Nephritic Syndrome: OSCE History Station Checklist

1. Introduction

• Wash hands, introduce yourself, confirm patient identity.
• Explain: “I’d like to ask about your urine symptoms, swelling, blood pressure symptoms, and possible causes. Is that okay?”
• Offer privacy and ask about any current pain or urgent symptoms.

2. Presenting Complaint

• “What brought you to hospital/clinic?”
• “When did this start?”
• “How has it progressed?”

• Dark, red, smoky, tea- or cola-coloured urine
• Reduced urine output
• Swelling
• Headache or high blood pressure symptoms
• Breathlessness

3. History of Presenting Illness

A. Urinary symptoms

• “Have you noticed blood or a dark colour in your urine?”
  • Colour: pink, red, brown, smoky, cola-coloured
  • Visible throughout the stream or only at the beginning/end?
  • Clots? Clots suggest a non-glomerular urinary tract source.
• “Has the amount of urine reduced?”
  • Estimate frequency and daily volume if possible.
  • Anuria or very little urine?
• “Any frothy urine?”
  • Suggests proteinuria.
• “Any pain or burning when passing urine?”
• “Any loin or flank pain?”
• “Any urgency, frequency, fever, rigors?”
  • Consider UTI or pyelonephritis rather than a primary glomerular process.

B. Fluid retention

• “Have you noticed swelling?”
  • Periorbital puffiness, especially in the morning
  • Ankles, legs, sacrum, abdomen, genital swelling
• “Any recent weight gain?”
• “Any tight shoes, rings, or clothes?”
• “Any breathlessness, needing extra pillows, or waking at night short of breath?”
  • Screen for pulmonary oedema.

C. Hypertension and uraemic symptoms

• Headache, blurred vision, dizziness
• Chest pain, palpitations
• Confusion, drowsiness, seizures
• Nausea, vomiting, poor appetite
• Itch, fatigue, reduced concentration

4. Search for a Cause

A. Recent infection

• Sore throat, tonsillitis, fever
• Skin sores, impetigo, cellulitis
• Recent dental, chest, urinary, or other infection
• Diarrhoea, particularly bloody diarrhoea

B. Systemic autoimmune or vasculitic disease

• Rash, photosensitivity, mouth ulcers, hair loss
• Joint pain, stiffness or swelling
• Raynaud phenomenon
• Dry eyes or dry mouth
• Sinusitis, nasal crusting or nosebleeds
• Cough, coughing blood, breathlessness
• Fever, night sweats, weight loss
• Purpura or non-blanching rash
• Neuropathy, such as foot drop, numbness or tingling

C. IgA nephropathy pattern

• “Does blood in the urine occur during, or within a few days of, a sore throat or cold?”
  • Synpharyngitic haematuria supports IgA nephropathy.

D. Endocarditis and chronic infection risk

• Persistent fever, night sweats, weight loss
• New heart murmur or known valvular heart disease
• Intravenous drug use
• Recent invasive procedures
• Hepatitis B, hepatitis C, HIV risk factors

E. Drugs and toxins

• NSAIDs
• Antibiotics, especially recent courses
• Proton-pump inhibitors
• Hydralazine, allopurinol, anticonvulsants
• Herbal or traditional medicines
• Cocaine or other recreational drugs
• Recent contrast imaging

5. Past Medical History

• Previous kidney disease, haematuria, proteinuria or renal stones
• Previous similar episodes
• Hypertension
• Diabetes
• Autoimmune disease, especially SLE or vasculitis
• Chronic infections: hepatitis B/C, HIV
• Heart valve disease or infective endocarditis
• Malignancy
• Recent hospital admissions, surgery or infections

• Previous renal function and known creatinine/eGFR
• Dialysis history
• Renal biopsy history
• Family history of kidney disease, deafness or haematuria
  • May suggest inherited conditions such as Alport syndrome.

6. Drug, Allergy and Social History

• Full prescribed, over-the-counter, herbal and recreational drug history
• Recent antibiotic use
• Allergies and reaction type
• Smoking, alcohol, recreational drugs
• Occupation and chemical exposures
• Recent travel
• Sexual history where clinically appropriate
• Pregnancy possibility in patients who may be pregnant

7. Functional and Impact Questions

• How has this affected daily activities and work?
• Can they monitor urine output or daily weight at home?
• Any difficulty obtaining medications or attending appointments?
• Who is available for support?

8. Focused Systems Review

• Cardiovascular: chest pain, orthopnoea, paroxysmal nocturnal dyspnoea.
• Respiratory: breathlessness, haemoptysis.
• Skin/MSK: rash, purpura, arthralgia.
• ENT: sinus symptoms, hearing changes.
• Neurological: headache, visual symptoms, confusion, seizures, neuropathy.
• GI: abdominal pain, diarrhoea, blood in stool.

Concise OSCE Summary

“This patient has symptoms suggestive of a nephritic syndrome, including haematuria, reduced urine output, oedema and possible hypertension. I would establish the timing and severity of renal symptoms, seek evidence of recent infection, autoimmune disease or vasculitis, review nephrotoxic medications, and screen urgently for pulmonary oedema, hypertensive emergency, rapidly worsening renal failure, or pulmonary-renal syndrome.”

Examiner-Pleasing Differentials

• Post-infectious glomerulonephritis
• IgA nephropathy
• Lupus nephritis
• ANCA-associated vasculitis
• Anti-GBM disease
• Membranoproliferative glomerulonephritis
• Infective endocarditis-associated glomerulonephritis
• Rapidly progressive crescentic glomerulonephritis

At the End of the Station

• Check observations, especially blood pressure, oxygen saturation and fluid status.
• Perform urinalysis and urine microscopy.
• Request urine protein quantification, U&E/creatinine/eGFR, FBC, albumin, CRP/ESR.
• Consider C3/C4, ANA, dsDNA, ANCA, anti-GBM antibody, ASO/anti-DNase B titres, hepatitis/HIV serology and blood cultures where indicated.
• Arrange urgent nephrology input if there is rapidly rising creatinine, oliguria/anuria, severe hypertension, pulmonary oedema, haemoptysis, or suspected rapidly progressive GN.

Nephritic Syndrome OSCE History Taking Marking Scheme

Itemised Examiner Checklist

1. Introduction and communication: 3 marks

• Introduces self and role.
• Confirms patient name/date of birth.
• Explains the consultation and gains consent.
• Uses clear, respectful, patient-centred communication.

2. Presenting complaint: 2 marks

• Establishes the main symptom(s).
• Clarifies onset, duration and progression.

3. Urinary symptoms: 5 marks

• Asks about haematuria.
• Clarifies urine colour, for example red, brown, smoky or cola-coloured.
• Asks about clots.
• Asks about oliguria/reduced urine output or anuria.
• Asks about frothy urine/proteinuria.
• Asks about dysuria, frequency, urgency and loin pain.

4. Oedema and uraemia: 3 marks

• Periorbital/facial swelling.
• Peripheral oedema, abdominal swelling or rapid weight gain.
• Uraemic symptoms: anorexia, nausea, vomiting, itch, fatigue or reduced concentration.

5. Hypertension and cardiorespiratory red flags: 3 marks

• Headache, visual disturbance or dizziness.
• Confusion, drowsiness or seizures.
• Breathlessness, orthopnoea, PND or chest pain.

6. Infection history: 3 marks

• Recent sore throat or upper respiratory infection.
• Recent skin infection, impetigo or cellulitis.
• Diarrhoea, especially bloody diarrhoea.
• Establishes interval between infection and haematuria.

7. Systemic disease screen: 4 marks

• Rash, palpable purpura or photosensitivity.
• Arthralgia, arthritis, oral ulcers or Raynaud phenomenon.
• ENT symptoms: chronic sinusitis, nasal crusting, epistaxis.
• Respiratory symptoms: cough, breathlessness, haemoptysis.
• Constitutional symptoms: fever, weight loss, night sweats.
• Neurological symptoms: peripheral neuropathy/foot drop.

8. Background history: 3 marks

• Past kidney disease, hypertension, diabetes or prior haematuria/proteinuria.
• Autoimmune disease, vasculitis, hepatitis/HIV or infective endocarditis risk.
• Drug history, including NSAIDs, antibiotics, herbal preparations and recreational drugs.
• Allergies.

9. Family and social history: 2 marks

• Family history of renal disease, haematuria or hearing loss.
• Smoking, alcohol, recreational/IV drug use, occupation and relevant travel.
• Functional impact and support at home.

10. Closure: 2 marks

• Summarises likely nephritic syndrome and relevant possible causes.
• Explains next steps: observations, fluid assessment, urinalysis, renal function and targeted serology.
• Safety-nets or escalates appropriately.

Critical Safety Markers

• Severe hypertension: severe headache, visual change, seizures, confusion.
• Pulmonary oedema/fluid overload: acute breathlessness, orthopnoea, PND.
• Rapidly progressive renal failure: severe oliguria/anuria, uraemic symptoms.
• Pulmonary-renal syndrome: haemoptysis with haematuria, suggesting vasculitis or anti-GBM disease.

Expected Closing Statement

“This history raises concern for nephritic syndrome, characterised by haematuria, reduced urine output, oedema and possible hypertension. I would assess the patient’s observations and fluid status urgently, perform urinalysis and renal function tests, and investigate for an infective, autoimmune or vasculitic cause. I would seek urgent senior or nephrology review if there is severe hypertension, pulmonary oedema, haemoptysis, rapidly worsening renal function, or anuria.”