THE COMPETENT CANDIDATE

The competent candidate should be able to:

Task 1: Take an appropriate history, exploring the patient’s symptoms and risk factors.

The competent candidate should:

• Use open-ended questions to allow the patient to describe their pain and associated symptoms.
• Clarify onset, duration, severity, and radiation of the pain (colicky, flank to groin).
• Identify associated symptoms, including hematuria, dysuria, nausea, vomiting, fever, and urinary urgency.
• Screen for red flag symptoms:
  • Fever and rigors (suggesting infection/sepsis).
  • Anuria or complete urinary obstruction.
  • Severe, persistent pain despite analgesia.
• Take a detailed past medical history, including:
  • Previous kidney stones or urological conditions.
  • Family history of kidney stones.
  • Dietary habits (e.g., low fluid intake, high protein or salt diet, excessive coffee or tea consumption).
  • Medications (e.g., diuretics, calcium supplements, vitamin C overuse, protease inhibitors).
• Address the patient’s ideas, concerns, and expectations (ICE) about their symptoms, including worries about surgery and work absence.

Task 2: Outline your differential diagnosis, discussing the most likely causes and serious considerations.

The competent candidate should:

• Consider urinary calculi (kidney stones) as the most likely diagnosis, given:
  • Colicky flank pain radiating to the groin.
  • Hematuria and dysuria.
  • Previous history of kidney stones.
• Discuss other differential diagnoses, including:
  • Pyelonephritis – fever, systemic illness, costovertebral angle tenderness.
  • Acute urinary retention – suprapubic pain, difficulty voiding.
  • Testicular torsion – scrotal pain, absent cremasteric reflex.
  • Appendicitis – right lower quadrant pain, nausea, anorexia.
  • Diverticulitis – left lower quadrant pain, bowel changes.
• Justify why urgent imaging is required to confirm diagnosis and assess for complications.

Task 3: Address the patient’s concerns regarding his symptoms and possible need for intervention.

The competent candidate should:

• Acknowledge and validate the patient’s pain, reassuring him that it will be managed effectively.
• Explain that kidney stones often pass spontaneously but may require monitoring.
• Clarify that surgery is only needed if the stone is large (>5-6 mm), causing obstruction, or not passing naturally.
• Reassure him that with adequate hydration and analgesia, most stones will pass without intervention.
• Discuss work implications, advising that pain control and hydration are key, and limited activity may be necessary for a few days.
• Provide realistic expectations, explaining that recurrence is common but preventable with lifestyle changes.

Task 4: Provide a structured management plan, including investigations, pain control, and follow-up.

The competent candidate should:

• Order appropriate investigations, including:
  • Non-contrast CT KUB (gold standard for kidney stones).
  • Urinalysis and urine microscopy (to check for infection, hematuria, or crystals).
  • Serum creatinine and eGFR (to assess renal function).
  • Electrolytes and calcium (to check for hypercalcaemia as a risk factor).
• Provide symptomatic relief:
  • Analgesia: NSAIDs (e.g., diclofenac 75 mg IM or oral ibuprofen) as first-line treatment.
  • Anti-emetics if nausea is present.
  • Opioids (e.g., oxycodone) only if severe pain persists.
• Advise on fluid intake:
  • Encourage hydration but avoid excessive intake during acute pain episodes to prevent worsening symptoms.
• Plan for follow-up and referral:
  • If stone is <5 mm, conservative management with repeat imaging in 2-4 weeks.
  • If stone is >6 mm, causing obstruction, or patient has worsening pain, urgent referral to urology.
  • If fever, worsening pain, or anuria develops, escalate to emergency care.
• Discuss preventive strategies:
  • Increase water intake (>2.5 L/day).
  • Reduce salt and excessive animal protein intake.
  • Avoid excessive oxalate-rich foods (e.g., spinach, nuts, tea).

SUMMARY OF A COMPETENT ANSWER

• Thorough history-taking, covering pain characteristics, red flags, dietary habits, and recurrence risk factors.
• Clear differential diagnosis, prioritising kidney stones while considering other causes of flank pain.
• Empathetic and structured reassurance, addressing pain management and concerns about surgery.
• Appropriate investigation and management plan, including analgesia, imaging, urology referral if needed, and prevention advice.
• Timely follow-up plan, ensuring symptom resolution and recurrence prevention.

PITFALLS

• Failure to recognise red flag symptoms, leading to delayed detection of obstruction or sepsis.
• Inadequate pain management, underestimating the severity of renal colic.
• Over-reassurance without appropriate investigations, missing potential complications.
• Ordering inappropriate imaging (e.g., ultrasound instead of CT KUB), delaying diagnosis.
• Not addressing patient concerns adequately, leading to dissatisfaction and anxiety.
• Failure to arrange follow-up, missing opportunities for recurrence prevention.

REFERENCES

• RACGP Guidelines on Acute Kidney Stones in General Practice
• Australian and New Zealand Urological Society (ANZUS) Guidelines on Urolithiasis
• Better Health Channel on Kidney Stones Overview
• UpToDate on Management of Nephrolithiasis
• GP Exams – Kidney stones

MARKING

Each competency area is on the following scale from 0 to 3.

☐ Competency NOT demonstrated
☐ Competency NOT CLEARLY demonstrated
☐ Competency SATISFACTORILY demonstrated
☐ Competency FULLY demonstrated

1. Communication and Consultation Skills

1.1 Communication is appropriate to the person and the sociocultural context.
1.2 Engages the patient to gather information about their symptoms, ideas, concerns, expectations of healthcare and the full impact of their illness experience on their lives.
1.5 Provides clear and sensitive explanations of potential diagnoses and management options.

2. Clinical Information Gathering and Interpretation

2.1 Takes a thorough history to identify red flags for obstructive uropathy.
2.2 Identifies concerning symptoms and orders appropriate initial investigations.
2.3 Interprets results to guide referral and management.

3. Diagnosis, Decision-Making and Reasoning

3.1 Recognises clinical features suggestive of kidney stones and considers it in the differential diagnosis.
3.3 Considers and rules out alternative causes of symptoms.

4. Clinical Management and Therapeutic Reasoning

4.2 Provides appropriate pain management and hydration advice.
4.4 Arranges imaging and specialist referral if indicated.

5. Preventive and Population Health

5.2 Provides lifestyle modification advice to reduce recurrence risk.

6. Professionalism

6.2 Demonstrates sensitivity in addressing pain and patient distress.

7. General Practice Systems and Regulatory Requirements

7.1 Ensures timely referral for urological assessment if indicated.

9. Managing Uncertainty

9.1 Addresses patient concerns regarding severity and recurrence risks.

10. Identifying and Managing the Patient with Significant Illness

10.1 Recognises and initiates urgent intervention if signs of sepsis or obstruction are present.

Competency at Fellowship Level

☐ CLEARLY BELOW STANDARD
☐ BELOW EXPECTED STANDARD
☐ BORDERLINE
☐ AT EXPECTED STANDARD
☐ ABOVE STANDARD