You are an FY2 in a GP clinic
Personal Details:
Name: Robert Jones
Age: 54
Medical Record:
Past medical history: Osteoarthritis of the knees for 6 years.
Regular medication: Ibuprofen 400mg PRN up to three times a day.
Allergies: None known.
Notes:
Robert attended a routine check-up one week ago. He felt well, with no new symptoms. Routine blood tests were performed.
BP 130/80
Investigation Results:
FBC normal
Liver function, including ALT, ALP, albumin and bilirubin normal
Creatine normal
eGFR: 57 mL/min/1.73m² (normal >60mL/min/1.73m² ) (12 months ago it was 85 mL/min/1.73m² )
Task:
1. Explain the blood test result, take the history
3. Address his concerns and discuss a management plan.
Opening Sentence: “Hi, Doctor, you called me about my blood tests. I thought everything was fine?”
Open History (to give freely): “I feel perfectly fine. I don’t have any problems with my waterworks, no pain, no swelling. I don’t understand what could be wrong.”
Cues to give: “The only thing I take is ibuprofen for my bad knees. I’ve been on it for years.”
ICE (Ideas, Concerns, Expectations):
Ideas: “I have no idea what’s going on. How can you have kidney damage with no symptoms?”
Concerns: “Doctor, I don't have any symptoms. How could this happen? Does this mean I’m going to need dialysis?”
Expectation: “What should I take for my knee pain now? Can I reverse the damage?”
How to Act: You are surprised and worried. You are a practical person and want to understand the problem and the solution.
More History (only if asked): You have had osteoarthritis in your knees for about 6 years and have been taking ibuprofen 400mg three times a day regularly for most of that time. It’s the only thing that helps the pain. You are a smoker (10 per day) and drink about 20 units of alcohol per week.
You haven’t had any flank pain, no blood in your urine
You are not on any other medication
Social History: You work as a builder. You are married.
Questions to ask:
Are you sure the test is right? I feel fine.
But if I stop the ibuprofen, what will I do about my knee pain?
Will my kidneys get better?
Opening & Setting the Scene:
Hi, thanks for coming for your review. We’ve got your blood results back to discuss. How have you been feeling?
Breaking the News (Warning Shot): While your blood pressure is looking good, I’m afraid one of the blood tests has come back out of normal range. The test that measures your kidney function has shown that your kidneys are not working as well as they were last year.
Exploring the Cause (Medication History):
To figure out why this has happened, we need to look at all the medications you are taking. I can see that you are on Ibuprofen for your knees. How often are you taking that? How long have you been taking it so regularly?
Have you noticed any blood in your urine? Have you noticed any swelling around your eyes or feet?
Social history:
Day to day life style habits can affect our kidney function. So let’s explore that, do you smoke? Do you drink alcohol?
ICE (Ideas, Concerns, Expectations):
I can see this is a surprise. What are your thoughts on what I’ve just told you?
What’s your biggest worry about hearing the words kidney disease?
What were you hoping we could do about your knee pain today?
Explain the results:
Thanks for coming in, Robert. Most of your blood tests were perfectly normal, but one of them, which checks your kidney function, was a little bit lower than we would like. It shows that your kidneys are not filtering the blood as efficiently as they should be. This is not something serious, and we see that a lot in new blood results. However, this could be an early sign of decline in your kidney function, which is something we call Chronic Kidney Disease, or CKD. It’s very common for there to be no symptoms at all in the early stages, which is why we do these routine checks.
Addressing and answering the patient’s ICE:
You’re asking how this could have happened, and you’re worried about needing dialysis. Let me reassure you straight away, you are a very, very long way from needing anything like dialysis. We have caught this very early. The most likely cause is the long-term, regular use of ibuprofen. Drugs like ibuprofen, which we call NSAIDs, can, over many years, affect the kidneys.
Next Steps:
The most important first step is to stop taking the ibuprofen. This will remove the cause of the damage and prevent your kidney function from getting worse.
I know you’re worried about your knee pain, and we won’t leave you in the lurch. We need to switch you to a safer alternative. You should start taking regular paracetamol, up to four times a day. In addition to that, you can take codeine 30mg up to two tablets four times a day if needed.
We can also refer you to a physiotherapist to work on exercises to strengthen the muscles around your knees, which is a very effective way to manage arthritis pain.
Lifestyle Modifications/self-help measures:
There are other things that can affect kidney health, such as smoking and high alcohol intake. Cutting down on these would also be very beneficial for your kidneys and your overall health.
Repeat blood test with ACR:
We will need to repeat the kidney function test after 2-4 weeks to see if it has improved after stopping the ibuprofen, and to confirm the previous result. We will also complete a urine test to look for any protein leakage in urine.
Your blood pressure is normal, which is reassuring, as high blood pressure can also affect the kidneys.
Reassure
You asked if the damage can be reversed. Sometimes, after stopping the offending drug, the kidney function can improve. In other cases, the kidney function change is permanent, but the main goal is to stop it from getting any worse, which we can do by stopping the ibuprofen and controlling other risk factors.
Your kidney function is still good enough to live a completely normal life; we just need to protect them for the future.
Addressing ideas, concerns, and expectations: Explain the possible diagnosis of early CKD and its likely cause (NSAID) in simple terms. Reassure him that he is not going to need dialysis. Provide a clear alternative plan for his knee pain.
The management plan is: 1. Advise stopping ibuprofen. 2. Recommend regular paracetamol. 3. Advise on lifestyle changes (smoking, alcohol). 4. Arrange a physiotherapy referral. 5. Plan for repeat blood tests and ACR urine test to confirm diagnosis.
What is scenario testing? This case tests the candidate’s ability to explain an unexpected, asymptomatic diagnosis found on routine testing. It requires knowledge of the common causes of CKD (specifically NSAID-induced) and the ability to create a multi-faceted management plan that addresses both the new diagnosis and the patient’s pre-existing chronic condition (osteoarthritis).