Acute Kidney Injury (AKI) History OSCE Checklist

1. Introduction

• Wash hands, introduce yourself, confirm patient identity
• Explain: “I’d like to ask some questions about your symptoms and kidney health.”
• Gain consent and ensure comfort
• Check if the patient is currently passing urine and if they feel acutely unwell

2. Presenting Complaint

• What brought you to hospital today?
• When did the problem start?
• Has it been getting worse, improving, or fluctuating?
• Has anyone told you your kidney function or creatinine is abnormal?

3. Urine History

• Have you noticed you are passing less urine than usual?
• When did you last pass urine?
• Are you passing no urine at all?
• What colour is your urine?
  • Dark/concentrated urine
  • Red, pink, or cola-coloured urine
  • Cloudy or foul-smelling urine
• Any frothy urine?
• Any pain or burning on passing urine?
• Urinary frequency, urgency, fever, or loin pain?
• Difficulty starting urine, weak stream, terminal dribbling, or incomplete emptying?
• Any urinary incontinence?
• Any lower abdominal fullness or suprapubic pain?

4. Volume Loss and Pre-renal Causes

• Have you had vomiting or diarrhoea? How frequent and for how long?
• Poor oral intake, thirst, inability to drink, or difficulty swallowing?
• Fever, sweats, or recent infection?
• Any bleeding:
  • Vomiting blood
  • Black stools or rectal bleeding
  • Heavy menstrual bleeding
  • Recent operation or trauma
• Have you felt dizzy, faint, or had palpitations when standing?
• Any recent burns?
• Recent excessive sweating, heat exposure, or strenuous exercise?

5. Sepsis and Systemic Illness

• Fever, rigors, or feeling generally unwell?
• Cough, breathlessness, sputum?
• Abdominal pain or diarrhoea?
• Painful urination or flank pain?
• Skin infection, wounds, ulcers, or recent surgery?
• Confusion or drowsiness?

6. Intrinsic Renal Disease Clues

• Blood in urine or cola-coloured urine?
• New swelling of legs, face, or around the eyes?
• Headache or symptoms of high blood pressure?
• Frothy urine?

• Rash or purpura?
• Joint pains?
• Mouth ulcers, photosensitivity, Raynaud symptoms?
• Sinus pain/nasal crusting or nosebleeds?
• Coughing blood or new breathlessness?

• New rash, fever, or joint pains after starting a medicine?

• Severe muscle pain, weakness, crush injury, prolonged immobility, seizures, intense exercise, or dark brown urine?

7. Obstruction and Post-renal Causes

• Previous kidney stones or renal colic?
• Loin-to-groin pain?
• History of enlarged prostate, prostate cancer, pelvic malignancy, or retroperitoneal disease?
• Previous urinary tract surgery, catheterisation, or urethral stricture?
• Neurological disease affecting bladder emptying, such as spinal injury, multiple sclerosis, or diabetes?

8. Drug History

• NSAIDs: ibuprofen, naproxen, diclofenac
• ACE inhibitors or ARBs: ramipril, lisinopril, losartan
• Diuretics: furosemide, bendroflumethiazide
• Antibiotics, especially aminoglycosides
• Proton-pump inhibitors
• Lithium
• Chemotherapy or immunotherapy
• Recent iodinated contrast scan or angiography
• Herbal remedies or bodybuilding supplements
• Recreational drugs, including cocaine or IV drug use

9. Past Medical History

• Previous AKI or kidney disease?
• Baseline renal function or known eGFR/creatinine?
• Diabetes, hypertension, heart failure, liver disease?
• Vascular disease?
• Recurrent UTIs, kidney stones, or prostate disease?
• Autoimmune disease such as lupus or vasculitis?
• Malignancy?
• Recent hospital admission, operation, ICU admission, or contrast exposure?

10. Social History

• Usual fluid intake and recent intake
• Alcohol intake
• Smoking
• Recreational drug use
• Recent travel, diarrhoeal illness, or infectious contacts
• Occupation and toxin exposure
• Functional status: can they independently access fluids and medications?

11. Systems Review

• Breathlessness, orthopnoea, leg swelling, chest pain
• Nausea, vomiting, anorexia, pruritus
• Confusion, drowsiness, headache
• Weight change
• Rash or bruising

Red Flags to Escalate Immediately

• Anuria or rapidly worsening oliguria
• Sepsis or hypotension
• Hyperkalaemia symptoms: palpitations, weakness, syncope
• Pulmonary oedema: acute breathlessness, orthopnoea
• Uraemic features: confusion, pericarditic chest pain, persistent vomiting
• Suspected infected urinary obstruction: fever plus loin pain/retention
• Haematuria with proteinuria suggesting nephritis

Closing Summary

“To summarise, this patient has had reduced urine output for ___ days, associated with ___, with possible causes including pre-renal fluid loss / sepsis / nephrotoxic medication / urinary obstruction. I would assess observations, volume status, fluid balance and urine output, review medications, check urinalysis and blood tests including U&Es, and consider renal ultrasound if obstruction is suspected.”

1. Pre-renal: hypovolaemia, sepsis, heart failure
2. Intrinsic renal: ATN, nephritis, interstitial nephritis, rhabdomyolysis
3. Post-renal: obstruction

AKI History OSCE Marking Scheme

Examiner Global Rating

Critical Errors

• Does not ask about urine output, oliguria, or anuria.
• Does not screen for urinary obstruction/retention.
• Does not ask about potentially nephrotoxic medications.
• Fails to identify or escalate potential sepsis, severe hypovolaemia, or anuria.
• Does not ask about a prior renal history or baseline function.
• Does not recognise urgent symptoms of hyperkalaemia, pulmonary oedema, or uraemia.

Expected Closing Statement

“This patient may have AKI. I would clarify the degree of oliguria and review baseline renal function, fluid losses, sepsis, nephrotoxic medication exposure, and symptoms of urinary obstruction. I would then assess observations and volume status, measure urine output, perform urinalysis, check U&Es including potassium and creatinine, review medications, and consider urgent bladder scan or renal ultrasound if obstruction is suspected.”

AKI History OSCE: Examiner Prompts and Model Candidate Answers

Station Brief for Candidate

You are an FY1 doctor in the acute medical unit. Please take a focused history from this patient, who has been referred with reduced urine output and a raised creatinine. You do not need to examine the patient.

Patient Role Brief

Examiner Prompts

Model Candidate Answers

1. Model Opening

“Hello, I’m [name], one of the doctors. Could I confirm your name and date of birth? I understand you have been passing less urine and have abnormal kidney blood tests. I would like to ask some questions to understand what may have caused this. Is that okay?”

2. Model History-Taking Sequence

“Can you tell me what has brought you into hospital today?”

“When did this start, and has it been getting better or worse?”

“You mentioned reduced urine output. How much urine have you passed compared with normal, and when did you last pass urine?”

“Have you noticed any blood, frothiness, cloudiness, or darkening of your urine? Any pain on passing urine, fevers, urgency, poor stream, or feeling unable to empty your bladder?”

“Have you had vomiting, diarrhoea, fever, poor fluid intake, heavy sweating, bleeding, or dizziness on standing?”

“Have you had symptoms of infection, such as fever, shivering, cough, abdominal pain, painful urination, or skin infections?”

“Have you noticed facial or leg swelling, blood in the urine, rashes, joint pains, mouth ulcers, or breathlessness?”

“Have you had severe muscle pains, a recent fall, prolonged time lying on the floor, seizures, crush injury, or strenuous exercise?”

“Do you have any difficulty starting urine, a weak stream, straining, incomplete emptying, loin-to-groin pain, kidney stones, prostate problems, or previous urinary tract procedures?”

“Do you have any previous kidney problems? Do you know your usual kidney function or creatinine? I would also ask about diabetes, high blood pressure, heart failure, liver disease, and autoimmune conditions.”

“Could we go through all of your medicines, including painkillers bought without a prescription, herbal medicines, supplements, antibiotics, or recent contrast scans?”

“Finally, can I ask about your usual fluid intake, alcohol, smoking, and whether you have been able to access fluids and manage your medications at home?”

3. Model Summary to the Examiner

“Mr Khan is a 72-year-old man with known CKD, diabetes, and hypertension, presenting with three days of profuse vomiting and diarrhoea with markedly reduced oral intake. He has developed oliguria, passing only very small volumes of dark urine, with postural dizziness.

He is taking ramipril and furosemide, and has recently taken regular ibuprofen, which may further impair renal perfusion. He has no symptoms suggesting urinary retention or upper tract obstruction, no features of glomerulonephritis or vasculitis, no rhabdomyolysis history, and no clear infective focus or heart failure symptoms.

My leading diagnosis is pre-renal AKI from hypovolaemia due to gastrointestinal fluid loss, compounded by ACE inhibitor, diuretic, and NSAID use, on a background of CKD.”

4. Model Answer: “What are your immediate management priorities?”

“I would first assess the patient using an ABCDE approach, obtain full observations, and assess for haemodynamic instability, sepsis, pulmonary oedema, and features of hyperkalaemia.

I would chart strict fluid balance, measure urine output, obtain a urinalysis, and send urgent blood tests including U&Es, creatinine, eGFR, bicarbonate, FBC, CRP, glucose, and creatine kinase if rhabdomyolysis were possible. I would check previous creatinine values to establish baseline renal function.

I would review and temporarily withhold potential contributors, including NSAIDs, ACE inhibitor, diuretic, and metformin as clinically appropriate. I would treat suspected hypovolaemia with cautious isotonic IV fluid replacement, reassessing regularly for response and fluid overload.

I would obtain an ECG and urgently treat hyperkalaemia if present. If there were any concern about obstruction, I would perform a bladder scan and arrange urgent urinary tract ultrasound. I would escalate early to senior clinicians and involve renal or urology teams where indicated.”

5. Model Answer: “How is AKI diagnosed?”

“AKI is diagnosed using a change in serum creatinine or urine output. It includes a rise in creatinine of at least 26 micromol/L within 48 hours, a rise of at least 50% from baseline within seven days, or urine output below 0.5 mL/kg/hour for more than six hours. I would compare the current creatinine with previous results and monitor urine output closely.”

6. Model Answer: “What are the main categories of AKI?”

“AKI is divided into pre-renal, intrinsic renal, and post-renal causes.

Pre-renal causes include hypovolaemia, sepsis, or reduced effective circulating volume in heart failure or liver disease.

Intrinsic renal causes include acute tubular injury, glomerulonephritis, acute interstitial nephritis, and rhabdomyolysis.

Post-renal AKI results from obstruction to urinary outflow, such as prostatic enlargement, stones, malignancy, or neurogenic bladder.”

Examiner Information: Expected Interpretation

• Likely cause: Pre-renal AKI due to gastrointestinal volume loss.
• Contributory medicines: Ramipril, furosemide, and ibuprofen.
• Important risk factors: Older age, CKD, diabetes, hypertension, hypovolaemia, and nephrotoxic medication exposure.
• Important exclusions: Urinary obstruction, sepsis, glomerulonephritis, acute interstitial nephritis, rhabdomyolysis, and cardiorenal syndrome.
• Urgent risks: Hypotension, hyperkalaemia, worsening oliguria/anuria, acidosis, and fluid overload after fluid administration.