "So a tablet to heal it, and some things I can do myself? That'd be a relief."
●If the Doctor addresses bone health positively: "So there are things that actually help my bones without a tablet — and you'll reassess my risk properly?"

Mark Scheme

Domain 1: Data Gathering and Diagnosis

0 / 20 indicators checked+0−0

Positive (0/10)

Negative (0/10)

Domain 2: Clinical Management and Medical Complexity

0 / 20 indicators checked+0−0

Positive (0/10)

Negative (0/10)

Domain 3: Relating to Others

0 / 12 indicators checked+0−0

Positive (0/6)

Negative (0/6)

Clinical Learning Points

Bisphosphonate-Related Oesophagitis

●Oral bisphosphonates are a recognised cause of oesophagitis, oesophageal erosions, and ulceration. Presentation is with retrosternal burning pain, dysphagia, or odynophagia. Risk is substantially increased by incorrect administration.

Correct Administration Is Essential

●Alendronic acid must be taken on an empty stomach with a full glass of plain water, and the patient must remain upright for at least 30 minutes and not lie down, taking it before food and other medicines. Taking it with tea and then returning to bed, as here, materially increases oesophageal exposure — and reflects a counselling failure as much as a patient error.

Treat the Oesophagitis and Remove the Cause

●Manage erosive oesophagitis with a proton pump inhibitor at treatment dose for a healing course, alongside reflux lifestyle measures and review of other contributing medicines (for example calcium-channel blockers). Crucially, address the cause — continuing the culprit drug undermines treatment.

Weigh Benefit Against Harm — and Revisit the Original Decision

●The decision to continue or stop rests on the balance of benefit and harm. Where the patient's fracture risk was low and the drug has caused significant erosive oesophagitis, that balance clearly favours stopping. This case is a reminder to revisit prescribing decisions, particularly those made against a risk assessment under pressure of patient anxiety.

Honesty About Iatrogenic Harm, Without Blaming Colleagues

●Where a patient has been harmed by a medicine they are unlikely to have needed, be honest about it. Honesty is compatible with not disparaging the prescribing colleague — the decision was made in the face of an understandable and powerful fear, and the appropriate route for learning is a significant event review, not criticism to the patient.

Address the Fear, Not Just the Prescription

●The original request was driven by bereavement and fear of fracture. Unless that fear is addressed — with an honest reassessment of risk and positive, non-drug bone protection (weight-bearing and resistance exercise, calcium and vitamin D, falls prevention, avoiding smoking and excess alcohol) — the patient will resist stopping, or will simply seek treatment again elsewhere.

Leave the Door Open, and Safety-Net

●Explain what would change the decision (a fragility fracture or a higher future risk assessment) and that non-oral bone-protection options exist that avoid the oesophagus. Safety-net for dysphagia, odynophagia, haematemesis, melaena, or weight loss, and arrange follow-up to confirm resolution.

Common Candidate Mistakes in This Case

●Continuing the alendronic acid: treating the oesophagitis without removing its cause.
●Not asking how she takes it: missing the administration error that both explains the harm and reflects a counselling gap.
●Avoiding the honest conversation: glossing over the fact that the drug was started against a low-risk assessment — or, conversely, blaming the colleague.
●Stopping the drug without addressing her fear: so she feels abandoned to the very outcome she dreads, and is unlikely to accept the plan.
●No PPI, safety-netting, or follow-up: failing to treat the oesophagitis properly or to confirm it resolves.

Free MRCGP SCA practice case for GP registrars covering Burning Chest Pain After Starting A Bone-protection Tablet — Prescribing. Includes candidate brief, patient script, marking scheme mapped to the RCGP SCA marking domains, and learning points. Built directly from the RCGP curriculum topic stations listed under "How this might be tested in the MRCGP SCA," part of a free library of 79 SCA practice cases for simulated consultation assessment preparation.

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