Cases/Smoking, Alcohol and Substance Misuse

Seventeen Year Old Who Wants to Cut Down His Ketamine Use — Free SCA Practice Case

Seventeen year old who wants to cut down his ketamine use

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

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Materials for Candidate

Please review before starting the consultation

Patient Profile

Full Name

Ezra Bellamy

Age

17 years

Consultation Type

Telephone

Age

Situation

Telephone Consultation. Booked by the patient online and asked to be called on his mobile.

Reason for Encounter

"Going to the toilet all the time for a few months. There's something else I want to talk about in confidence."

Medical Records

●PMH: Childhood eczema, no treatment for years. Hay fever.
●Medications: None.
●Allergies: NKDA.
●Social: Lives with his parents and younger sister. Works as a junior chef.

Recent Notes

●No consultations in the last two years.

Patient Script

For the friend playing the patient role

Character Overview: You are Ezra Bellamy, 17, a junior chef at a gastropub. You left school at 16 and work split shifts, usually Wednesday to Sunday, with a long gap in the afternoon. You live with your dad Barry, who works for a water company, your mum Rowena, who works in the office of a building society, and your sister Phoebe, who is 12. Your dad has been off alcohol for six years after it nearly cost him his job and his marriage. Your mum has said more than once that she could not cope with another thing going wrong, and you promised yourself you would never be the next problem. For a year you have used ketamine, snorted, with three friends from school at one friend's flat, most weekends after your Saturday shift. You got it from Troy, a friend's cousin who is 19. You use it to switch off after a hard week. Three months ago you began needing the toilet far more often. It has got steadily worse and now interrupts your shifts. You are frightened by it, and a friend who went to hospital with the same problem told you to get seen. Mum looked after all your medical matters on her phone when you were younger. You are polite, quiet and a little ashamed. You speak in short sentences at first and open up if the doctor is calm and non judgemental. If the doctor lectures you or says they will tell your parents, you shut down, say "forget it, I shouldn't have called" and try to end the call.

Opening Sentence: "Hi. Before I say anything, is this properly confidential? I'm seventeen, and I really don't want my mum and dad finding out what I tell you."

History if Asked (Data Gathering Phase)

●The toilet problem: "About three months. At first it was a bit more than usual. Now I need to go about every half hour, in the day and at night. It's three or four times a night and I'm tired all the time. At work I keep having to leave the line, and my head chef has noticed."
●Pain and urgency: "When I need to go, I need to go straight away. Sometimes I only get a dribble. It stings at the end, and low down in my belly there's an ache that comes in waves, worse the day after a weekend."
●Blood: "Once, about two weeks ago, it was pink. It hasn't happened since."
●Leaking: "Twice I've not quite made it and leaked a bit in my pants. I haven't told anyone that."
●Fever and back pain: "No fever, no pain in my back or sides, no vomiting."
●Sexual health: "I had a girlfriend until about four months ago, the only person I've been with. We used condoms. No discharge or anything like that."
●What he has tried: "Cranberry juice, and I've cut down on tea. It does nothing. I haven't taken any tablets for it."
●The drug: "Ketamine, snorted. Usually Friday after work or Saturday night with my mates. About a year now. A gram bag between four of us on a normal weekend, and I'd have maybe a third of it. Lately I've been having more, and I've done some on a Sunday as well."
●Pattern lately: "It used to be once a month, then most weekends since last summer. In the last two months I've had some on my own in my room, which I never did before."
●Why he wants to stop: "The toilet thing scares me. A lad I know ended up in hospital with his bladder. I want to cut right down or stop, but all my friends use it, so it's hard to say no."
●Cost: "About thirty quid a weekend, out of my wages."
●Other drugs and alcohol: "I drink four or five cans at the flat, and I have had cans and ketamine together. I've smoked weed a few times. Pills once, a long time ago. Nothing else, nothing injected. I vape most days."
●How he feels: "Tired, a bit down, snappy with Phoebe. I'm not depressed. I don't want to hurt myself and I've never thought about it."
●Safeguarding screen: "Troy sells it to a few people and I only buy for myself. Nobody has asked me to hold or carry anything, I don't owe anyone money, and nobody pressures me. I'm not scared of anyone. I've never had anything bad happen at the flat apart from being unable to move once for a while."

Ideas, Concerns, Expectations

Gating note: Ezra does not volunteer any of the following. Each part comes out only when the doctor asks what he thinks is going on, what is worrying him, or what he is hoping for.

●Ideas: He thinks the ketamine is damaging his bladder because of what happened to his friend, and he is not sure if it can heal. "I think it's the K. I know it can wreck your bladder. Is mine wrecked?"
●Concerns: His main worry is his parents finding out. His dad's sobriety is fragile in his mind and he believes it would crush him and upset his mum. "Dad's been dry six years. If he finds out I'm doing drugs it'll finish him. And Mum would never forgive it." He also worries about losing his job and about the bladder being permanent.
●Expectations: He wants help to cut down or stop, and to know whether his bladder will recover. He wants the doctor to keep it private. "I just want it fixed, and I want to do it without them knowing."

If Asked: Medical History and Medications

Gating note: Ezra answers each of these plainly when the doctor asks about it.

●Other health problems: "Eczema when I was little, and hay fever. Nothing else."
●Medicines and allergies: "None, and no allergies."
●Waterworks history: "Never had a water infection or kidney problem."
●Mood and sleep: "Sleeping badly because of the toilet. No low mood I'd call depression."
●Driving: "I don't drive. I cycle to work."

Social History and Lifestyle Impact

●Home: Lives with Barry, Rowena and Phoebe. No one has noticed the drugs, although Rowena has asked why he is so tired. His mum set up his NHS App from a phone of hers when he was 14, and he thinks she can still see his appointments. If asked how to contact him, he says to use his own mobile only and to text, not to ring the landline.
●Work: Junior chef, split shifts, Wednesday to Sunday. He could come to the surgery on a Monday or Tuesday, or in the afternoon gap on a working day.
●Tobacco, vaping and alcohol: Vapes most days. Four or five cans on a weekend night. No alcohol in the week.
●Support: His mate Jonty knows and is worried. He would talk to his gran, but not his parents.

If Asked: Associated Symptoms

Gating note: Ezra answers these only when asked. Every one is negative unless stated.

●If asked about fever, loin pain, vomiting or feeling unwell: "No, I feel okay apart from tired."
●If asked about thoughts of harming himself, or not wanting to be here: "No, never."
●If asked about hearing or seeing things, or feeling paranoid: "No, only the weird feeling while I'm high, and it goes."
●If asked about having been hurt or pushed into anything, or being asked to carry drugs: "No, nothing like that."
●If asked about injecting or sharing equipment: "Never injected. We share the same rolled note sometimes."
●If asked about diarrhoea, yellow eyes or dark urine apart from the pink once: "No."

Responses to Management (The Negotiation Phase)

●
If the doctor explains confidentiality and its limits at the start, including when they would have to share:
- ●Reaction: Relieved. "So you'd only tell someone if I was in real danger, and you'd tell me first? Okay, then." He opens up. If the doctor gives no answer, or says it depends, he stays guarded, answers in one word and keeps asking "so will my parents find out?"
●
If the doctor suggests telling his parents, or says he should:
- ●Reaction: Panicked. "Please don't. It would break Dad." If the doctor encourages him to think about it at his own pace, offers to help him if he ever wants, and accepts it is his choice: "Maybe, one day, not now." If the doctor says they will tell them: "Then I'm hanging up."
●
If the doctor wants to see him in person, take a urine test, check bloods, or refer him to a bladder specialist:
- ●Reaction: Worried about home. "Will letters go to the house? Mum sorted my app, can she see this?" Once told how his contact details and records will be handled: "Okay. Can it be on my mobile only?" He asks "Will it get better if I stop?" and "Is it cancer?" He asks to come on a Monday or Tuesday.
●
If the doctor advises stopping or cutting down, and explains the bladder risk:
- ●Reaction: Honest. "I want to stop but my mates all do it. Could I just have it once a month?" Accepts a plan once he is told stopping is the best chance of the bladder healing. He asks what he can say to his mates and if there are tablets to help him stop.
●
If the doctor suggests a young people's drug service, or an adult service:
- ●Reaction: Wary. "Is that like rehab? Will they ring my parents?" If told it is confidential and that he can self refer or be referred, with appointments to suit his shifts: "I'd try that, if they don't ring the house." He asks how to be safe if he does use.
●
If the doctor gives harm reduction and safety netting:
- ●Reaction: Wants specifics. "How do I know if it's serious? Where would I go if I couldn't tell anyone?" He repeats back clearly when given concrete warning signs and told where to go.

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 / 24 indicators checked+0−0

Positive (0/12)

Negative (0/12)

Domain 3: Relating to Others

0 / 14 indicators checked+0−0

Positive (0/7)

Negative (0/7)

Clinical Learning Points

The Core Dilemma and the Model Plan

●Ezra is 17, has used ketamine most weekends for a year and now has three months of frequency, urgency, stinging and one episode of pink urine. He wants help but begs the doctor not to tell his parents, because his father has been sober for six years and he fears breaking him. The station tests confidentiality and its limits, recognising ketamine bladder damage, harm reduction and the right services for a young person.
●The model plan has seven parts. State confidentiality and its limits at the start. Take a full drug, mental health and safeguarding history. Judge that he can decide for himself and that nothing reaches the threshold for sharing. Name the urinary harm and arrange an in person examination and tests. Refer for specialist assessment and for drug service support. Give practical harm reduction and specific safety netting. Make contact and records safe, then follow up within days.
●Acceptable alternatives: examining him first and arranging bloods and referral at that visit, or requesting tests and imaging then referring to urology after the results. A referral to a young people's service or a self referral supported by the doctor both pass. Encouraging him to involve a parent later, without pressing him, is good practice. Insisting on telling the parents is not.

Confidentiality in Adolescents and Its Limits

●Young people are entitled to confidential care. The GMC 0 to 18 years guidance (principles of confidentiality, paragraphs 46 to 49, checked on an Internet Archive snapshot) says information can be disclosed without consent where there is an overriding public interest, where the young person lacks the maturity to decide, or where the law requires it. It says to disclose where necessary to protect the young person or someone else from risk of death or serious harm, for example abuse or neglect, and to tell the young person what is proposed and why unless that would undermine the purpose or increase the risk.
●The Orange Book (the UK drug guidelines, 2017 text, GOV.UK page updated 13 August 2026) says young people should receive confidential care but that information must be shared to protect them from abuse or neglect.
●Say it early, in plain words: what he says stays private, and the exceptions are a serious risk to his life or health, abuse or exploitation, or a legal duty, and he would be told before anything was shared. Candidates who start taking a history without addressing this lose him, as the script shows.
●Drug use alone, even regular drug use by a 17 year old, does not meet the threshold for telling his parents.

Capacity and Consent at 16 and 17

●Young people of 16 and 17 are presumed able to consent to their own medical treatment and, under the Mental Capacity Act, are presumed to have capacity. The Gillick and Fraser tests apply to those under 16. Candidates need not use these terms but should show they have considered whether he understands the risks and the choices.
●Ezra clearly can. He understands the bladder harm, can give reasons for wanting to cut down and can weigh the choices. Parental consent is not needed for assessment, tests, referral or drug service support.

Safeguarding Screen and the Threshold

●Ask about exploitation, not as an accusation. Ezra buys from a friend's 19 year old cousin for his own use, owes nothing, has not been asked to carry or sell and is not frightened of anyone. That is not child criminal exploitation. A case with debt, carrying drugs, an older supplier controlling him, or sexual exploitation would change the threshold and involve the practice safeguarding lead.
●Also check for acute risk: self harm, suicidal thoughts, psychotic symptoms and use alone. He has used twice alone, which is a warning sign worth naming, but not a reason to breach confidentiality.
●Record the reasoning clearly: what was asked, what was found and why nothing was shared. Say that this could change.

Ketamine and the Urinary Tract

●Regular ketamine use can cause bladder inflammation and scarring, with frequency, urgency, pain, blood in the urine and incontinence, and the harm can extend to the kidneys. FRANK reports that stopping can help but that damage can be severe enough to need surgical repair or bladder removal. Abdominal pain known as "K cramps" and emerging liver damage have also been reported. The Orange Book lists ketamine related urological damage as a developing area of knowledge.
●Ezra has the typical picture: three months of worsening symptoms, a dose that has crept up, a past episode of pink urine, small leaks and low abdominal cramps worse after weekends. Do not label it as a urine infection or anxiety. A urine infection should still be excluded.
●Examine in person: abdominal and suprapubic tenderness, with a urine dipstick and culture if indicated, and bloods including kidney function. Do not diagnose by phone or ask him to examine himself. Refer to urology for assessment of bladder and kidney damage. The BAUS consensus statements (BJU International 2024) recommend renal profile, liver profile and renal tract ultrasound as baseline tests, with cessation as the mainstay. There is no NICE or CKS topic and no national referral timescale, so routine urology referral with baseline tests passes; same day assessment is for retention, fever, loin pain or raised creatinine.
●Be honest about outlook. Stopping gives the best chance of recovery, and earlier is better. Do not promise a full recovery and do not frighten him with the worst case.

Treatment: Psychosocial, Not Medication

●The Orange Book states there are no effective medications for dependence on ketamine, and that the mainstay of treatment is abstinence oriented psychosocial interventions. Prescribing a drug as treatment for ketamine dependence is therefore wrong.
●NICE CG51 (2007) recommends opportunistic brief motivational interventions in primary care when drug misuse concerns arise (rec 1.3.1.3). Its scope is opioids, stimulants and cannabis, so for ketamine it is used by analogy alongside the Orange Book. Ezra is motivated: he is frightened of his bladder. Reflect that back and build on it.
●Refer or support a self referral to a local young people's substance misuse service, which offers confidential motivational and psychosocial support. The Orange Book notes that involving parents is good practice but must consider the young person's consent, so involvement is encouraged, not forced. Also address his tiredness and irritability, vaping and alcohol use, and offer sexual health information given a past relationship.
●He says it is hard because all his friends use it. Plan what he can say, how to spend weekends differently and what a first small step might be. Cutting down is a legitimate step, but the safest plan is to stop.

Harm Reduction

●Advise that stopping is safest, and that if he does use: use less, less often, avoid using alone, do not mix with alcohol, benzodiazepines or opioids, and do not share snorting equipment. FRANK says mixing is dangerous and that ketamine reduces pain, so injuries can go unnoticed, and heavy doses can cause a loss of ability to move.
●Avoid cycling, roads and kitchen equipment while intoxicated or the day after if still affected. He works with knives and heat.
●The Orange Book notes that evidence that giving information alters behaviour is limited. So give it briefly, in the context of a warm relationship, as part of a plan.

Safety Netting and Safe Contact

●Ask him to seek urgent help for inability to pass urine, fever, loin pain, vomiting, heavy bleeding or clots, severe pain, or feeling unwell after use, with a clear route: the practice on the same day, NHS 111, or A&E. Make sure he knows he can go without telling his parents.
●Check how he can be contacted: his own mobile and text only, no landline or letters home. Ask who can see his online record and appointments. His mother set up his NHS App. RCGP and NHS England guidance says people aged 16 or over are presumed competent to decide who has proxy access and parental access should be reviewed at 16, so continuing it needs his consent. A young person with an NHS Login and the NHS App sees their own record automatically. Agree follow up within days, fitting his shifts.

Common Mistakes in This Station

●Taking a history before dealing with confidentiality, then losing him when he asks again whether his parents will find out.
●Promising absolute secrecy, or saying the parents will be told.
●Treating the symptoms as a urine infection and prescribing antibiotics by phone.
●Lecturing about the law and ignoring his own reasons for wanting to change.
●Prescribing a medicine for ketamine dependence.
●Missing the screen for coercion, other drugs, alcohol and mood.
●Forgetting the practical leaks in confidentiality: letters, the landline and parental access to the online account.
●Giving the vague safety net "come back if it gets worse".

Mapped to the RCGP curriculum topic: Smoking, Alcohol and Substance Misuse.

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