CCE-CE-016.1

Case ID: CKD-2025-001
Case Name: Simon Taylor
Age: 56
Gender: Male
Indigenous Status: Non-Indigenous
Year: 2025
ICPC-2 Codes: A91 – Abnormal results investigations NOS​

COMPETENCY OUTCOMES

Competency DomainCompetency Element
1. Communication and Consultation Skills1.1 Engages the patient to understand their ideas, concerns, and expectations.
1.2 Uses appropriate communication strategies to discuss sensitive test results.
1.4 Explains complex medical information in an accessible manner.
2. Clinical Information Gathering and Interpretation2.1 Gathers a comprehensive history, including relevant medical, dietary, and exercise history.
2.2 Interprets investigation results appropriately, considering clinical context.
3. Diagnosis, Decision-Making and Reasoning3.1 Demonstrates structured clinical reasoning in evaluating kidney function.
3.3 Identifies limitations of creatinine-based eGFR in muscular individuals.
4. Clinical Management and Therapeutic Reasoning4.1 Develops an appropriate management plan, considering unnecessary interventions.
4.4 Recognises the role of additional testing (cystatin C) in refining diagnosis.
5. Preventive and Population Health5.1 Discusses strategies to avoid unnecessary medicalisation and overdiagnosis.
5.3 Provides patient education regarding reliable kidney function assessment.
6. Professionalism6.2 Acknowledges errors in medical judgment and communicates openly with the patient.
7. General Practice Systems and Regulatory Requirements7.1 Understands the implications of non-MBS subsidised tests (cystatin C) and discusses cost considerations with the patient.
9. Managing Uncertainty9.1 Recognises uncertainty in test results and seeks specialist input when required.
10. Identifying and Managing the Patient with Significant Illness10.1 Ensures appropriate referrals and investigations to rule out significant renal pathology.

CASE FEATURES

  • Cost considerations of non-MBS subsidised tests.
  • Middle-aged male with abnormal kidney function test results despite good health.
  • Concern about potential misdiagnosis of CKD in a muscular individual.
  • Use of cystatin C as an alternative biomarker for kidney function assessment.
  • Importance of shared decision-making and specialist input.
  • Psychological impact of receiving a serious diagnosis unexpectedly.

NSTRUCTIONS

You have 15 minutes to complete the tasks for this case.

You should treat this consultation as if it is face-to-face.

You are not required to perform an examination.

A patient record summary is provided for your information.

Perform the following tasks:

  1. Take an appropriate history from Simon
  2. Discuss the differential diagnoses
  3. Address Simon’s concerns
  4. Outline your management plan

SCENARIO

Simon Taylor, a 56-year-old bank manager, has come to discuss his test results from his recent routine check-up. He is physically active, lifting weights three times a week, and follows a high-protein, low-carb diet. He has a visibly muscular build.

Simon’s results show that HbA1c is in the healthy range at 5% (normal: 3.5-6). His CRP is <0.4mg/L (normal: <5.0). There is no albuminuria.

However, his creatinine is raised at 130μmol/L (normal for age: 60-110), and based on this, his estimated GFR using the CKD-EPI formula is low at 54mL/min/1.73m2 (lab normal range: >59).

The UEC is repeated on two more occasions, confirming these findings.

He has coeliac disease but no other significant medical history and no family history of renal disease.

PATIENT RECORD SUMMARY

Patient Details

Name: Simon Taylor
Age: 56
Gender: Male
Indigenous Status: Non-Indigenous

Allergies and Adverse Reactions

  • Nil known

Medications

  • Nil

Past History

  • Coeliac disease

Social History

  • Works as a bank manager
  • Regular weightlifting (three times per week)
  • High-protein, low-carb diet

Family History

  • No history of diabetes, cardiovascular, or renal disease

Smoking

  • Never smoked

Alcohol

  • Occasional alcohol consumption

Vaccination and Preventative Activities

  • Up to date

ROLE PLAYER INSTRUCTIONS

Just like a consultation with a doctor, the candidate will ask you a series of questions.
The OPENING LINE is always to be said exactly as written. This is the only part of the script
which will be the same for all candidates. Where the candidate goes after the opening line is
up to them.

The remainder of the information is to be given based on the questions asked by the
candidate.

The information in the following script are core pieces of information. The core pieces of
information will not necessarily follow the order in the script but should be given when cued
by the candidate’s question.

GENERAL INFORMATION can be given relatively freely. After the opening line, most
candidates will ask an open question like “Can you tell me more about that?” You can provide
the GENERAL INFORMATION in response to that sort of question.

SPECIFIC INFORMATION should only be given when the candidate asks a relevant question.
Candidates don’t need to ask for all the information in the SPECIFIC INFORMATION section,
but all the relevant information is given there should they want to.

Each line or dot point in the SPECIFIC INFORMATION section is an appropriate chunk of
information which can be provided to the candidate when asked a relevant question.

Do not give extra information than asked.

Do not provide details which are not given in the information chunks (i.e.: do not elaborate
or ad-lib).

If the candidate asks a question that is not given in the script, the best way to respond is with
a generic response indicating there is no problem. For example:

Candidate: “How many hours do you sleep?”
Response: “I’m sleeping fine.” / “I don’t have any concerns about my sleep.”

The case may have specific QUESTIONS to ask the candidate. You can start asking the
QUESTIONS if the candidate asks about your ideas or concerns or questions.

Ask the other questions in a conversational way. You do not need to ask all the questions. The
aim should be to ask most of the questions but without interrupting the candidate.

The Patient Record Summary is also included. This is not part of the script but is included for
your general information.

If you need help in understanding any of the medical information in the script, ask the College
examiner who will be with you, and they can help to explain the terms or the conditions.

Opening Line

“Doctor, I’ve just seen my test results, and I’m really concerned about my kidneys. I’ve Googled it a bit. Do I really have stage 3a chronic kidney disease?”

General Information

  • You have always been in good health and take pride in your fitness.
  • You work as a bank manager, which can be stressful, but you prioritise exercise and a healthy diet.
  • You lift weights three times a week and follow a high-protein, low-carb diet.
  • You have coeliac disease, which is well controlled with a strict gluten-free diet.
  • You have no family history of kidney disease, diabetes, or heart disease.
  • You have never smoked and only drink alcohol occasionally.

Specific Information

(Only to be shared when asked relevant questions)

Symptoms

  • You feel completely well with no fatigue, swelling, or changes in urination.
  • You have not had any recent infections or illnesses.
  • You have not experienced any changes in appetite or weight loss.
  • You have no pain or discomfort related to your kidneys.

Exercise and Diet

  • You have been weightlifting for over 10 years and have a visibly muscular build.
  • You consume a lot of lean protein, including red meat, chicken, and fish.
  • You sometimes take creatine supplements but not consistently.
  • You drink plenty of water and avoid processed foods.

Concerns & Emotional Reactions

  • You were shocked and confused when you saw the low eGFR result, as you feel completely healthy.
  • You double-checked with your family, and no one has kidney disease, which makes the diagnosis seem even more unexpected.
  • You have started researching kidney function and now wonder if your high muscle mass could be affecting the test results.
  • You have heard about other people at the gym being diagnosed with kidney disease and then told they did not have kidney disease.
  • You are feeling a mix of frustration and anxiety—this diagnosis could impact your lifestyle, and you are unsure what to do next.

Questions for the Doctor

  1. “Is this result accurate? I don’t have any symptoms of kidney disease.”
  2. “Could my high muscle mass be causing a falsely high creatinine level?”
  3. “I read that creatinine-based eGFR isn’t always reliable for people who lift weights. Is there another test that would be more accurate?”
  4. “Should I change my diet or exercise routine to help my kidneys?”
  5. “Do I need to see a specialist for this?”

Emotional Cues & Body Language

  • At the start of the consultation, you appear slightly tense and worried, leaning forward with a furrowed brow.
  • If the doctor is reassuring and explains things clearly, you gradually relax and become more engaged in the discussion.
  • If the doctor dismisses your concerns or does not address them directly, you become more frustrated and may push for alternative explanations.

Expected Outcome

  • You are looking for a logical and evidence-based explanation of your results.
  • If the doctor explains the limitations of creatinine-based eGFR and suggests additional testing, such as a cystatin C test, you feel relieved and open to the idea.
  • If reassured that your kidneys are likely functioning normally, you leave the consultation feeling more confident and less anxious.
  • If the doctor insists on the CKD diagnosis without considering alternative explanations, you may push back and request a second opinion.

THE COMPETENT CANDIDATE

The competent candidate should be able to:

Task 1: Take an appropriate history from Simon, focusing on his health, lifestyle, and concerns regarding his test results.

The competent candidate should:

  • Use open-ended questions to explore Simon’s understanding of his results and his main concerns.
  • Take a comprehensive history, including:
    • Medical history: Coeliac disease, any previous kidney issues, past investigations.
    • Family history: Any renal, cardiovascular, or metabolic diseases.
    • Lifestyle history: Exercise routine, weightlifting, protein intake, creatine supplementation, hydration habits.
    • Dietary factors: Protein and meat intake, potential for transient creatinine elevations.
    • Medication and supplement use: Creatine, protein powders, non-prescribed medications.
    • Symptoms review: Signs of CKD such as fatigue, oedema, nocturia, or urinary changes.
  • Address Simon’s emotional state, acknowledging his shock and uncertainty while providing empathetic reassurance.
  • Identify any misconceptions Simon may have regarding CKD and clarify them.

Task 2: Discuss the differential diagnoses and explain potential reasons for his elevated creatinine and low eGFR.

The competent candidate should:

  • Explain the limitations of creatinine-based eGFR in individuals with high muscle mass.
  • Discuss alternative explanations for Simon’s elevated creatinine, including:
    • Increased muscle mass leading to higher baseline creatinine.
    • High dietary protein intake causing transient increases in creatinine.
    • Creatine supplementation potentially affecting results.
    • Dehydration or recent intense exercise prior to testing.
  • Clearly differentiate true CKD (e.g., persistent decline in kidney function, proteinuria) from pseudo-CKD due to physiological factors.
  • Explain why cystatin C-based eGFR may provide a more accurate assessment in Simon’s case.
  • Provide information in layman’s terms and check for understanding.

Task 3: Address Simon’s concerns about his diagnosis empathetically and clarify the role of additional testing.

The competent candidate should:

  • Validate Simon’s concerns and acknowledge his distress about the diagnosis.
  • Reassure him that renal function assessment is complex, and additional testing may help clarify the situation.
  • Explain that a cystatin C test is a more reliable measure for those with high muscle mass and may provide a clearer picture.
  • Clarify that CKD is not diagnosed on eGFR alone and requires a comprehensive assessment, including:
    • Absence of albuminuria.
    • Normal renal ultrasound.
    • Stable creatinine levels over time.
  • Provide realistic expectations about next steps, ensuring Simon understands the reasoning behind further investigations.

Task 4: Outline a safe, patient-centred management plan, including further investigations and possible referral.

The competent candidate should:

  • Recommend repeating kidney function tests under controlled conditions (e.g., avoiding exercise/meat intake prior to testing).
  • Order cystatin C-based eGFR to provide a more accurate measure of renal function.
  • If cystatin C eGFR is normal, explain that Simon likely does not have CKD and no intervention is needed.
  • If results remain uncertain, consider referral to a nephrologist for specialist input.
  • Discuss the cost implications of the cystatin C test, as it is not MBS-subsidised.
  • Provide ongoing follow-up to ensure Simon feels supported and has a clear management plan.

SUMMARY OF A COMPETENT ANSWER

  • Thorough history-taking, including exercise, diet, and supplements.
  • Acknowledges patient concerns and provides reassurance.
  • Explains the limitations of creatinine-based eGFR in muscular individuals.
  • Discusses alternative causes of elevated creatinine.
  • Suggests appropriate further investigations, including cystatin C.
  • Provides clear, patient-centred communication, checking for understanding.
  • Outlines a safe and rational management plan with appropriate follow-up.

PITFALLS

  • Failure to acknowledge Simon’s distress, leading to a breakdown in rapport.
  • Over-reliance on creatinine-based eGFR without considering confounders.
  • Inadequate history-taking, missing key lifestyle factors affecting creatinine levels.
  • Overdiagnosis of CKD without confirming findings with additional tests.
  • Not discussing cost implications of the cystatin C test.
  • Failure to offer follow-up, leaving Simon with ongoing uncertainty.

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

Competency Assessment

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, and expectations.
1.4 Communicates effectively in routine and difficult situations.

2. Clinical Information Gathering and Interpretation

2.1 Takes a thorough history to explore factors affecting kidney function.
2.2 Interprets investigation results appropriately, considering clinical context.

3. Diagnosis, Decision-Making and Reasoning

3.1 Demonstrates structured clinical reasoning in evaluating kidney function.
3.3 Identifies limitations of creatinine-based eGFR in muscular individuals.

4. Clinical Management and Therapeutic Reasoning

4.1 Develops an appropriate management plan, considering unnecessary interventions.
4.4 Recognises the role of additional testing (cystatin C) in refining diagnosis.

5. Preventive and Population Health

5.1 Discusses strategies to avoid unnecessary medicalisation and overdiagnosis.
5.3 Provides patient education regarding reliable kidney function assessment.

6. Professionalism

6.2 Acknowledges errors in medical judgment and communicates openly with the patient.

7. General Practice Systems and Regulatory Requirements

7.1 Understands the implications of non-MBS subsidised tests (cystatin C) and discusses cost considerations with the patient.

9. Managing Uncertainty

9.1 Recognises uncertainty in test results and seeks specialist input when required.

10. Identifying and Managing the Patient with Significant Illness

10.1 Ensures appropriate referrals and investigations to rule out significant renal pathology.

Competency at Fellowship Level

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