CCE-CBD-217

EXAMINER ONLY INFORMATION

QUESTIONS

Q1. How would you approach John’s concerns and gather relevant information?

• Prompt: Explore his understanding of his symptoms and potential causes
• Prompt: Identify specific concerns, ideas, and expectations
• Prompt: Explore psychosocial impact, including his work and functional limitations

Q2. What are your differential diagnoses, and how would you manage uncertainty?

• Prompt: Discuss differential diagnoses (renal colic, pyelonephritis, AAA, appendicitis)
• Prompt: Rationalise your investigation choices (urinalysis, imaging, blood tests)
• Prompt: Explain your safety-netting strategy if diagnosis is uncertain

Q3. What is your immediate management plan for John?

• Prompt: Pain management (NSAIDs, opioids if needed)
• Prompt: Hydration strategies and monitoring
• Prompt: Referral considerations (urology, emergency if deteriorating)

Q4. What preventive health advice would you offer John to reduce recurrence?

• Prompt: Advice on hydration, particularly with physical labour in hot weather
• Prompt: Dietary modifications (reduce salt, oxalate foods)
• Prompt: Discuss alcohol reduction and impact on kidney health

Q5. How would you involve other healthcare providers in John’s care?

• Prompt: Follow-up plan for monitoring renal function and prevention
• Prompt: Referral to urology if indicated
• Prompt: Coordination with dietitian for dietary advice

THE COMPETENT CANDIDATE

The competent candidate should be able to:

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Q1: How would you approach John’s concerns and gather relevant information?

Answer:

In approaching John Murray, a 42-year-old farm manager presenting with acute right-sided flank pain, it is essential to establish rapport and ensure effective communication. Begin by acknowledging his distress and offering immediate support.

History Taking and Exploration:

• Elicit the History of Present Illness:
  • Onset, duration, and progression of the pain.
  • Character of the pain: colicky, severe, radiates to the groin.
  • Associated symptoms: nausea, vomiting, dysuria, haematuria, fever, rigors.
  • Recent fluid intake, dehydration risk, especially considering his outdoor work.
• Explore John’s Understanding and Concerns:
  • What does he think is causing his symptoms?
  • Any previous episodes or family history (his father had kidney stones).
  • Clarify his immediate concerns—pain relief, time off work, implications on his job as a farm manager.
• Assess Impact on Life:
  • Impact of symptoms on work and daily activities.
  • Psychosocial aspects: emotional distress, anxiety about recurrence, economic concerns due to rural location and workload.
• Red Flag Questions:
  • Fever or rigors (suggesting infection/pyelonephritis).
  • Haematuria, reduced urine output.
  • Gastrointestinal symptoms (AAA, appendicitis differential).
• Relevant Past Medical History:
  • Past surgeries, medication use, alcohol intake.
  • Risk factors for stone formation: dietary habits, hydration status, family history.

Professionalism: Communicate clearly and empathetically. Validate his concerns, ensure privacy and confidentiality, and allow him to express fears.

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Q2: What are your differential diagnoses, and how would you manage uncertainty?

Answer:

Differential Diagnoses:

1. Renal Colic (Ureteric Stone) – Primary diagnosis based on sudden onset severe flank pain, radiation to the groin, microscopic haematuria, and risk factors (dehydration).
2. Pyelonephritis – Less likely (no fever or systemic signs), but should be ruled out.
3. Abdominal Aortic Aneurysm (AAA) – Unlikely but important to consider in middle-aged males with sudden abdominal pain.
4. Appendicitis – Considered with right lower quadrant pain, though unlikely with flank presentation.
5. Musculoskeletal Strain – Less likely with the colicky nature and haematuria.

Managing Uncertainty:

• Investigations:
  • Urinalysis: Microscopic haematuria supports stone diagnosis; absence of infection signs.
  • Bedside Ultrasound (POCUS): Hydronephrosis suggests obstruction; no AAA visualised.
  • Formal Imaging: Non-contrast CT KUB is the gold standard if uncertainty remains.
  • Blood Tests: Renal function (U&E), FBC, CRP to assess infection and kidney impact.
• Safety Netting:
  • Explain potential risks: infection, worsening obstruction, sepsis.
  • Advise urgent review if fever, rigors, vomiting, or worsening pain occur.
  • Arrange close follow-up and referral to ED if deterioration.

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Q3: What is your immediate management plan for John?

Answer:

Pain Management:

• NSAIDs (e.g., Diclofenac 75mg IM): First-line for renal colic; reduces pain and ureteric spasm.
• Opioids (e.g., Oxycodone): If pain persists despite NSAIDs.

Hydration:

• Encourage oral hydration if tolerated, or consider IV fluids if nausea prevents intake.

Anti-emetics:

• Metoclopramide or Ondansetron for nausea management.

Monitoring:

• Vital signs monitoring for signs of sepsis.
• Monitor urine output and colour.

Referral:

• Immediate referral to urology or ED if:
  • Pain uncontrolled.
  • Suspected infection/sepsis.
  • Solitary kidney or renal failure.

Documentation:

• Clear notes including assessment, treatment, and safety-netting advice.

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Q4: What preventive health advice would you offer John to reduce recurrence?

Answer:

Hydration:

• Encourage drinking at least 2-3 litres/day, more during physical activity and hot weather.

Dietary Modifications:

• Reduce sodium intake (salt).
• Limit oxalate-rich foods (spinach, nuts, tea, chocolate).
• Maintain normal dietary calcium (avoid supplements unless deficient).
• Reduce animal protein (meat) intake if excessive.

Lifestyle:

• Address alcohol intake: Limit to recommended <2 standard drinks/day.
• Encourage regular exercise and healthy weight maintenance.

Monitoring:

• Regular renal ultrasound to detect recurrence.
• Metabolic workup: Consider if recurrent stones occur (24-hour urine analysis, serum calcium).

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Q5: How would you involve other healthcare providers in John’s care?

Answer:

Referrals:

• Urologist: For stones >5-7mm, recurrent stones, infection, or impaired renal function.
• Dietitian: For dietary advice tailored to stone type (once analysis done).
• Radiologist: For formal CT KUB or ultrasound as indicated.

Follow-up GP Care:

• Monitor kidney function and assess for complications.
• Reinforce preventive strategies.

Coordination:

• Document care plan clearly.
• Ensure communication with allied health professionals.
• Discuss patient understanding and provide written instructions.

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SUMMARY OF A COMPETENT ANSWER

• Thorough history-taking, exploring symptoms, ideas, concerns, and expectations.
• Broad differential diagnosis with structured reasoning and investigations.
• Clear, evidence-based acute management, including pain relief and safety-netting.
• Preventive advice targeting hydration, diet, and lifestyle modification.
• Coordination of care involving specialists and allied health with appropriate follow-up.

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PITFALLS

• Missing differential diagnoses, such as AAA or pyelonephritis.
• Inadequate pain relief, delaying definitive management.
• Failure to safety-net, especially regarding sepsis signs.
• Neglecting preventive education, leading to recurrent stones.
• Lack of interdisciplinary coordination, missing specialist referral when needed.

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REFERENCES

• RACGP Guidelines: Kidney Stones Management
• Murtagh’s General Practice, 8th Edition
• Therapeutic Guidelines: Urology (eTG Complete)

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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.
1.4 Communicates effectively in routine and difficult situations.

2. Clinical Information Gathering and Interpretation

2.1 Gathers and interprets information about health and health determinants.

3. Diagnosis, Decision-Making and Reasoning

3.1 Generates and tests diagnostic hypotheses and makes evidence-based decisions.

4. Clinical Management and Therapeutic Reasoning

4.1 Develops and implements management plans.
4.2 Provides patient-centred management.

5. Preventive and Population Health

5.1 Provides care that anticipates and addresses health determinants.
5.2 Provides screening and intervention strategies.

6. Professionalism

6.1 Ethical behaviour and professional integrity.

7. General Practice Systems and Regulatory Requirements

7.1 Uses quality and safety systems in practice.

8. Procedural Skills

8.1 Performs clinical procedures effectively and safely.

9. Managing Uncertainty

9.1 Manages uncertainty in clinical practice.

10. Identifying and Managing the Patient with Significant Illness

10.1 Provides appropriate management for patients with complex and serious health needs.

12. Rural Health Context (RH)

RH1.1 Provides comprehensive care in rural and remote communities.

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Competency at Fellowship Level

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