Nephrotic syndrome osce history station check list
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Nephrotic syndrome OSCE history checklist
1. Introduction and consent
- Wash hands, introduce yourself, confirm patient identity.
- Explain: “I’d like to ask about your swelling and urine symptoms, and about possible causes. Is that okay?”
- Check comfort, privacy, and whether a parent/carer is needed for a child.
2. Presenting complaint and history of symptoms
Ask open first:
- “What problems have you noticed?”
- “When did they start, and how have they changed?”
Then clarify:
Oedema
- Periorbital puffiness, especially on waking?
- Ankle, leg, genital or abdominal swelling?
- Does it worsen by evening or improve overnight?
- Rapid weight gain, tighter clothing/shoes?
- Reduced mobility or skin weeping?
Urinary symptoms
- Frothy/foamy urine?
- Reduced urine volume or dark urine?
- Visible blood in urine?
- Dysuria, frequency, urgency, fever, loin pain?
- Nocturia?
Fluid overload / systemic symptoms
- Breathlessness, orthopnoea, cough, chest discomfort?
- Abdominal distension or early satiety from ascites.
- Fatigue, poor appetite.
The typical nephrotic symptom pattern includes peripheral oedema, fatigue, dyspnoea and foamy urine; examination may show pitting oedema, ascites and pleural effusions. Frameworks for Internal Medicine, “Nephrotic Syndrome” section.
3. Screen for complications
Thromboembolism
- Unilateral painful swollen leg?
- Sudden dyspnoea, pleuritic chest pain, haemoptysis, palpitations?
- New flank/loin pain or haematuria, which could suggest renal vein thrombosis.
- Headache, visual symptoms, focal weakness or seizures.
Infection
- Fever, chills, sore throat, cough, urinary symptoms?
- Abdominal pain or tenderness, especially in children, suggesting spontaneous bacterial peritonitis.
- Skin redness, warmth, ulcers or cellulitis.
Acute kidney injury / severe illness
- Marked oliguria or anuria?
- Dizziness, vomiting, diarrhoea, poor oral intake?
- Confusion or drowsiness.
Nephrotic syndrome increases thrombotic risk through urinary loss of natural anticoagulants and increased procoagulant factors; renal and lower-limb veins are common sites. Frameworks for Internal Medicine, “Nephrotic Syndrome” section.
4. Identify likely cause
A. Primary glomerular disease
- Previous episodes of oedema or proteinuria?
- Childhood nephrotic syndrome or steroid treatment?
- Family history of kidney disease, dialysis, deafness, genetic syndromes?
- Recent infection, especially upper respiratory infection?
- Medication exposure: NSAIDs, lithium, interferon, bisphosphonates, gold, penicillamine, heroin or other recreational drugs.
B. Diabetes
- Diabetes duration and control.
- Polyuria, polydipsia, neuropathy, visual symptoms.
- Diabetic retinopathy or foot disease.
C. Autoimmune / inflammatory disease
- Rash, photosensitivity, mouth ulcers, hair loss.
- Joint pain/swelling, Raynaud phenomenon.
- Sinus symptoms, epistaxis, cough/haemoptysis.
- Purpura, neuropathy, arthralgia.
D. Infection-related causes
- Hepatitis B/C risk: jaundice, intravenous drug use, tattoos, transfusions, sexual exposure.
- HIV risk factors or recurrent infections.
- Recent malaria or travel where relevant.
E. Malignancy
- Unintentional weight loss, night sweats, persistent fever.
- New lumps, change in bowel habit, abnormal bleeding.
- In adults, ask age-appropriate cancer-screening history. Membranous nephropathy can be associated with malignancy, so this is particularly relevant in older adults.
F. Amyloidosis / plasma cell disease
- Chronic inflammatory illness such as rheumatoid arthritis, inflammatory bowel disease or chronic infection.
- Bone pain, recurrent infections, neuropathy, postural dizziness, tongue enlargement.
5. Past history
- Previous renal disease, hypertension, diabetes, autoimmune disease, hepatitis or HIV.
- Previous urine dipsticks showing protein or blood.
- Prior renal biopsy, dialysis, transplant, admissions for oedema or thrombosis.
- Cardiovascular, liver or thyroid disease, as alternative or contributing causes of oedema.
6. Drug and allergy history
- Current and recent prescribed medication, including steroids and immunosuppressants.
- NSAIDs and over-the-counter/herbal medications.
- Diuretics, ACE inhibitor/ARB, anticoagulation.
- Allergies and nature of reaction.
7. Family, social and functional history
- Family history of renal disease, deafness, autoimmune disease, diabetes.
- Smoking, alcohol and recreational drugs.
- Occupation and toxin exposure.
- Diet, especially high salt intake.
- Effect on walking, work/school, sleep and self-care.
- For women: pregnancy status, pre-eclampsia history and contraceptive use. Oestrogen-containing contraception may add to thrombotic risk.
8. Paediatric additions
If the station is a child, ask the parent/carer:
- Age at onset and any prior relapses.
- Recent viral illness or immunisations.
- Reduced appetite, irritability, abdominal pain, diarrhoea or fever.
- Growth and development.
- Steroid response, adherence and adverse effects.
- Family history of early-onset renal disease or syndromic features.
- Urine testing at home and relapse triggers.
Current KDIGO guidance defines childhood nephrotic-range proteinuria as spot urine protein:creatinine ratio at least 2 g/g, or 3+ protein on dipstick in the appropriate clinical setting. The KDIGO 2025 guideline also highlights that early steroid response and relapse pattern help predict prognosis.
9. Summarise and close
Summarise:
“You have developed progressive periorbital and leg swelling with frothy urine and weight gain, suggesting significant urinary protein loss. I would be concerned about nephrotic syndrome and would also assess for complications such as infection, blood clots and impaired kidney function.”
Then:
- Ask if the patient has questions or concerns.
- Thank them.
- State next steps if required: examination, urinalysis, urine protein:creatinine ratio, serum albumin, renal function, lipid profile, glucose/HbA1c, autoimmune/infection screen and renal ultrasound or biopsy guided by presentation.
Examiner-friendly red flags to state
- Sudden breathlessness/chest pain: pulmonary embolism.
- Unilateral painful leg swelling: DVT.
- Fever with abdominal pain: peritonitis or serious infection.
- Severe oliguria, hyperkalaemic symptoms or confusion: acute kidney injury.
- Gross haematuria, marked hypertension, rash or systemic inflammatory symptoms: consider a nephritic or systemic glomerulonephritis process rather than uncomplicated nephrotic syndrome.
For context, nephrotic syndrome is generally characterized by heavy proteinuria, hypoalbuminaemia and oedema, with hyperlipidaemia commonly present, as summarized in the Merck Manual overview.
Create a nephrotic OSCE marking scheme
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KDIGO 2025 nephrotic syndrome children guideline diagnosis clinical characteristics
Nephrotic syndrome OSCE history-taking marking scheme
Station: History from a patient with suspected nephrotic syndrome
Suggested time: 8 minutes
Total: 30 marks
Pass standard: 18/30, with no major patient-safety concern
Suggested time: 8 minutes
Total: 30 marks
Pass standard: 18/30, with no major patient-safety concern
| Domain | Checklist item | Marks |
|---|---|---|
| 1. Introduction and communication | Introduces self, confirms patient identity, explains purpose, obtains consent | 1 |
| Uses open questions initially and a logical, empathetic approach | 1 | |
| Checks patient comfort, uses appropriate language and signposting | 1 | |
| Subtotal | 3 | |
| 2. Presenting complaint and symptom analysis | Establishes onset, duration, progression and previous episodes | 1 |
| Elicits oedema: periorbital, ankles/legs, sacral, genital and abdominal swelling | 1 | |
| Asks about weight gain, tight clothes/shoes, or change in abdominal girth | 1 | |
| Asks about frothy/foamy urine | 1 | |
| Asks about urine volume, oliguria, dark urine and visible haematuria | 1 | |
| Screens for breathlessness, orthopnoea or cough, suggesting significant fluid overload or pleural effusion | 1 | |
| Subtotal | 6 | |
| 3. Associated urinary and systemic symptoms | Asks about dysuria, frequency, urgency, fever, loin pain or recurrent urinary infection | 1 |
| Asks about fatigue, reduced appetite, nausea or reduced exercise tolerance | 1 | |
| Asks about headache, visual disturbance or symptoms of hypertension | 1 | |
| Subtotal | 3 | |
| 4. Complications of nephrotic syndrome | Screens for DVT: unilateral painful leg swelling, redness or calf pain | 1 |
| Screens for pulmonary embolism: sudden dyspnoea, pleuritic chest pain, haemoptysis or syncope | 1 | |
| Screens for renal vein thrombosis: flank pain, haematuria or abrupt worsening of renal function/urine output | 1 | |
| Screens for infection: fever, rigors, cellulitis, cough, urinary symptoms and abdominal pain | 1 | |
| Subtotal | 4 | |
| 5. Causes: renal and systemic disease | Asks about diabetes and evidence of microvascular complications | 1 |
| Screens for SLE/connective-tissue disease: rash, photosensitivity, oral ulcers, joint symptoms, Raynaud phenomenon | 1 | |
| Screens for vasculitis: sinus symptoms, epistaxis, purpura, neuropathy, haemoptysis | 1 | |
| Asks about chronic infection risks: hepatitis B/C, HIV, tuberculosis, recent infection or relevant travel | 1 | |
| Screens for malignancy: weight loss, night sweats, persistent fever, lymphadenopathy or organ-specific symptoms | 1 | |
| Asks about chronic inflammatory disease or symptoms of amyloidosis/myeloma where appropriate | 1 | |
| Subtotal | 6 | |
| 6. Drug, past, family and social history | Asks about nephrotoxic or causative drugs, particularly NSAIDs, lithium, interferon, gold/penicillamine and recreational drugs | 1 |
| Establishes past renal disease, hypertension, diabetes, autoimmune disease, thrombosis and previous renal biopsy/admissions | 1 | |
| Asks about current medicines, including diuretics, ACE inhibitor/ARB, steroids, immunosuppression and anticoagulation; checks allergies | 1 | |
| Asks about family history of renal disease, dialysis/transplant, deafness or autoimmune disease | 1 | |
| Covers smoking, alcohol, intravenous drug use, occupation, functional impact and dietary salt intake | 1 | |
| Subtotal | 5 | |
| 7. Closure and clinical judgement | Summarises the key findings accurately and checks understanding | 1 |
| States concern for nephrotic syndrome and identifies proteinuria, hypoalbuminaemia, oedema and hyperlipidaemia as key features | 1 | |
| Mentions appropriate next steps: examination, urine dipstick/microscopy, urine protein:creatinine ratio, serum albumin, renal function and lipid profile | 1 | |
| Subtotal | 3 |
Global rating: 0-5 marks
Use this in addition to the 30-point checklist if your school uses global scoring.
| Rating | Descriptor |
|---|---|
| 0 | Unsafe, disorganised, misses major symptoms and complications |
| 1 | Very limited history, substantial prompting required |
| 2 | Basic history but misses key complications or important secondary causes |
| 3 | Safe, structured and satisfactory history |
| 4 | Thorough, focused and clinically insightful |
| 5 | Excellent rapport, prioritisation, synthesis and safety-netting |
Critical errors / automatic concerns
The examiner should consider a significant penalty or fail where the candidate:
- Does not ask about thromboembolic symptoms.
- Does not ask about infection or fever.
- Does not assess urine output or breathlessness in a markedly oedematous patient.
- Fails to recognise that haematuria, severe hypertension or systemic inflammatory symptoms may point toward a nephritic or mixed glomerular presentation.
- Advises treatment or reassurance without arranging appropriate renal assessment.
Examiner prompts for a standardised patient
Only give these if specifically asked:
- “My eyes are puffy in the morning and my ankles swell later in the day.”
- “My urine has looked very bubbly for about two weeks.”
- “I have gained 4 kg recently.”
- “I have no pain passing urine and no visible blood.”
- If asked about red flags: “I have no chest pain, shortness of breath, fever or painful swollen leg.”
- If asked about cause: adapt to the station, for example diabetes, lupus symptoms, NSAID use, hepatitis risk or recent infection.
The history should particularly identify oedema, foamy urine, reduced urine output and symptoms of fluid overload. Nephrotic syndrome is also associated with thromboembolism and increased infection susceptibility. Frameworks for Internal Medicine, “Nephrotic Syndrome” section. For paediatric stations, include relapse frequency, steroid response, family history and syndromic features, consistent with the KDIGO childhood nephrotic syndrome guideline.
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