Cases/Gastroenterology

Over-the-counter Remedies — Free SCA Practice Case

Man with persistent indigestion self-treating with over-the-counter remedies

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

Steven Ball

Age

48 years

Consultation Type

Telephone

Age

Situation

Telephone Consultation.

Reason for Encounter

"I've had indigestion on and off for months and I've been buying stuff from the chemist for it, but it keeps coming back. I want something stronger to sort it out for good."

Medical Records

●PMH: Nil significant.
●Medications: None on repeat. (Patient self-purchasing over-the-counter antacids and, more recently, over-the-counter omeprazole.)
●Allergies: NKDA.
●Recent contact: No recent consultations.

Patient Script

For the friend playing the patient role

Character Overview: You are Steven, a 48-year-old lorry driver. You are practical and a bit impatient — you have been "managing it myself" and want a stronger tablet to make it go away so you can get on. You have been buying antacids and, for the last few weeks, omeprazole from the chemist. You are not especially worried about anything sinister; you just want it fixed. You will answer questions honestly if asked.

Opening Sentence: "Morning, Doctor. I've had this indigestion for months now — burning in the middle of my chest and my upper tummy, worse after meals and when I lie down. I've been buying antacids and then those omeprazole tablets from the chemist. They help a bit but it always comes back. Can I just get something stronger on prescription?"

History if Asked (Data Gathering Phase)

●The symptoms: "A burning feeling behind my breastbone and in the top of my tummy. Worse after big meals, and worse at night when I lie down. Sometimes an acidic taste comes up into my throat."
●Duration: "On and off for about four or five months now. Never really clears completely."
●What he's tried: "Started with Gaviscon-type antacids, then moved on to omeprazole from the chemist about three or four weeks ago. It settles it while I take it but it comes back."
●Lifestyle: "I'm a lorry driver, so I eat on the go — lots of takeaways, big meals late when I finish a shift, loads of coffee to stay awake. I've put on a bit of weight. I smoke, and I have a few beers most evenings."
●Painkillers: "I take ibuprofen fairly regularly for a dodgy shoulder, actually. Most days."

ICE — Ideas, Concerns, Expectations

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

●Ideas: Steven thinks it is "just indigestion / acid" and that a stronger tablet will cure it. He has not considered that his ibuprofen, smoking, diet, or a bacterial cause could be involved. "In my head it's just acid, and a stronger pill fixes acid. I've not thought much beyond that."
●Concerns: He is not consciously worried about anything serious, though when asked he admits a passing thought about "whether it could be something worse." He is more worried about it interfering with his work. "I've not let myself think it might be serious. Mostly I just want it gone so it stops nagging at me on long drives."
●Expectations: He expects a prescription for a stronger acid tablet today. "I was hoping you'd just prescribe me the strong version and that'd be that."

If Asked — Medical History and Medications

The patient confirms these details only when directly asked.

●NSAID use: "Yeah, ibuprofen most days for my shoulder — I buy it myself, take a fair bit."
●Omeprazole: "Chemist omeprazole, one a day, for the last three or four weeks."
●Other medications: "Nothing on prescription."
●Alcohol and smoking: "Three or four beers most nights, and I smoke about ten a day."
●Family history: "No stomach cancer or anything like that in the family that I know of."

Social History and Lifestyle Impact

Steven is a long-distance lorry driver. He lives with his partner.

●Work and diet: "Long shifts, irregular meals, lots of service-station food and coffee, big late dinners when I get in."
●Weight: "I've gained maybe a stone over the last couple of years. Not much exercise with the driving."
●Habits: "Smoke ten a day, few beers most evenings."
●Impact: "It's more of a nuisance than anything — the burning on long drives is distracting."

If Asked — Alarm-Feature Screen

The patient answers these only when directly asked.

●If asked about difficulty swallowing (dysphagia): "No, food goes down fine."
●If asked about unintentional weight loss: "No — if anything I've put weight on."
●If asked about vomiting, or vomiting blood: "No vomiting, definitely no blood."
●If asked about black/tarry stools (melaena): "No, nothing like that. Stools are normal."
●If asked about feeling full quickly / loss of appetite: "No, appetite's good, maybe too good."
●If asked about a lump in the tummy or persistent pain: "No lump, no constant pain — it's the burning that comes and goes."
●If asked about anaemia symptoms (tiredness, breathlessness): "No, I feel well in myself, not especially tired."

Responses to Management (The Negotiation Phase)

●If the Doctor recommends testing for Helicobacter pylori: "A test for a stomach bug? What's that got to do with heartburn? And you're saying I have to stop the omeprazole first?" (The tested point is explaining test-and-treat and, crucially, that recent PPI use must be stopped before H. pylori testing to avoid a false-negative result.)
●If the Doctor addresses his ibuprofen use: "The ibuprofen? I only take it for my shoulder. You think that's causing it?"
●If the Doctor recommends lifestyle change: "I know, I know — but with my job it's hard to eat properly and cut the coffee. Is that really going to make a difference?"
●If the Doctor offers a full-dose PPI trial rather than 'something stronger' indefinitely: "So a course, not just forever? Why can't I just stay on a strong one all the time?"
●If the Doctor safety-nets about alarm symptoms: "What would mean I need to be seen properly or have a camera test?"

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 / 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

Uninvestigated Dyspepsia — The Framework

●Dyspepsia encompasses upper-abdominal pain/discomfort, heartburn, acid regurgitation, and related symptoms. Most uninvestigated dyspepsia without alarm features is managed in primary care (NICE CG184).
●The first task is always to screen for alarm features that mandate urgent endoscopy.

Alarm Features and the Age Threshold

●Urgent upper GI endoscopy (suspected-cancer pathway) is indicated for dysphagia; for people aged 55 and over with weight loss and upper-abdominal pain/reflux/dyspepsia; and should be considered for other alarm features such as GI bleeding, persistent vomiting, iron-deficiency anaemia, epigastric mass, or unexplained weight loss.
●New alarm features at any age warrant assessment; new, unexplained, persistent dyspepsia at 55 or over lowers the threshold for endoscopy.

Reversible Contributors — Especially NSAIDs

●NSAIDs (including self-purchased ibuprofen) are a major, reversible cause of dyspepsia and peptic ulceration. Reviewing and stopping them is often the single most effective step.
●Other contributors: smoking, alcohol, caffeine, large/late meals, obesity, and certain drugs.

First-Line Strategy: Test-and-Treat or PPI Trial

●For uninvestigated dyspepsia without alarm features, offer either Helicobacter pylori test-and-treat or a 4-week trial of a full-dose proton-pump inhibitor — both are acceptable first-line options.
●Address lifestyle in parallel regardless of the pharmacological choice.

H. pylori Testing — The PPI Washout

●Test with a stool antigen test or urea breath test.
●Crucial nuance: stop proton-pump inhibitors for at least 2 weeks (and antibiotics for 4 weeks) before testing, because they suppress the organism and cause false-negative results. A patient self-treating with over-the-counter omeprazole must have a washout before testing.

Eradication Therapy

●H. pylori-positive patients are treated with a 7-day triple regimen: a PPI plus two antibiotics (e.g. amoxicillin with either clarithromycin or metronidazole), with regimen choice guided by allergy and local resistance.
●Confirm eradication (e.g. urea breath test) where indicated, particularly after ulcer disease.

Rational PPI Use

●PPIs are used as a defined course with review and step-down to the lowest effective dose, rather than open-ended high-dose use. Explain this to patients who expect to "stay on a strong one forever."

Review and Referral

●Review response; persistent or relapsing dyspepsia despite optimisation, or the emergence of alarm features, warrants endoscopy referral. Provide clear alarm-feature safety-netting.

Common Candidate Mistakes in This Case

●Skipping the alarm-feature screen: issuing a stronger PPI without excluding red flags.
●Missing the NSAID: not asking about, or not addressing, the regular ibuprofen.
●Botching H. pylori testing: arranging a test without a PPI washout, guaranteeing an unreliable result.
●Open-ended PPI prescribing: committing the patient to indefinite high-dose treatment with no strategy or review.
●Ignoring the driver's reality: giving lifestyle advice that cannot be followed on the road, so it is disregarded.

Free MRCGP SCA practice case for GP registrars covering Over-the-counter Remedies — Gastroenterology. 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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