Hyperkalemia osce history station check list
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Hyperkalemia OSCE History Station Checklist
Opening and safety
- Wash hands, introduce yourself, confirm patient identity
- Explain: “I’d like to ask some questions about your health and medicines to understand why your potassium may be high.”
- Obtain consent
- Check whether the patient is currently unwell:
- Palpitations, chest pain, dizziness or fainting
- Severe weakness, inability to move limbs, breathlessness
- If unstable symptoms are present, state you would call for urgent senior help, assess ABCDE, obtain urgent ECG and repeat potassium.
Hyperkalemia may cause life-threatening arrhythmias. An urgent ECG is recommended for hospitalised patients with potassium ≥6.0 mmol/L in the UK Kidney Association guideline.
1. Presenting complaint and history of current problem
- Why was the blood test taken? Was this an incidental finding or during an acute illness?
- When was high potassium first identified?
- Any previous episodes of hyperkalemia?
- Do they know the potassium value or whether it is increasing?
- Recent change in health, medications, diet, or dialysis?
Symptoms of hyperkalemia
Ask specifically about:
- Palpitations, irregular heartbeat
- Chest pain
- Light-headedness, presyncope or syncope
- Generalized weakness or heaviness in limbs
- Difficulty standing, walking, or climbing stairs
- Tingling or numbness, especially in hands/feet
- Progressive weakness or paralysis
- Breathlessness or respiratory muscle weakness
Note: patients may be asymptomatic. Severe hyperkalemia can produce weakness, flaccid paralysis, conduction disturbance and ventricular arrhythmias. National Kidney Foundation Primer on Kidney Diseases, “Clinical Manifestations of Hyperkalemia.”
2. Renal history
Ask about reduced potassium excretion.
- Known chronic kidney disease: stage, usual creatinine/eGFR, nephrologist follow-up
- Acute kidney injury or recent worsening renal function
- Reduced urine output, oliguria, anuria
- Change in urine appearance: blood, froth, dark urine
- Dysuria, frequency, fever, loin pain suggesting infection
- Symptoms of urinary obstruction:
- Hesitancy, poor stream, incomplete emptying
- Nocturia
- Suprapubic discomfort
- Renal replacement therapy:
- Hemodialysis or peritoneal dialysis?
- Last dialysis session and any missed/shortened sessions?
- Problems with access or dialysis?
- Interdialytic weight gain?
- Previous kidney transplant or renal surgery
3. Precipitants of acute kidney injury
Ask about recent fluid loss, infection, hypoperfusion, and nephrotoxins:
- Vomiting, diarrhea, poor oral intake
- Fever, sepsis, recent infection
- Recent surgery, bleeding, trauma, burns
- Heart failure symptoms: worsening breathlessness, orthopnea, ankle swelling
- Hypotension, dehydration, dizziness on standing
- Contrast scan or angiography
- Recent hospital admission
Diarrhea, vomiting, infection and medications may precipitate AKI and hyperkalemia in susceptible patients, particularly those with CKD. UKKA guidance
4. Drug history: high-yield section
Ask for prescribed, over-the-counter, herbal, and recently stopped/started medicines. Confirm dose changes and adherence.
Drugs that reduce aldosterone activity or potassium excretion
- ACE inhibitor: ramipril, lisinopril, enalapril
- ARB: losartan, candesartan
- ARNI: sacubitril/valsartan
- Mineralocorticoid receptor antagonist: spironolactone, eplerenone, finerenone
- Direct renin inhibitor: aliskiren
- NSAIDs: ibuprofen, naproxen, diclofenac
- Trimethoprim or co-trimoxazole
- Heparin
- Calcineurin inhibitors: tacrolimus, ciclosporin
- Beta-blockers, especially if other risk factors coexist
Potassium intake or potassium-retaining therapy
- Potassium supplements or potassium-containing effervescent tablets
- Potassium-containing salt substitutes, “low-sodium” salt
- Potassium-sparing diuretics: amiloride, triamterene
- Recent reduction/stopping of loop or thiazide diuretic
- Herbal remedies or supplements
ACE inhibitors, ARBs, renin inhibitors and mineralocorticoid receptor antagonists are common medication-associated causes, especially in combination and in people with diabetes or CKD. Brenner and Rector’s The Kidney, “Medication-Associated Hyperkalemia.”
5. Relevant medical history
- CKD or previous AKI
- Diabetes mellitus:
- Poor glycemic control?
- Polyuria, polydipsia, weight loss, vomiting or abdominal pain suggesting DKA?
- Heart failure, ischemic heart disease, hypertension
- Liver disease/cirrhosis
- Adrenal insufficiency/Addison disease:
- Weight loss, fatigue, postural dizziness
- Hyperpigmentation
- Salt craving, abdominal pain
- Known renal tubular acidosis or hypoaldosteronism
- Malignancy, especially recent chemotherapy or tumor lysis risk
- Sickle cell disease or hematological disease
- Major burns, crush injury, severe trauma
- Seizure, prolonged immobilization, intense exercise, muscle pain or dark urine suggesting rhabdomyolysis
- Hemolytic condition or recent blood transfusion
Acute hyperkalemia is commonly associated with renal failure, acidosis, and muscle injury such as rhabdomyolysis; chronic hyperkalemia is often medication-related or due to renal tubular disorders. Goldman-Cecil Medicine, “Hyperkalemic Disorders.”
6. Dietary history
- Recent increase in high-potassium foods:
- Bananas, oranges, tomatoes, potatoes, dried fruit
- Coconut water, fruit juices, smoothies
- Beans, lentils, nuts, chocolate
- Use of salt substitutes
- Nutritional supplements, protein drinks, electrolyte drinks
- Any renal diet advice and adherence?
Diet alone is usually not the sole cause in people with normal renal function, but it can contribute significantly when renal excretion is impaired.
7. Social history
- Alcohol use, especially if contributing to liver disease, poor intake, vomiting, or rhabdomyolysis
- Recreational drugs, including cocaine or injected drugs
- Smoking
- Functional status and ability to manage medications/dialysis
- Recent travel, illness, or access to healthcare
- Support at home
8. Systems review
- Cardiovascular: chest pain, palpitations, syncope, edema
- Respiratory: breathlessness, orthopnea
- Gastrointestinal: vomiting, diarrhea, abdominal pain
- Neurological: weakness, paresthesia, paralysis
- Urinary: urine output, infection, obstruction symptoms
- Constitutional: fever, weight loss, fatigue
9. Summarize and close
- Summarize the likely cause and key concerns
- Ask if the patient has questions
- Thank the patient
Example summary:
“Mr Smith has newly detected hyperkalemia in the context of stage 4 CKD, recent diarrhea and reduced oral intake, and use of ramipril and spironolactone. He reports weakness but no palpitations, chest pain or syncope. I am concerned about impaired renal potassium excretion, potentially worsened by acute kidney injury and medication effects.”
“Mr Smith has newly detected hyperkalemia in the context of stage 4 CKD, recent diarrhea and reduced oral intake, and use of ramipril and spironolactone. He reports weakness but no palpitations, chest pain or syncope. I am concerned about impaired renal potassium excretion, potentially worsened by acute kidney injury and medication effects.”
If asked, “What would you do next?”
- Assess ABCDE and observations, calculate early-warning score
- Cardiac monitoring and urgent 12-lead ECG
- Repeat potassium urgently using a non-hemolyzed sample to exclude pseudohyperkalemia
- Urea, creatinine/eGFR, bicarbonate, glucose, magnesium, calcium, venous blood gas
- Review fluid status, urine output, and drug chart
- Stop potassium supplements and potassium-raising drugs where clinically appropriate
- Escalate urgently to senior/renal team if severe hyperkalemia, ECG changes, AKI, or symptoms
Recent evidence syntheses exist for acute pharmacological management, including a 2025 systematic review, but for an OSCE history station your priority is recognizing instability, identifying renal disease/AKI, and conducting a meticulous medication review.
Create a hyperkalaemia OSCE marking scheme
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hyperkalemia AND management
Searching the Web
UK Kidney Association hyperkalaemia clinical assessment history examination ECG 2023 guideline
Hyperkalaemia OSCE Marking Scheme
Station: Focused history for a patient with hyperkalaemia
Suggested duration: 8 minutes
Total: 30 marks
Pass mark: Set locally, for example 18/30, with no critical safety concern.
Suggested duration: 8 minutes
Total: 30 marks
Pass mark: Set locally, for example 18/30, with no critical safety concern.
| Domain | Item assessed | Marks |
|---|---|---|
| 1. Introduction and communication | Introduces self, confirms patient identity, explains purpose, gains consent | 1 |
| Uses clear, empathetic language and signposts the consultation | 1 | |
| Subtotal | 2 | |
| 2. Immediate safety assessment | Asks about palpitations, chest pain, dizziness, syncope or collapse | 1 |
| Asks about severe weakness, paralysis, or breathlessness | 1 | |
| Recognises that these symptoms may indicate severe hyperkalaemia and states need for urgent escalation/ECG if present | 1 | |
| Subtotal | 3 | |
| 3. History of presenting problem | Establishes how/when hyperkalaemia was detected and whether it is new or recurrent | 1 |
| Establishes the potassium level, trend, and reason bloods were taken if known | 1 | |
| Asks about acute illness, recent deterioration, hospital admission, or recent medication changes | 1 | |
| Subtotal | 3 | |
| 4. Symptoms of hyperkalaemia | Asks about muscle weakness, fatigue, difficulty walking or climbing stairs | 1 |
| Asks about paraesthesia, numbness, or tingling | 1 | |
| Recognises that hyperkalaemia may be asymptomatic | 1 | |
| Subtotal | 3 | |
| 5. Renal and urinary history | Identifies CKD, previous AKI, renal transplant, or known renal disease | 1 |
| Asks about urine output, oliguria/anuria, dark urine, haematuria or frothy urine | 1 | |
| Screens for urinary obstruction: hesitancy, poor stream, incomplete emptying, suprapubic discomfort | 1 | |
| If on dialysis: asks modality, timing of last session, missed/shortened sessions, and access problems | 1 | |
| Subtotal | 4 | |
| 6. AKI and volume-status precipitants | Asks about vomiting, diarrhoea, poor intake, dehydration, or hypotension | 1 |
| Asks about infection/sepsis symptoms: fever, urinary or respiratory symptoms | 1 | |
| Screens for cardiac failure: worsening breathlessness, orthopnoea, peripheral oedema | 1 | |
| Asks about recent contrast exposure, surgery, trauma, bleeding, or nephrotoxins | 1 | |
| Subtotal | 4 | |
| 7. Drug history | Specifically asks about ACE inhibitors, ARBs, or sacubitril/valsartan | 1 |
| Specifically asks about spironolactone, eplerenone, finerenone, amiloride, or other potassium-sparing diuretics | 1 | |
| Specifically asks about NSAIDs | 1 | |
| Specifically asks about trimethoprim/co-trimoxazole | 1 | |
| Asks about potassium supplements, salt substitutes, over-the-counter and herbal drugs | 1 | |
| Subtotal | 5 | |
| 8. Relevant medical history and other causes | Identifies diabetes and considers DKA/poor glycaemic control | 1 |
| Asks about heart failure, hypertension and liver disease | 1 | |
| Considers adrenal insufficiency/Addison disease or type IV renal tubular acidosis | 1 | |
| Screens for cellular potassium release: crush injury, rhabdomyolysis, seizures, burns, haemolysis, tumour lysis/chemotherapy | 1 | |
| Subtotal | 4 | |
| 9. Diet and social history | Asks about high-potassium foods, juices/smoothies, electrolyte drinks and salt substitutes | 1 |
| Asks about alcohol/recreational drugs and ability to manage medicines/dialysis | 1 | |
| Subtotal | 2 | |
| 10. Closure and clinical reasoning | Summarises key findings accurately and identifies likely cause(s) | 1 |
| States appropriate immediate next steps: observations/ABCDE, ECG and cardiac monitoring, repeat non-haemolysed potassium sample, renal function and blood gas, medication review, senior/renal escalation as indicated | 1 | |
| Subtotal | 2 | |
| Total | 30 |
Global rating scale
| Rating | Descriptor |
|---|---|
| Clear fail | Disorganised, misses major causes and/or fails to assess immediate cardiac or neuromuscular danger. |
| Borderline | Obtains some relevant history but has important omissions, especially in renal or medication history. |
| Pass | Structured history, identifies key symptoms, renal risk factors, common medications, and acute precipitants. |
| Good | Thorough, focused and safe; integrates renal, medication, endocrine and cellular-release causes. |
| Excellent | Efficient, patient-centred and clinically reasoned; clearly prioritises instability and communicates a coherent plan. |
Critical safety concerns
Consider a critical error or major mark reduction if the candidate:
- Does not ask about cardiac symptoms or severe weakness/paralysis.
- Does not recognise hyperkalaemia as a potential arrhythmic emergency.
- Fails to propose urgent ECG/cardiac monitoring in a symptomatic patient or when potassium is markedly elevated.
- Does not review potassium-raising medications.
- Suggests giving potassium or continuing potassium supplements without justification.
A high-quality candidate should identify CKD/AKI and medication causes, especially RAAS inhibitors, mineralocorticoid receptor antagonists, NSAIDs and trimethoprim. The UK Kidney Association guideline recommends a comprehensive medical and drug history for all patients presenting with hyperkalaemia, plus urgent ECG assessment for hospitalised patients with potassium ≥6.0 mmol/L.
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