Man Whose Kidney Function Is Declining While Taking Ibuprofen for His Knees — Free SCA Practice Case
Man whose kidney function is declining while taking ibuprofen for his knees
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 MinuteMaterials for Candidate
Please review before starting the consultation
Patient Profile
Full Name
Alan Reeve
Age
60 years
Consultation Type
TelephoneAge
60
Situation
Telephone Consultation, booked to discuss blood-test results.
Reason for Encounter
"I've rung about my blood results. I had them done because of my knees and the tablets I've been taking."
Medical Records
- ●PMH: Osteoarthritis (both knees). Hypertension.
- ●Medications: Ramipril 10 mg OD. Ibuprofen 400 mg TDS (bought over the counter, taken regularly for ~8 months). Paracetamol PRN.
- ●Allergies: NKDA.
- ●Recent notes: Bloods 1 week ago. eGFR 42 mL/min/1.73 m² (previously 58 eighteen months ago; 74 three years ago). Creatinine rising. Urine ACR normal. Potassium 4.9 mmol/L. No haematuria. BP 138/84. Patient has not previously been told he has chronic kidney disease.
Patient Script
For the friend playing the patient role
Character Overview: You are Alan, a 60-year-old warehouse supervisor with painful osteoarthritis in both knees. For about eight months you have been buying ibuprofen over the counter and taking it three times a day, most days, because it is the only thing that touches the pain — paracetamol alone does nothing. You did not think tablets you can buy in a shop could be harmful. You take ramipril for blood pressure. You have had blood tests and are ringing for the results. You have no urinary symptoms and feel well in yourself. You have never been told anything about your kidneys. You will be shocked to hear there is a problem, and your main worry will be your knees — if you stop the ibuprofen, how will you cope with the pain and keep working?
Opening Sentence: "Hello Doctor. I'm ringing for my blood results. I've been having trouble with my knees and taking ibuprofen for it — the nurse said to get some bloods done. Is everything alright?"
History if Asked (Data Gathering Phase)
- ●The ibuprofen: "I buy it from the chemist — 400 mg, three times a day, most days, for about eight months now. It's the only thing that helps my knees."
- ●Paracetamol: "I take paracetamol too but on its own it does nothing."
- ●His knees: "Both knees, worn out. Painful on stairs and standing all day at work. It's my job — I'm on my feet."
- ●How he feels: "I feel fine in myself, honestly. No problems at all."
- ●What he knew about his kidneys: "Nobody's ever said anything to me about my kidneys."
ICE — Ideas, Concerns, Expectations
The patient does not volunteer this information unprompted. These responses surface only when the candidate directly explores his perspective.
- ●Ideas: Alan assumes his results are probably fine, and had no idea a shop-bought painkiller could damage his kidneys. "I assumed it'd all be normal. I never thought tablets you can just buy could do any harm."
- ●Concerns: Once told, he will be shocked and worried about his kidneys — but his dominant practical concern is his knees and his job: how he will cope with the pain without ibuprofen. "That's frightening about my kidneys. But what do I do about my knees? I can't work in that much pain."
- ●Expectations: He expects his results explained and, above all, a plan for his knee pain. "I want to know what the results mean and what I can take instead."
If Asked — Renal, Drug, and Red-Flag Screen
The patient answers these only when directly asked.
- ●If asked about other NSAIDs or painkillers (including gels, aspirin, codeine): "Just the ibuprofen tablets and paracetamol. No gels, no codeine."
- ●If asked about other medications, supplements, or herbal remedies: "Only the ramipril, and nothing herbal."
- ●If asked about urinary symptoms (frequency, poor stream, nocturia, retention): "No waterworks problems at all."
- ●If asked about visible blood in the urine or frothy urine: "No blood, and nothing frothy."
- ●If asked about swelling, breathlessness, or fatigue: "No swelling in my ankles, no breathlessness, and I'm not unusually tired."
- ●If asked about dehydration/fluid intake/diarrhoea or vomiting: "I drink normally, no vomiting or diarrhoea."
- ●If asked about recent illness, infections, or contrast scans: "No infections, no scans."
- ●If asked about diabetes/family history of kidney disease: "No diabetes, and nobody in the family with kidney trouble that I know of."
- ●If asked about BP monitoring/adherence to ramipril: "I take the ramipril every day. My BP's usually reasonable."
- ●If asked about smoking/alcohol: "Non-smoker, a couple of pints at the weekend."
Responses to Management (The Negotiation Phase)
- ●If the Doctor explains the kidney results and that he has CKD: "So my kidneys aren't working as well as they should — and they've been getting worse? Nobody told me that before." (The tested point is explaining a CKD diagnosis he did not know about, clearly and without alarm.)
- ●If the Doctor identifies the ibuprofen as the likely driver: "The ibuprofen's been damaging my kidneys? I honestly had no idea." (The tested point is identifying and explaining the NSAID as the culprit — including its interaction with his ramipril.)
- ●If the Doctor advises stopping the ibuprofen — the key action: "You want me to stop it? But it's the only thing that works — how am I going to manage my knees and my job?" (The tested point is stopping the culprit AND providing effective alternative analgesia, not just withdrawing what works.)
- ●If the Doctor offers alternative analgesia and OA management: "So topical anti-inflammatory gel, regular paracetamol, physio, and other options? I'd give that a go if it helps." (The tested point is a proper osteoarthritis management plan.)
- ●If the Doctor arranges repeat bloods and monitoring: "You'll recheck my kidneys to see if they recover? And keep an eye on things?"
Mark Scheme
Domain 1: Data Gathering and Diagnosis
0 / 18 indicators checked+0−0
Positive (0/9)
Negative (0/9)
Domain 2: Clinical Management and Medical Complexity
0 / 18 indicators checked+0−0
Positive (0/9)
Negative (0/9)
Domain 3: Relating to Others
0 / 12 indicators checked+0−0
Positive (0/6)
Negative (0/6)
Clinical Learning Points
1
NSAIDs and Renal Function
- ●NSAIDs reduce renal perfusion (via prostaglandin inhibition) and are a common, reversible cause of declining eGFR/acute kidney injury, especially with sustained use. Always take a full drug history including over-the-counter and herbal medicines — patients often do not consider shop-bought tablets to be "medication".
2
The "Triple Whammy" and Nephrotoxic Combinations
- ●The combination of an NSAID + ACE inhibitor/ARB (± diuretic) is particularly nephrotoxic (the "triple whammy"). Recognise nephrotoxic pairings when interpreting a falling eGFR.
3
Interpret the Trend, Not the Isolated Result
- ●Assess renal function as a trend (here 74 → 58 → 42), distinguishing chronic kidney disease from acute kidney injury superimposed on CKD, and quantify with eGFR and urine ACR.
4
Stop the Culprit — But Replace the Analgesia
- ●Stopping the NSAID is the key intervention, but it will only stick if effective alternative analgesia is provided: regular paracetamol and a topical NSAID (first-line in knee osteoarthritis, with far lower systemic absorption), with other options considered — otherwise the patient will simply resume it.
5
Manage the Osteoarthritis Properly
- ●Provide core OA management — exercise and muscle strengthening, physiotherapy, weight management, footwear/aids, and workplace advice — with intra-articular injection or orthopaedic referral for severe disease (NICE NG226).
6
CKD Care and Monitoring
- ●Recheck U&Es/eGFR after ~2 weeks to see whether function recovers, then monitor eGFR, urine ACR, and BP. Provide BP and cardiovascular-risk management, sick-day guidance, advice to avoid nephrotoxins, and lifestyle/vaccination advice, and know the nephrology referral criteria (rapidly declining eGFR, significant proteinuria/ACR, eGFR <30, unexplained CKD, or haematuria).
7
Reviewing the ACE Inhibitor
- ●ACE inhibitors are renal-protective in CKD but require monitoring; decisions to continue, hold, or adjust should be reasoned in the context of the decline and volume status — not reflexive.
8
Common Candidate Mistakes in This Case
- ●Not identifying the NSAID: missing the reversible cause of the decline (or the ACE-inhibitor interaction).
- ●Stopping the ibuprofen with no alternative: leaving him in pain, so he resumes it and the CKD progresses.
- ●Ignoring the osteoarthritis: treating the blood result and not the person's actual problem.
- ●Poor delivery of an unexpected diagnosis: alarming or blaming him for taking over-the-counter tablets.
- ●No repeat bloods or monitoring plan: failing to check for recovery or set up CKD follow-up.
Free MRCGP SCA practice case for GP registrars covering Man Whose Kidney Function Is Declining While Taking Ibuprofen for His Knees — Renal and Urology. 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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