# CKD-Focused OSCE History Checklist

**Station:** Chronic Kidney Disease Assessment | **Time:** 5-10 minutes | **Format:** History-taking focused on CKD identification and staging

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## A. OPENING & RAPPORT
- [ ] Greet patient, introduce self, verify name/DOB
- [ ] Explain purpose of consultation
- [ ] Confirm consent and obtain permission to take notes
- [ ] Position comfortably, make eye contact, use open body language

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## B. PRESENTING COMPLAINT & DURATION
- [ ] Open-ended question: "What brings you in today?" / "Tell me about your concerns"
- [ ] Duration of symptoms
- [ ] Clarify if patient is aware of kidney disease
- [ ] Ascertain whether routine check-up, referral, or acute problem

**Red flags to identify:**
- [ ] Fatigue, lethargy, malaise
- [ ] Nausea, vomiting, anorexia
- [ ] Swelling (face, hands, feet, abdomen)
- [ ] Shortness of breath
- [ ] Joint/bone pain
- [ ] Itching/skin changes

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## C. RISK FACTORS FOR CKD (ESSENTIAL)

### C1. DIABETES
- [ ] Type 1 or Type 2 diabetes?
- [ ] How long? (Age at diagnosis, number of years)
- [ ] Current control: A1C, last check? (if known)
- [ ] On insulin, oral agents, lifestyle modification?
- [ ] Known diabetic complications? (retinopathy, neuropathy, nephropathy)
- [ ] Blood sugar monitoring at home?

### C2. HYPERTENSION
- [ ] Known hypertension? When diagnosed?
- [ ] Current BP readings (at home or clinic)?
- [ ] Medications: ACE inhibitor, ARB, calcium channel blocker, diuretic, beta-blocker, other?
- [ ] Adherence to medications?
- [ ] Previous BP control?
- [ ] Any episodes of very high BP or hypertensive crisis?

### C3. FAMILY HISTORY
- [ ] Family history of kidney disease?
- [ ] Family history of diabetes, hypertension?
- [ ] Family history of polycystic kidney disease or genetic renal disease?
- [ ] Family history of ESRD requiring dialysis or transplant?

### C4. OTHER CKD RISK FACTORS
- [ ] Autoimmune disease? (SLE, vasculitis, IgA nephropathy)
- [ ] Glomerulonephritis or recurrent urinary infections?
- [ ] Kidney stones or obstruction?
- [ ] Recurrent UTIs or pyelonephritis?
- [ ] Enlarged prostate (BPH) or urinary retention?
- [ ] History of contrast exposure or nephrotoxic drugs?
- [ ] Chronic NSAID use? Herbal or traditional medicine use?

### C5. SOCIAL & OCCUPATIONAL
- [ ] Smoking history (pack-years)?
- [ ] Alcohol consumption?
- [ ] Illicit drug use?
- [ ] Occupational exposures (heavy metals, silica)?

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## D. SYSTEMS REVIEW FOR CKD COMPLICATIONS

### D1. CARDIOVASCULAR
- [ ] Chest pain, angina, or shortness of breath?
- [ ] Palpitations or heart problems diagnosed?
- [ ] History of MI, stroke, or TIA?
- [ ] Known hypertension (already covered in C2)?
- [ ] Leg swelling or pain (DVT/PAD)?

### D2. FLUID OVERLOAD SYMPTOMS
- [ ] Swelling of legs, feet, face, or abdomen?
- [ ] Recent weight gain (rapid)?
- [ ] Shortness of breath, especially lying down (orthopnea)?
- [ ] Waking at night short of breath (PND)?
- [ ] Difficulty breathing with exertion?

### D3. URINARY SYMPTOMS
- [ ] Change in urine output (decreased, frequent)?
- [ ] Nocturia? How many times per night?
- [ ] Visible blood in urine (hematuria)?
- [ ] Frothy or foamy urine (proteinuria)?
- [ ] Dysuria, frequency, urgency, hesitancy?
- [ ] Incontinence?

### D4. CONSTITUTIONAL SYMPTOMS
- [ ] Fatigue: when started? Worse with activity?
- [ ] Weakness, lethargy?
- [ ] Low appetite, nausea, vomiting?
- [ ] Metallic taste in mouth?
- [ ] Weight loss or weight gain?
- [ ] Fever, chills, night sweats?

### D5. BONE & MINERAL DISORDERS (CKD-MBD)
- [ ] Bone pain or aches?
- [ ] Muscle cramps or spasms?
- [ ] Fractures or falls?
- [ ] Itching/skin changes (uremic pruritus)?

### D6. NEUROLOGICAL
- [ ] Headaches?
- [ ] Confusion, memory problems, cognitive changes?
- [ ] Difficulty concentrating?
- [ ] Peripheral tingling/numbness (neuropathy)?
- [ ] Seizures?

### D7. GASTROINTESTINAL
- [ ] Nausea, vomiting?
- [ ] Loss of appetite?
- [ ] Constipation or diarrhea?
- [ ] Abdominal pain or discomfort?
- [ ] Oral ulcers or taste changes?

### D8. ANEMIA-RELATED
- [ ] Pallor, shortness of breath?
- [ ] Fatigue (worse than expected)?
- [ ] Dizziness or lightheadedness?
- [ ] Chest pain with exertion?

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## E. PAST RENAL HISTORY

- [ ] Any previous kidney tests? (baseline creatinine, eGFR, urinalysis)
- [ ] When was kidney disease first identified?
- [ ] Any previous renal imaging (ultrasound, CT)?
- [ ] Any renal biopsies performed?
- [ ] Previous hospitalizations for kidney issues?
- [ ] Ever told diagnosis of specific kidney disease? (IgA, FSGS, MPGN, membranous, etc.)

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## F. PAST MEDICAL HISTORY (Expanded for CKD Context)

- [ ] Acute kidney injury (AKI) previously?
- [ ] Acute glomerulonephritis?
- [ ] Pyelonephritis or recurrent UTI?
- [ ] Urolithiasis (kidney stones)?
- [ ] BPH, prostate disease?
- [ ] Autoimmune diseases (SLE, vasculitis, Sjögren's)?
- [ ] Hepatitis B or C?
- [ ] HIV?
- [ ] Malignancy (especially myeloma, lymphoma)?
- [ ] Hypertension, diabetes (already covered)
- [ ] Cardiovascular disease (MI, stroke, PAD)
- [ ] Heart failure?
- [ ] Connective tissue disease?
- [ ] Recurrent infections?

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## G. MEDICATIONS (CRITICAL FOR CKD)

**Ask about ALL medications, including:**
- [ ] ACE inhibitors or ARBs (for BP/proteinuria)?
- [ ] Diuretics?
- [ ] Beta-blockers, calcium channel blockers?
- [ ] NSAIDs? (Frequency and duration)
- [ ] Statins?
- [ ] Anticoagulants (warfarin, DOACs)?
- [ ] Diabetic medications (metformin, GLP-1, SGLT2i)?
- [ ] Phosphate binders?
- [ ] Vitamin D or calcimimetics?
- [ ] Erythropoiesis-stimulating agents (ESA)?
- [ ] Antibiotics (aminoglycosides, fluoroquinolones)?
- [ ] Herbal supplements or traditional remedies?
- [ ] Over-the-counter analgesics?

**For each medication:**
- [ ] Name, dose, frequency
- [ ] How long taking?
- [ ] Adherence/compliance?
- [ ] Any side effects?
- [ ] Recent dose changes?

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## H. ALLERGIES & ADVERSE REACTIONS
- [ ] Drug allergies?
- [ ] Reactions to contrast agents (important for CKD)?
- [ ] ACE inhibitor cough or angioedema?
- [ ] Other medication intolerances?

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## I. SOCIAL HISTORY (CKD Context)

### I1. LIVING SITUATION
- [ ] Lives alone or with family?
- [ ] Has caregiving support?
- [ ] Adequate housing, utilities?
- [ ] Access to kitchen for dietary management?

### I2. EMPLOYMENT & FUNCTIONAL STATUS
- [ ] Currently working? Full-time/part-time?
- [ ] Able to perform activities of daily living (ADLs)?
- [ ] Functional limitations from CKD symptoms?
- [ ] Need for work/school adjustments?

### I3. LIFESTYLE
- [ ] Regular exercise? (if tolerated by CKD stage)
- [ ] Dietary habits: high salt, high protein, processed foods?
- [ ] Fluid intake awareness?
- [ ] Able to follow dietary/fluid restrictions?

### I4. SOCIAL SUPPORT
- [ ] Family understanding of CKD?
- [ ] Emotional support available?
- [ ] Previous nephrology care or education?

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## J. DIALYSIS & RENAL REPLACEMENT THERAPY (If applicable)

- [ ] Ever been on dialysis or need for dialysis discussed?
- [ ] Vascular access? (Fistula, graft, catheter)
- [ ] On dialysis now? Type, frequency, duration?
- [ ] Transplant history or on waiting list?
- [ ] Complications of dialysis or transplant?

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## K. PREVIOUS INVESTIGATIONS & MONITORING

- [ ] Last serum creatinine? eGFR? When?
- [ ] Last urinalysis? (proteinuria, hematuria?)
- [ ] 24-hour urine protein or spot urine protein/creatinine ratio?
- [ ] Last electrolytes (K+, Na+, HCO3-)?
- [ ] Last hemoglobin? (checking for anemia)
- [ ] Last calcium, phosphate, PTH?
- [ ] Lipid profile?
- [ ] Imaging: renal ultrasound, CT, MRI? Findings?
- [ ] Renal biopsy? Pathology results?
- [ ] Regular monitoring by nephrologist? How often?

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## L. PREVIOUS INTERVENTIONS & MANAGEMENT

- [ ] Previous counseling on salt, fluid, protein restriction?
- [ ] Previous BP goal and management?
- [ ] Previous patient education on CKD?
- [ ] Any specialist referrals (cardiology, nephrology, endocrinology)?
- [ ] Any previous attempts at treatment modification?

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## M. PROGRESSION & STABILITY

- [ ] Trend in kidney function? (Stable, declining, rapidly declining?)
- [ ] If declining: how fast? (GFR slope?)
- [ ] Any recent acute worsening?
- [ ] Recent infections, exposures, or medication changes that might affect kidneys?
- [ ] Changes in proteinuria or hematuria?

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## N. PATIENT UNDERSTANDING & GOALS

- [ ] Does patient understand they have kidney disease?
- [ ] What does the patient know about their diagnosis?
- [ ] Patient's understanding of disease progression and prognosis?
- [ ] Patient's goals of care?
- [ ] Concerns or anxieties about kidney disease?
- [ ] Readiness for dialysis, transplant, or conservative management?

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## O. COMPLIANCE & BARRIERS

- [ ] Medication adherence challenges?
- [ ] Dietary adherence (salt, fluid, protein restrictions)?
- [ ] Financial barriers to medications or appointments?
- [ ] Difficulty accessing specialist care?
- [ ] Language or health literacy barriers?

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## SUMMARY OF KEY EXAM FINDINGS TO COMMUNICATE

After history taking, note:

**CKD Stage Indicators (from history):**
- [ ] GFR range (if known): _____ mL/min/1.73m²
- [ ] Presence of proteinuria/hematuria: _____
- [ ] Duration of kidney disease: _____

**Red Flags Identified:**
- [ ] AKI risk or recent acute change
- [ ] Advanced CKD (stages 4-5)
- [ ] Uncontrolled HTN or DM
- [ ] Signs of uremia or complications
- [ ] Medication-related issues

**Patient Readiness for Management:**
- [ ] Level of health literacy
- [ ] Adherence potential
- [ ] Need for education or referral

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## DOCUMENTATION CHECKLIST

Before leaving the station, ensure you have elicited and documented:

- [ ] Clear risk factor profile (DM, HTN, family history)
- [ ] CKD-related symptoms (if any)
- [ ] Degree of functional impairment
- [ ] Current management and medications
- [ ] Awareness and understanding of diagnosis
- [ ] Barriers to care and compliance
- [ ] Impression of CKD stage and urgency of intervention
- [ ] Plan for investigations or referral (if applicable)

---

## DIFFERENTIAL CONSIDERATIONS

While taking history, consider other causes of abnormal renal function:

- **Acute kidney injury (AKI)** - recent change, reversible
- **Prerenal azotemia** - dehydration, hypotension
- **Intrinsic renal disease** - glomerulonephritis, interstitial nephritis
- **Postrenal obstruction** - BPH, stones, malignancy
- **Diabetic nephropathy** - DM + proteinuria + HTN
- **Hypertensive nephrosclerosis** - severe/uncontrolled HTN
- **Secondary CKD** - SLE, vasculitis, amyloidosis, HIV, hepatitis C

---

## OSCE MARK SCHEME (Examiner Reference)

**Communication & Rapport** (5-10%)
- [ ] Respectful, empathetic approach
- [ ] Clear explanations
- [ ] Appropriate use of open and closed questions

**Risk Factor Elicitation** (20-25%)
- [ ] Systematically covered diabetes, hypertension, family history
- [ ] Explored other risk factors
- [ ] Identified relevant past medical history

**Symptom Assessment** (20-25%)
- [ ] Thorough systems review for CKD complications
- [ ] Identified constitutional, urinary, and cardiovascular symptoms
- [ ] Probed functional impact

**Drug & Allergy History** (10-15%)
- [ ] Complete medication list
- [ ] Key CKD-relevant drugs identified (ACE-I, ARB, NSAIDs)
- [ ] Allergy to contrast noted

**Investigations & Monitoring** (10-15%)
- [ ] Asked about previous renal tests
- [ ] Enquired about renal imaging
- [ ] Assessed frequency of monitoring

**Patient Understanding & Compliance** (5-10%)
- [ ] Assessed patient knowledge
- [ ] Identified adherence barriers
- [ ] Gauged readiness for management

**Organization & Efficiency** (5-10%)
- [ ] Logical flow of questions
- [ ] Appropriate time management
- [ ] Clear summary at end

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**Total Duration:** 5-10 minutes | **Aim:** Obtain comprehensive history relevant to CKD staging, complications, and management planning

# CKD OSCE History-Taking Marking Scheme

**Station:** Focused history in a patient with known or suspected chronic kidney disease (CKD)  
**Candidate time:** 8 minutes | **Reading time:** 2 minutes | **Total:** 40 marks  
**Candidate task:** Take a focused history, identify CKD severity/complications and relevant risks, then summarise to the examiner.

## Examiner instructions

Award each item only if it is clearly elicited. Do not award points for vague questions such as “Any other symptoms?” unless the candidate follows up appropriately. Accept clinically equivalent wording. The candidate does **not** need to ask every question to pass, but must identify the core risk factors, renal symptoms, medication risks, and important complications.

### Global rating

| Rating | Descriptor |
|---|---|
| Clear fail | Unsafe, disorganised, misses major red flags or drug risks, poor communication |
| Borderline | Covers some core areas but important omissions or limited structure |
| Pass | Safe, structured CKD-focused history; identifies most core factors and complications |
| Good | Efficient, patient-centred, elicits severity, cause, complications, and barriers |
| Excellent | Thorough but focused; prioritises risk, progression, renal replacement planning, and shared decision-making |

**Suggested pass mark:** 24/40, with no critical safety omission.

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## 1. Introduction, consent and agenda - 4 marks

| Criterion | Marks |
|---|---:|
| Introduces self, confirms patient identity, explains purpose | 1 |
| Obtains consent and ensures comfort/privacy | 1 |
| Uses appropriate open opening question | 1 |
| Establishes presenting complaint and duration | 1 |

**Score: ____ /4**

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## 2. Presenting problem and CKD background - 5 marks

| Criterion | Marks |
|---|---:|
| Establishes whether CKD is known or newly detected, and when first recognised | 1 |
| Asks about previous renal function trend: creatinine/eGFR, stable versus progressive decline | 1 |
| Asks about proteinuria/albuminuria, haematuria, or abnormal urinalysis | 1 |
| Establishes past renal diagnosis, ultrasound, biopsy, AKI, stones, UTI/pyelonephritis or obstruction | 1 |
| Clarifies nephrology follow-up and previous CKD education/management plan | 1 |

**Score: ____ /5**

---

## 3. Aetiology and CKD risk factors - 7 marks

| Criterion | Marks |
|---|---:|
| Diabetes: type, duration, control, treatment and microvascular complications | 1 |
| Hypertension: duration, control/home readings and treatment | 1 |
| Cardiovascular disease: heart failure, ischaemic heart disease, stroke/TIA, peripheral arterial disease | 1 |
| Family history: kidney disease, dialysis/transplant, polycystic kidney disease, diabetes/hypertension | 1 |
| Autoimmune/systemic disease: SLE, vasculitis, connective-tissue disease | 1 |
| Infection/malignancy risks where appropriate: hepatitis B/C, HIV, myeloma | 1 |
| Obstructive/urological history: LUTS/BPH, retention, recurrent stones or urinary infection | 1 |

**Score: ____ /7**

---

## 4. Symptoms and CKD complications - 9 marks

| Criterion | Marks |
|---|---:|
| Urinary symptoms: oliguria/polyuria, nocturia, dysuria, frequency, haematuria, frothy urine | 1 |
| Fluid overload: peripheral/facial oedema, rapid weight gain, ascites | 1 |
| Breathlessness including exertional dyspnoea, orthopnoea or PND | 1 |
| Uraemic/constitutional symptoms: fatigue, anorexia, nausea/vomiting, metallic taste, weight change | 1 |
| Anaemia symptoms: exercise intolerance, dizziness, palpitations, chest discomfort | 1 |
| CKD-mineral and bone disorder: bone pain, fractures, muscle cramps/pruritus | 1 |
| Neurological features: headache, poor concentration, confusion, paraesthesia/restless legs | 1 |
| Hypertension/vascular symptoms: headache, visual symptoms, chest pain, focal neurological symptoms | 1 |
| Identifies urgent features: severe breathlessness/pulmonary oedema, markedly reduced urine, confusion, chest pain, severe vomiting or possible hyperkalaemia symptoms | 1 |

**Score: ____ /9**

---

## 5. Medication and allergy history - 6 marks

| Criterion | Marks |
|---|---:|
| Obtains a complete prescribed, over-the-counter and herbal/traditional medicine list | 1 |
| Specifically asks about NSAIDs and other potential nephrotoxins, including recent contrast exposure | 1 |
| Identifies antihypertensives/renoprotective therapy: ACE inhibitor or ARB, diuretics, and adherence | 1 |
| Asks about diabetes drugs and recent changes; checks safety/adherence in reduced renal function | 1 |
| Asks about CKD-specific therapy if relevant: erythropoiesis-stimulating agent, iron, phosphate binder, vitamin D/calcimimetic | 1 |
| Drug allergies and nature of reaction, including contrast reaction where relevant | 1 |

**Score: ____ /6**

---

## 6. Social history, functional impact and lifestyle - 4 marks

| Criterion | Marks |
|---|---:|
| Smoking, alcohol and recreational drug use | 1 |
| Diet: salt intake, processed food, dietary advice and ability to follow it | 1 |
| Fluid advice/restriction where relevant; recent fluid intake/losses | 1 |
| Functional status, work, home support, financial/access barriers and health literacy | 1 |

**Score: ____ /4**

---

## 7. Renal replacement therapy and patient perspective - 2 marks

| Criterion | Marks |
|---|---:|
| Asks whether dialysis/transplant/conservative care has been discussed; if on dialysis, asks modality, schedule and access | 1 |
| Elicits patient understanding, concerns, expectations, goals and support needs | 1 |

**Score: ____ /2**

---

## 8. Summary, prioritisation and communication - 3 marks

| Criterion | Marks |
|---|---:|
| Gives a concise, accurate summary of likely cause, progression and relevant complications | 1 |
| States appropriate priorities: assess renal function/urinalysis/albuminuria, blood pressure, electrolytes and complications, or escalate urgent symptoms | 1 |
| Checks patient questions, uses empathetic non-technical language and closes professionally | 1 |

**Score: ____ /3**

---

# Critical safety items

A candidate who fails to explore or recognise any applicable item should be considered **borderline or fail**, depending on the scenario:

- New severe oliguria/anuria, rapidly worsening renal function, or recent acute illness suggesting AKI
- Pulmonary oedema or severe fluid overload: escalating dyspnoea, orthopnoea, PND
- Possible uraemia: confusion, persistent vomiting, marked anorexia
- Possible severe hyperkalaemia or cardiovascular instability: palpitations, weakness, syncope, chest pain
- Ongoing NSAID use, unregulated herbal remedies, recent contrast exposure, or other nephrotoxic medication
- Uncontrolled hypertension or diabetes

---

# Mark total

| Domain | Mark |
|---|---:|
| 1. Introduction, consent and agenda | ____ /4 |
| 2. Presenting problem and CKD background | ____ /5 |
| 3. Aetiology and risk factors | ____ /7 |
| 4. Symptoms and complications | ____ /9 |
| 5. Medication and allergies | ____ /6 |
| 6. Social history and lifestyle | ____ /4 |
| 7. RRT and patient perspective | ____ /2 |
| 8. Summary and communication | ____ /3 |
| **TOTAL** | **____ /40** |

**Global rating:** Clear fail / Borderline / Pass / Good / Excellent  
**Critical safety concern:** Yes / No  
**Examiner feedback:** ________________________________________________

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## CKD staging prompt for the examiner

CKD is defined by abnormalities of kidney structure or function present for at least 3 months. Record available cause, GFR category and albuminuria category (CGA classification). GFR categories: G1 ≥90, G2 60-89, G3a 45-59, G3b 30-44, G4 15-29, G5 <15 mL/min/1.73 m². Ask about albuminuria because it adds prognostic information. KDIGO recommends at least annual assessment of GFR and albuminuria in people with CKD, with more frequent assessment when progression risk is higher or results will affect treatment.

Reference: [KDIGO 2024 CKD guideline](https://kdigo.org/wp-content/uploads/2024/03/KDIGO-2024-CKD-Guideline.pdf). CKD is also described as kidney damage or decreased kidney function for 3 months or longer in *Textbook of Family Medicine 9e*, p. 154.