History Taking · Foundation · Nephrology

Progressive Renal Impairment in a 64-Year-Old Woman

Practise this PLAB 2 history taking station on Analgesic Nephropathy. 8-minute voice AI simulation with feedback on all 3 marking domains.

Clinical scenario

You are an FY2 doctor in a GP surgery. Mrs Frances Selby, a 64-year-old woman, has come for a routine blood test follow-up. Her eGFR has declined from 52 mL/min/1.73m2 six months ago to 38 mL/min/1.73m2 today. Please take a focused history and discuss your findings with the patient.

Background notes: PMH: Osteoarthritis, Hypothyroidism, Hypertension, Hypercholesterolaemia, Appendicectomy

What this station tests

  • Identifying long-term NSAID use as the cause of progressive CKD: analgesic nephropathy from chronic interstitial nephritis
  • The 'triple whammy': NSAID plus ACE inhibitor plus dehydration as a high-risk combination for acute kidney injury
  • Stopping the nephrotoxic medication as the primary intervention: this is more important than any other treatment
  • Providing alternative pain management: paracetamol, topical NSAIDs, physiotherapy, specialist referral
  • Non-judgmental delivery: she has been managing her pain with OTC medication and did not know it was harmful

How to use your 8 minutes

  • 0-1 min — Introduction: Introduce yourself, confirm identity, open question. 'What's brought you in today?'
  • 1-4 min — Systematic History: Presenting complaint detail (SOCRATES for pain, timeline, severity). Systems review. PMH, medications, allergies.
  • 4-6 min — Context and ICE: Social history (smoking, alcohol, occupation, living situation). Family history. Ideas, Concerns, Expectations.
  • 6-7 min — Summary and Plan: Summarise findings back to patient. Share differential/working diagnosis. Outline investigation and management plan.
  • 7-8 min — Closing: Safety netting with specific red flags. Arrange follow-up. Check for questions.

Consultation approach

The opening

Progressive CKD with declining eGFR in a patient on long-term NSAIDs requires the candidate to identify the medication as the cause. The challenge is delivering bad news about a medication the patient has relied on for years. Mrs Selby is 64, attending for routine bloods showing eGFR decline from 52 to 38 in 6 months. She feels well and is not expecting a problem. Open with: 'Mrs Selby, thank you for coming in. I need to discuss your blood test results with you. There has been a change that I want to explain.'

Core approach

Explain the result clearly. 'Your kidney function has declined since your last blood test. Six months ago it was 52, and now it is 38. This means your kidneys are working at about 38% of their full capacity. This is a significant change and I want to understand why.'

Take a detailed medication history. She has osteoarthritis and has been taking ibuprofen regularly for 15 years, often daily, sometimes with paracetamol. This is the likely cause. Long-term NSAID use causes analgesic nephropathy through chronic interstitial nephritis and papillary necrosis. Ask about the dose, frequency, and whether she buys additional OTC NSAIDs.

She may not realise ibuprofen is harmful to kidneys. Many patients consider it safe because it is available over the counter. The conversation must be non-judgmental: she has been managing her pain with the tools available to her.

Check for other nephrotoxic medications. She is on an ACE inhibitor for hypertension (renoprotective in CKD but can worsen AKI in combination with NSAIDs and dehydration, the 'triple whammy'). Levothyroxine (not nephrotoxic). Statin (not nephrotoxic). No diabetes medications.

Screen for CKD symptoms: none currently (she feels well). Check BP (target <130/80 in CKD). Urine ACR for proteinuria.

Closing and safety netting

The most important intervention: stop the ibuprofen. 'Mrs Selby, the most likely reason your kidney function has declined is the ibuprofen you have been taking for your arthritis. Over many years, it can damage the kidneys. The most important thing we can do now is stop the ibuprofen to prevent further decline.' She will be worried about pain management. Offer alternatives: regular paracetamol (safe in CKD), topical NSAIDs (minimal systemic absorption), physiotherapy, weight management, and consider referral for specialist pain management or orthopaedics if severe.

Investigations: renal ultrasound, urine ACR, repeat U&E in 4 to 6 weeks after stopping ibuprofen (to see if eGFR stabilises or improves). If no improvement, nephrology referral.

Address her concern: 'This does not mean you will need dialysis. Many people stabilise at this level once the cause is removed.' Safety net: 'If you develop ankle swelling, breathlessness, significant nausea, or reduced urine output, come in urgently.' Follow-up in 6 weeks.

How examiners mark this station

Examiners will focus on the thoroughness and structure of your history taking for analgesic nephropathy. Domain 1 (Data Gathering) carries the most weight: expect marks for systematic coverage of presenting complaint, red flags, PMH, medications, social and family history. Domain 2 (Clinical Management) requires a clear differential, appropriate investigations, and a safe management plan with safety netting. Domain 3 (Interpersonal Skills) is assessed throughout: genuine exploration of ICE, active listening, empathic responses, and clear communication without jargon.

Domain 1: Data Gathering, Technical and Assessment Skills (Primary focus)

Scores well: Detailed medication history including OTC. NSAID duration and frequency quantified. Triple whammy risk identified. CKD symptoms screened. BP checked. Urine ACR planned. Other nephrotoxins reviewed.

Costs marks: Not asking about OTC medications. Not quantifying NSAID use. Not checking BP. Not planning urine ACR.

Domain 2: Clinical Management Skills (Primary focus)

Scores well: Ibuprofen stopped as primary intervention. Alternative pain management provided. Renal USS arranged. Repeat eGFR in 6 weeks. Nephrology referral if no improvement. CKD monitoring plan.

Costs marks: Not stopping ibuprofen. No alternative pain plan. No renal imaging. No follow-up.

Domain 3: Interpersonal Skills (Primary focus)

Scores well: Non-judgmental about OTC NSAID use. Explaining how ibuprofen can damage kidneys without blame. Addressing her pain concern alongside the renal concern. Reassuring about dialysis (unlikely if cause removed).

Costs marks: Being judgmental. Not addressing pain management. Being alarmist about dialysis. Not explaining why ibuprofen is harmful.

Common examiner feedback (and how to fix it)

Did not gather sufficient information to make an adequate assessment of the patient's condition

Fix: Use a consistent framework for every history. After covering the presenting complaint, systematically move through PMH, drug history, social history, family history, and ICE. Keep a mental checklist.

Did not identify the patient's problems and/or did not develop a management plan adequately

Fix: Reserve the final 2 minutes to summarise your findings, share your working diagnosis with the patient, and outline your investigation and management plan including safety netting.

Common mistakes in this station

  1. Not taking a detailed medication history including OTC drugs. She buys ibuprofen over the counter. Candidates who check her prescription list but do not ask about OTC medications miss the cause.
  2. Not stopping the ibuprofen. Identifying it as the cause but being reluctant to stop it because of her arthritis pain leaves the kidneys exposed to ongoing damage. The ibuprofen must stop, and alternatives must be provided.
  3. Not addressing the pain management gap. Stopping ibuprofen without offering alternatives leaves her in pain and likely to resume it. Candidates must provide a concrete alternative plan.

Resitting PLAB 2?

If you have previously struggled with history taking stations, focus on building a consistent systematic framework that you apply to every case. Practise structuring your history into clear phases (presenting complaint, systems review, PMH, social, ICE) so that even under pressure, you cover all domains. Many resitters lose marks not on knowledge but on organisation and time management.

Example opening

Good morning/afternoon, my name is Dr [Name], I'm one of the doctors here today. Could I confirm your name and date of birth please? Thank you. So, what's brought you in to see me today?

Frequently asked questions

How do I approach the consultation in this analgesic nephropathy station?

Progressive CKD with declining eGFR in a patient on long-term NSAIDs requires the candidate to identify the medication as the cause. The challenge is delivering bad news about a medication the patient has relied on for years. Mrs Selby is 64, attending for routine bloods showing eGFR decline from 52 to 38 in 6 months.

What does a strong performance look like to the examiner in this station?

Strong performances show: Detailed medication history including OTC. NSAID duration and frequency quantified. Triple whammy risk identified. CKD symptoms screened. BP checked. Weak performances: Not asking about OTC medications. Not quantifying NSAID use. Not checking BP. Not planning urine ACR.

What is the biggest pitfall in this analgesic nephropathy station?

Not taking a detailed medication history including OTC drugs. She buys ibuprofen over the counter. Candidates who check her prescription list but do not ask about OTC medications miss the cause.

How should I prepare for analgesic nephropathy if I have never seen it in practice?

Structure beats experience here. Focus on the 'triple whammy': NSAID plus ACE inhibitor plus dehydration as a high-risk combination for acute kidney injury. The written guidance on this page covers the full approach, and practising the consultation aloud builds the fluency the examiner is listening for.

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