Roofer Told He May Have Kidney Disease After Months On A High Protein Diet — Free SCA Practice Case

Character Overview: You are Lloyd Rutter, a 54 year old roofer who works for a building firm. You live with your wife Gaynor, who works in a school kitchen, and your grown up son Tyler comes round most weekends. You have had high blood pressure for three years and take one tablet for it. At your blood pressure review last week you had blood tests, and yesterday afternoon the receptionist rang to say your kidney result was "off" and booked this call. Your dad, Ray, was told he had diabetes when you were sixteen, never got on top of it, and needed dialysis in his sixties. He always said he felt fine until a doctor read him a number, and you feel fine now. Last night you read online that protein shakes "wreck your kidneys" and lay awake thinking you had done this to yourself. Roofing is all you have done for twenty five years. You are plain speaking, and under the bluntness you are frightened. Your voice goes quiet and flat when you mention your dad or the shakes. You are impatient with waiting and want something done today.

Opening Sentence: "The receptionist said my kidney test was off. It's the same thing that happened to my dad, I'm sure of it. I want a scan and to see a specialist today, please."

History if Asked (Data Gathering Phase)

• ●The result: "She rang yesterday and just said it was off and a doctor needed to ring me. Nobody's told me the numbers."
• ●How you feel: "Honestly, fine. Fitter than I've been in years. No tiredness beyond normal, no itching, no metallic taste, no feeling sick. Not breathless, and my ankles and face aren't puffy."
• ●Passing urine: "Normal. Up once in the night at most. No burning, no blood, no foam, no colour change, and the stream's fine. Plenty during the day when I'm at home. No loin pain."
• ●Recent illness: "None. No vomiting, no runny tummy, no flu or chest infection, no fevers lately. No operations or hospital stays."
• ●The diet: "I started it four months ago. I'd put on weight and my belt wouldn't do up. It's a high protein plan from a gym channel online. Two whey shakes a day, one after breakfast and one in the evening, and meat with every meal: chicken, beef, bacon and eggs. Hardly any bread, rice or fruit. I've lost two stone and I'm made up about it."
• ●The day of the test: "I had a big steak the evening before, then a bacon sandwich on the way to the review. Nobody told me not to. I'd had a shake as usual that morning too."
• ●Fluids: "Honestly not much. Tea at breakfast, a mug on site, a bottle of squash usually still half full by the end of the day. I sweat a lot up there and there's nowhere to go to the toilet on a roof, so I don't drink until I'm home."
• ●Other supplements: "Only the whey. No creatine, no pre workout, no fat burners, no herbal stuff."
• ●Painkillers (if asked): "Nothing for pain, bar a paracetamol now and then if my back aches after a long day. No ibuprofen or anti inflammatories, no gels or patches, and no steroids or antibiotics lately."

Ideas, Concerns, Expectations

Gating note: Lloyd does not raise any of the following unprompted. Each part comes out only when the doctor asks what he thinks is going on, what is worrying him, or what he was hoping for.

• ●Ideas: He thinks what happened to his dad has started in him, and that he has made it worse himself. "I looked it up last night and it said shakes wreck your kidneys. Two a day for four months. Dad was told to look after his sugar and didn't. I swore I'd never be like him, and then I do this with a tub of powder."
• ●Concerns: He fears he has done lasting damage that cannot be put right, and that it will end his work. "Dad said he was fine right up until they gave him the number. I feel fine. That's what frightens me." He cannot picture doing anything but roofing. "It's all I know. If my kidneys are shot, I'm off the roofs."
• ●Expectations: He wants a scan today to see whether there is damage, and a specialist to tell him straight. "If there's something wrong I want it found now, not weeks down the line." He also asks whether to bin the shakes and whether he can carry on working.

If Asked: Medical History and Medications

Gating note: Lloyd answers each of these plainly when the doctor asks about it.

• ●Blood pressure: "Fine on the amlodipine. One every morning, nothing changed. They said my blood pressure was good at the review."
• ●Other conditions: "Nothing else. No diabetes; my sugar was normal last year. No heart trouble, gout, kidney stones, prostate problems or water infections. As far as I know nobody ever told me I'd got protein in my urine."
• ●Family history: "My dad, Ray, was told he had diabetes in his forties, when I was about sixteen. He never took it seriously, with tablets in a drawer and appointments missed. By his sixties his kidneys had failed and he needed dialysis for the last few years of his life. My mum's fine. I've got a sister and she's fine, as far as I know. There's no one else with kidney trouble."
• ●Dad's last years (if asked what it was like): "Hospital transport at the crack of dawn. A lump in his forearm he had to guard. Mum counting every cup he drank."
• ●Tablets and allergies: "Only the amlodipine. I'm not allergic to anything."
• ●Weight before: "I was nearly fifteen stone and now I'm thirteen, eating normal home cooking before."
• ●Practical questions: If tests are suggested he asks whether he can come in on his day off.

Social History and Lifestyle Impact

• ●Work: Roofer for twenty five years, employed by a firm that does repairs and new builds. Carries slates, lead and bundles of tiles up ladders all day. "Heavy lifting, up and down, I'm built like a barn door."
• ●Home: Lives with Gaynor in a semi. Tyler is 26 and lives in his own flat.
• ●Lifestyle: Non smoker. About ten pints a week, mostly at the weekend. No drugs. Walks the dog most evenings.
• ●Impact: He has been snappy at home since the call and could not eat his tea. "Gaynor knows something's up."

If Asked: Associated Symptoms

Gating note: Answers are brief. All negative: swelling, breathlessness, chest pain, palpitations, blood or froth in the urine, reduced urine, difficulty passing urine, loin pain, fever, rash, joint pains, tiredness, itching, nausea, loss of appetite, muscle pain or dark urine after work, and weight loss apart from the diet.

Responses to Management (The Negotiation Phase)

• ●If the doctor explains that one result is not a diagnosis and that the test should be repeated, perhaps after avoiding meat:
  • ●Reaction: Surprised, a little sceptical. "Meat? I live on chicken. What counts? And what about my shakes?" He asks how soon, and whether he can come in tomorrow. "So it could be wrong? How can a test be wrong?" He accepts once told cooked meat and muscle can push the number up. He asks about drinking. "Dad had to count every cup, so I thought kidneys meant drinking less?" He will drink properly once told normal drinking is wanted.
• ●If the doctor explains how diet, muscle and protein shakes can affect the creatinine, or mentions a different blood test (cystatin C):
  • ●Reaction: Thoughtful. "So I'm all muscle and that makes it look worse?" Then, quietly: "I read shakes wreck your kidneys. Have I done damage that can't be put right?" If told the diet has definitely harmed them, he goes quiet: "So I did do it myself." If told there is nothing to worry about, he does not believe it. If told honestly that nobody can say yet and the repeat will show more, he steadies: "Fair enough, at least that's straight." He asks what the other blood test is for and whether it is more accurate.
• ●If the doctor declines a scan or specialist today and explains that kidney disease is only diagnosed if the problem lasts three months:
  • ●Reaction: Pushes back at first. "Three months? I can't wait three months not knowing. Dad left it too late." He softens if the doctor takes his fear seriously, gives a clear plan with dates and says what would make things move faster. "So you're not brushing me off? What number would make you send me?" He also asks, "Can I carry on working? I'm up a ladder first thing tomorrow."
• ●If the doctor discusses a urine test, blood pressure checks, diabetes testing, or avoiding painkillers and other drugs that harm the kidneys:
  • ●Reaction: Agreeable and practical. "Right, a wee sample, I can do that. Morning one is easy, I'm up early anyway. Can I keep taking the amlodipine? What about ibuprofen, I might need it for my back?" He will come for his blood pressure check and tests on his day off.
• ●If the doctor addresses his father's kidney problem and whether it runs in the family:
  • ●Reaction: Quiet, then steadier. "He felt fine too, right up until they gave him the number." Once told that his father's kidneys were harmed by many years of uncontrolled diabetes, that early kidney problems give no symptoms so tests are the way to look, and that his own sugar was normal last year, he says, "So getting it checked now is the opposite of what Dad did." He asks if he could get diabetes himself and wants it checked. "What do I tell Gaynor?"
• ●If the doctor gives vague safety netting such as "come back if you are worried":
  • ●Reaction: "Worried about what exactly? Give me the actual signs, and who do I ring at the weekend?" He wants a date for results. "Will somebody ring me, or do I have to chase?"