Telephone Consultation · Intermediate · Nephrology

Deteriorating Renal Function in a 72-Year-Old Man

Practise this PLAB 2 telephone consultation station on Acute-on-Chronic Kidney Disease. 8-minute voice AI simulation with feedback on all 3 marking domains.

Clinical scenario

You are an FY2 doctor on call. Mr Khalid Parmar, a 72-year-old man with known chronic kidney disease stage 4, has rung the GP out-of-hours service. He reports that his creatinine has risen significantly on recent blood tests, his urine output appears reduced, and he feels increasingly unwell. Please take a focused telephone history and determine urgency of referral.

Background notes: PMH: CKD stage 4, Hypertension, T2DM on insulin, PVD, Previous stroke, Previous MI with stent, BPH, Hearing loss

What this station tests

  • Remote severity assessment: using uraemic symptoms (nausea, metallic taste, pruritus, confusion, oliguria) to triage urgency
  • Screening for life-threatening complications over the phone: fluid overload, hyperkalaemia, uraemic pericarditis
  • Making a clear triage decision: this patient needs hospital tonight, not a morning appointment
  • Holding medications before admission: stopping ACE inhibitor and metformin to prevent further renal insult
  • Telephone communication: being clear, decisive, and reassuring without physical examination available

How to use your 8 minutes

  • 0-1 min — Introduction: Introduce yourself and confirm patient identity. Explain purpose and check they can talk. Verify phone number for callback.
  • 1-3 min — Gather Information: Take focused history. Compensate for lack of visual cues with explicit questions about severity.
  • 3-5 min — Assessment: Summarise findings. Share working assessment. Identify any red flags requiring face-to-face review.
  • 5-7 min — Management Plan: Discuss management. Clear instructions. Ensure patient has means to follow plan (medications, transport to hospital).
  • 7-8 min — Safety Netting: Explicit safety netting (patient cannot see your expressions). When to call back, when to go to A&E. Confirm understanding.

Consultation approach

The opening

Telephone assessment of a deteriorating CKD patient requires rapid triage: is this an emergency requiring immediate hospital attendance, or can it wait until morning? The candidate must assess severity remotely and make a clear decision. Mr Parmar is 72, CKD stage 4, calling out-of-hours with rising creatinine, reduced urine output, and feeling unwell for a week. Open with: 'Mr Parmar, I want to understand how you are feeling right now so I can advise you on the best next step. Can you tell me your symptoms?'

Core approach

Assess severity remotely. He feels very tired and lethargic, has persistent nausea, metallic taste in mouth, itching on arms and legs, is confused at times, and has passed urine only once or twice today (normally 5 to 6 times). These are uraemic symptoms: nausea, metallic taste, pruritus, confusion, and oliguria. This is acute-on-chronic kidney disease with significant clinical deterioration.

Screen for emergencies over the phone. Breathlessness at rest? (Fluid overload or pulmonary oedema.) Chest pain? (Uraemic pericarditis.) Palpitations or muscle weakness? (Hyperkalaemia.) Seizures? (Severe uraemia or electrolyte disturbance.) He reports no breathlessness at rest and no chest pain, which is reassuring, but the confusion and oliguria indicate significant deterioration.

Identify the precipitant. Has he been unwell (infection, vomiting, diarrhoea)? He has not been eating properly for a few days (dehydration risk). Any new medications or dose changes (NSAIDs, ACE inhibitor increase)? Has his insulin dose been adjusted (hypoglycaemia could contribute to confusion)? Any urinary retention symptoms (his BPH could cause obstruction)?

This patient needs hospital assessment. CKD stage 4 baseline, now symptomatic with uraemia, oliguria, and confusion. This cannot wait until morning.

Closing and safety netting

Make a clear decision and communicate it: 'Mr Parmar, based on what you have told me, your kidneys are not working well enough right now, which is causing the tiredness, nausea, and confusion. You need to come to hospital tonight for blood tests, fluids, and monitoring. I am going to arrange this now.'

Address his concern about dialysis: 'We will not know if dialysis is needed until we have your blood results. Many people in this situation improve with fluids and treatment of the underlying cause.' Practical instructions: 'Do not take your blood pressure medication or metformin tonight. Bring your medication list. Your wife should bring you or call an ambulance if you feel worse.'

Safety net: 'If you become more confused, develop chest pain, severe breathlessness, or stop passing urine completely, call 999 immediately.' Contact the medical registrar to arrange admission.

How examiners mark this station

Examiners will assess all three domains, with particular attention to how you compensate for the lack of visual cues. Domain 1 (Data Gathering) focuses on your ability to take a thorough history remotely. Domain 2 (Clinical Management) assesses the clarity of your management plan and quality of safety netting. Domain 3 (Interpersonal Skills) assesses your telephone communication skills.

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

Scores well: Uraemic symptoms systematically assessed. Emergency complications screened (breathlessness, chest pain, palpitations). Precipitant sought (dehydration, medications, infection, retention). Urine output quantified. Baseline CKD stage known.

Costs marks: Not assessing uraemic symptoms. Not screening for emergencies. Not identifying precipitant. Not checking urine output.

Domain 2: Clinical Management Skills (Primary focus)

Scores well: Clear decision to admit tonight. Medications held (ACE inhibitor, metformin). Medical registrar contacted. Practical transport instructions. 999 criteria specified. Dialysis concern addressed proportionately.

Costs marks: Advising morning appointment. Not holding medications. No clear decision. No 999 criteria.

Domain 3: Interpersonal Skills (Throughout)

Scores well: Clear, decisive communication over the phone. Addressing dialysis fear without false reassurance. Practical instructions for wife. Calm, reassuring tone matching the urgency without causing panic.

Costs marks: Being indecisive. Causing panic. Not giving practical instructions. Being vague about the plan.

Common examiner feedback (and how to fix it)

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

Fix: Ask explicitly about things you would normally observe: 'Can you describe the rash for me?', 'How severe is the pain on a scale of 1-10?', 'Are you able to walk around?'

Did not provide adequate safety netting

Fix: Be very specific: 'If you develop X, Y, or Z, go directly to A&E or call 999.' Confirm the patient has understood and can access care if needed.

Common mistakes in this station

  1. Advising him to wait until morning. A CKD stage 4 patient with uraemic symptoms, confusion, and oliguria needs same-night hospital assessment. Delaying until morning risks hyperkalaemia, pulmonary oedema, or cardiac arrest.
  2. Not advising to hold medications. ACE inhibitors and metformin should be held in acute kidney injury. Candidates who do not give this specific instruction allow ongoing renal insult during transit to hospital.
  3. Not screening for hyperkalaemia. Palpitations and muscle weakness on the phone should prompt immediate 999 referral. Candidates who do not ask about these symptoms miss a potentially fatal complication.

Resitting PLAB 2?

If telephone consultation stations have been difficult, remember that you must compensate for the lack of visual cues with explicit verbal checking. Describe what you would normally observe, ask about severity in concrete terms, and provide very clear safety netting since the patient cannot see your facial expressions.

Example opening

Hello, am I speaking with [patient name]? Could I confirm your date of birth please? My name is Dr [Name], I'm calling from [surgery/hospital]. Is this a good time to talk? Are you somewhere private?

Frequently asked questions

How should I run this acute-on-Chronic kidney disease telephone consultation in PLAB 2?

Telephone assessment of a deteriorating CKD patient requires rapid triage: is this an emergency requiring immediate hospital attendance, or can it wait until morning? The candidate must assess severity remotely and make a clear decision. Mr Parmar is 72, CKD stage 4, calling out-of-hours with rising creatinine, reduced urine output, and feeling unwell for a week.

What are examiners marking in this acute-on-Chronic kidney disease station?

Marks are won for: Uraemic symptoms systematically assessed. Emergency complications screened (breathlessness, chest pain, palpitations). Precipitant sought (dehydration, medications, infection, retention). Urine output quantified. Marks are lost for: Not assessing uraemic symptoms. Not screening for emergencies. Not identifying precipitant. Not checking urine output.

What is the most common mistake candidates make in this acute-on-Chronic kidney disease station?

Advising him to wait until morning. A CKD stage 4 patient with uraemic symptoms, confusion, and oliguria needs same-night hospital assessment. Delaying until morning risks hyperkalaemia, pulmonary oedema, or cardiac arrest.

How do I prepare for this station if I have not managed acute-on-Chronic kidney disease in clinical practice?

This station rewards process over personal experience. The skill being assessed: Screening for life-threatening complications over the phone: fluid overload, hyperkalaemia, uraemic pericarditis. 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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