CASE INFORMATION

Case ID: CKD-2025-06
Case Name: David Thompson
Age: 62
Gender: Male
Indigenous Status: Non-Indigenous
Year: 2025
ICPC-2 Codes: U88 (Chronic Kidney Disease)

COMPETENCY OUTCOMES

Competency Domain	Competency Element
1. Communication and Consultation Skills	1.1 Engages effectively with the patient to explain chronic kidney disease (CKD) 1.3 Uses patient-centred language to discuss disease progression and management 1.5 Uses shared decision-making regarding lifestyle changes and treatment options
2. Clinical Information Gathering and Interpretation	2.1 Conducts a thorough history and examination to assess CKD risk factors 2.3 Interprets kidney function tests and urine albumin-creatinine ratio (ACR) appropriately 2.4 Identifies secondary causes of CKD
3. Diagnosis, Decision-Making and Reasoning	3.1 Stages CKD based on eGFR and ACR 3.5 Recognises indications for nephrology referral
4. Clinical Management and Therapeutic Reasoning	4.2 Implements evidence-based management for CKD, including lifestyle and pharmacological interventions 4.4 Prescribes renoprotective medications (ACE inhibitors/ARBs) appropriately
5. Preventive and Population Health	5.1 Counsels on cardiovascular risk reduction and lifestyle modifications 5.3 Encourages smoking cessation, blood pressure control, and diabetes management
6. Professionalism	6.1 Provides a non-judgmental and supportive approach to managing chronic disease
7. General Practice Systems and Regulatory Requirements	7.1 Documents CKD stage, management plan, and follow-up schedule clearly 7.2 Ensures appropriate referral pathways for advanced CKD
9. Managing Uncertainty	9.1 Addresses patient concerns regarding prognosis and potential dialysis
10. Identifying and Managing the Patient with Significant Illness	10.1 Recognises and manages CKD complications (e.g., anaemia, electrolyte imbalances)

CASE FEATURES

Older male with hypertension, type 2 diabetes, and obesity, presenting with fatigue and swelling in his legs.
Recently noted elevated creatinine and reduced eGFR on routine blood tests.
Patient is unaware of CKD diagnosis and is concerned about dialysis.
Needs assessment for disease progression and cardiovascular risk.
Requires education on CKD management and lifestyle modifications.

INSTRUCTIONS

Review the following patient record summary and scenario.
Your examiner will ask you a series of questions based on this information.

You have 15 minutes to complete this case.

The time for each question will be managed by the examiner.
The time allocation for each question is roughly as follows:

Question 1 – 3 minutes
Question 2 – 3 minutes
Question 3 – 3 minutes
Question 4 – 3 minutes
Question 5 – 3 minutes

PATIENT RECORD SUMMARY

Patient Details

Name: David Thompson
Age: 62
Gender: Male
Gender Assigned at Birth: Male
Indigenous Status: Non-Indigenous

Allergies and Adverse Reactions

Nil known

Medications

Metformin 1g BD
Amlodipine 5mg daily
Atorvastatin 40mg nocte

Past History

Type 2 diabetes (diagnosed 12 years ago, HbA1c 8.1%)
Hypertension (diagnosed 10 years ago, BP 145/90 mmHg)
Obesity (BMI 32)

Social History

Ex-smoker (quit 5 years ago)
Drinks 3–4 standard drinks per week
Sedentary lifestyle, limited physical activity

Family History

Father had end-stage kidney disease (ESKD) requiring dialysis
Mother had hypertension and stroke

Smoking

Quit smoking 5 years ago (20 pack-year history)

Alcohol

Drinks 3–4 standard drinks per week

Vaccination and Preventative Activities

Up to date with influenza and pneumococcal vaccines
No recent diabetic foot or eye screening

SCENARIO

David Thompson, a 62-year-old male, presents with fatigue and swelling in his legs over the past two months. He has type 2 diabetes, hypertension, and obesity, with suboptimal glycaemic and blood pressure control.

Recent blood tests show:

eGFR 45 mL/min/1.73m² (previously 55)
Urine ACR: 45 mg/mmol (moderately increased albuminuria)
Serum creatinine: 160 µmol/L (previously 130 µmol/L)

He is concerned about dialysis, as his father had kidney disease. He has never been told he has CKD and is unsure what it means for his future health.

On examination, he has bilateral pitting oedema, BP 145/90 mmHg, and no signs of uraemia.

David is seeking clarity on his condition and management options.

EXAMINATION FINDINGS

General Appearance: Well, no acute distress
Vital Signs: BP 145/90 mmHg, HR 75 bpm, BMI 32
Cardiovascular: No murmurs, peripheral pulses intact
Respiratory: No crackles, no signs of pulmonary oedema
Renal: Bilateral pitting oedema, no costovertebral angle tenderness

EXAMINER ONLY INFORMATION

QUESTIONS

Q1. What aspects of history and examination are critical in assessing this patient’s CKD?

Prompt: What risk factors contribute to CKD progression?
Prompt: How do you assess for CKD complications?

Q2. Based on the findings, what is your differential diagnosis, and what is your working diagnosis?

Prompt: How do you differentiate between CKD and acute kidney injury (AKI)?
Prompt: What factors indicate worsening CKD?

Q3. How would you manage David’s CKD and cardiovascular risk?

Prompt: What are the key lifestyle and pharmacological interventions?
Prompt: When should renoprotective medications (ACE inhibitors/ARBs) be used?

Q4. How would you counsel David about his CKD diagnosis and prognosis?

Prompt: How do you explain CKD progression and the likelihood of dialysis?
Prompt: What lifestyle changes could slow CKD progression?

Q5. What follow-up and referral plan would you implement?

Prompt: When should he return for review?
Prompt: When should a nephrologist be involved?

THE COMPETENT CANDIDATE

The competent candidate should be able to:

Q1: What aspects of history and examination are critical in assessing this patient’s CKD?

A structured history and clinical examination are essential for assessing chronic kidney disease (CKD), determining the stage, and identifying contributing factors.

1. History

Symptoms of CKD progression: Fatigue, nausea, pruritus, nocturia, dyspnoea, or cognitive changes.
Fluid retention symptoms: Swelling in legs, shortness of breath, weight gain.
Risk factors for CKD:
- Diabetes mellitus (T2DM) – duration and control (HbA1c).
- Hypertension – duration, medication adherence, control.
- Cardiovascular disease (CVD) – previous heart disease or stroke.
- Family history – CKD, dialysis, or genetic kidney diseases.
- Medications – NSAIDs, diuretics, ACE inhibitors/ARBs, nephrotoxic drugs.
- Lifestyle factors – Diet (salt intake), physical activity, smoking, alcohol.

2. Examination

Vital signs: Blood pressure (hypertension contributes to CKD progression).
Fluid status: Peripheral oedema, pulmonary crackles (fluid overload).
Cardiovascular: Signs of hypertension or heart failure.
Abdominal exam: Palpable kidneys (suggesting polycystic kidney disease).
Neurological: Restless legs, altered cognition (uremic symptoms).
Skin: Pallor (anaemia), dry skin (uraemia), bruising (platelet dysfunction).

3. Investigations to Consider

Urinalysis & urine ACR: Proteinuria suggests CKD progression.
eGFR & creatinine: Monitor kidney function decline.
Electrolytes: Hyperkalaemia, metabolic acidosis.
FBC & iron studies: Anaemia of CKD.
ECG: Hyperkalaemia-related arrhythmias.

This comprehensive assessment ensures appropriate staging and guides long-term management.

SUMMARY OF A COMPETENT ANSWER

Thorough history, including CKD risk factors (T2DM, hypertension, CVD, medications).
Identifies symptoms of CKD progression, such as fatigue and fluid overload.
Performs focused examination, assessing blood pressure, fluid status, and cardiovascular risk.
Requests relevant investigations, including eGFR, urine ACR, and electrolytes.

PITFALLS

Failing to assess for CKD complications, such as anaemia and metabolic acidosis.
Not considering nephrotoxic medications, which may accelerate CKD progression.
Overlooking fluid status examination, missing signs of volume overload.
Ignoring cardiovascular risk, a major cause of mortality in CKD patients.

REFERENCES

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

2. Clinical Information Gathering and Interpretation

2.1 Conducts a thorough history and examination to assess CKD risk factors.
2.3 Interprets kidney function tests and urine albumin-creatinine ratio (ACR) appropriately.
2.4 Identifies secondary causes of CKD.

Competency at Fellowship Level

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