Renal patient OSCE stations are an invaluable component of medical education, providing medical students with the opportunity to apply their knowledge and clinical skills in real-world scenarios involving patients with renal disorders. These stations simulate patient encounters and require students to perform tasks such as evaluating a patient history, interpreting laboratory results, and formulating a diagnosis.

As a medical student, engaging in renal patient OSCE stations is an excellent way to gain confidence and competence in managing renal conditions. It allows you to apply your theoretical knowledge to practical situations, and improve your overall clinical performance. These stations will not only deepen your understanding of renal disorders but also help you develop the essential analytical competencies needed to provide optimal care for patients with kidney diseases.

Table of Contents

18 year old male
21 year old female
42 year old man
46 year old woman

18 year old male

A 18 year old male presents with non specific malaise. He has no other Resp/GI/GU symptoms. His blood tests show the following

Na 124 (135-145)

K 8.2 (3.5-5.1)

U 43 (4-9)

Creatinine 645 (60-100)

Hb 8.2 (13-15)

O2 sats 94% air

What would be your immediate priority in this case?

Treat hyperkalaemia
Treat hyponatraemia
Treat dehydration
Treat Anaemia
Treat Low O2 sats

Treat hyperkalaemia

Hyperkalaemia is the most serious problem here and puts him at risk of cardiac arrhythmia’s and sudden death. He should therefore be on a cardiac monitor and receive

Calcium gluconate
Insulin&dextrose
Salbutamol Nebs
In terms of Airway Breathing Circulation that applies here but sats of 94 on air are less important than his hyperkalaemia cardiac arrest.

The sodium/Hb/ Sats are all significant but the most serious problem is his K+

What do you estimate his glomerular filtration rate is? (Normal range 80-120ml/min)

>150
80
60
40
<20

<20

He is in established renal failure. Its likely his GFR is minimal. To get a creatinine of 600 he is essentially in renal failure and his GFR will be <5ml/min.

He subsequently has haemopysis. His blood results include the following.

ANA negative

ANCA negative

CRP 92 (<5)

CXR: fleeting interstitial shadowing.

What is the most likely diagnosis?

Wegeners Granulomatosis
IgA nephropathy
Rapidly Progressive Glomerulonephritis (GN)
Post Streptococcal (lung infection) GN
Goodpasture’s syndrome

He is likely to have Goodpasture’s a disease affecting both the kidney and the lung presenting with haemopysis. Most cases of Wegeners granulomatosis are ANCA positive (cANCA). This swings the diagnosis towards Goodpasture’s syndrome (incidence approx 1 per million).

Which test is likely to achieve a definitive diagnosis?

Anti GBM antibody
Renal Biopsy
MRI /MRAngiogram kidneys
Lung biopsy
Anti DsDNA

Renal biopsy is the gold standard in ARF caused by inflammaroty disease like this. GMB antibody is helpful, but a biopsy would be needed in this case. DsDNA would not be positive without a positive ANA, and is a marker for lupus. This is covered separately in rheumatology/immunology!

You do get a 1/2 mark for the only time on this site for answering GBM antibody!

21 year old female

A 21 year old female presents with swollen legs.
She has no other systemic symptoms.
She works on a farm and walks over 10 miles every day during her job
She is a non smoker and drinks 42 units of alcohol a week.

Her blood tests including Full blood count and renal function are normal.
Observations show: BP 112/88 P 72 Sats 99% Air
Examination of the cardiovascular respiratory and gastrointestinal systems are normal

What is the next most important test to do?

24 hour protein
Renal Ultrasound
Urinalysis
Echocardiogram
Lung Function test

Urinalysis

Always opt for the simple answer in exams if it seems appropriate. The key question is:
1) Is she losing protein
2) Is there evidence of renal inflammation (nephritis).

For the purposes of this a urine dipstick is ideal.

It will tell you the degree of proteinuria (1+ to 4+)

If there is Blood and Protein (glomerulonephritis)

If there is glucose (diabetes)

If there is leukocytes (infection)

A 24 hour urine collection will tell you the degree of proteinuria and is the best method for assessing this. However it will not tell you if there is any evidence of “nephritis”.

Her Urinalysis shows the following

Urinalysis	Result
Blood	+++
Protein	++++
Leukocytes	–
KEtones	–
glucose	–

Which of the following 2 conditions are the most likely diagnoses?

Please select 2 (only 2) answers

IgA nephropathy
Minimal change GN
Mesangiocapilliary GN
Focal Proliferative GN
Membranous GN
Rapidly Progressive GN
Proliferative GN

IgA nephropathy
Membranous GN

The 3 commonest causes of GN are:
IgA Nephropathy , Minimal Change Nephropathy and Membranous Nephropathy

From these three ONE does not have an active urinary sediment.
That is minimal change psychopathy. Minimal change has the best prognosis!
However this patient has both blood and protein in her urine and therefore its not the most likely diagnosis.

Which investigation is likely to achieve a definitive diagnosis?

Renal Biopsy
MRI MR angiography Kidneys
Nephrectomy
HIV test
Autoimmune serology (ANA/ ANCA/ DsDNA/ Complement/ ASOT/ Anti GBM/ Ig’s etc)

Renal Biopsy

Clinical Pearls
Blood and Protein in on urinalysis: Think Glomerulonephritis
Next step: Urine for casts and MSU to exclude infection: then consider renal biopsy.

Diagnostic investigation of choice is a renal biopsy to define the cause of the glomerulonephritis histologically (i.e. minimal change GN/IgA nephropathy/ Focal segmental glomerulosclerosis/ mesangiocapilliary GN/ membranous GN / Proliferative GN)

42 year old man

A 42 year old man develops a sore throat. He does not consult his GP but takes some over the counter painkillers and an anti-inflammatory. 1 week later he has a non itchy rash starting on his feet then spreading to his trunk. The rash has the appearance of tiny teardrops

What is the most likely cause for the rash?

Pityriasis
Psoriasis
Other fungal infection
Adverse drug reaction
HIV infection
None of the listed answers

Psoriasis

This is most likely to be guttate psoriasis triggered by a streptococcal infection (the sore throat). This is a classical presentation. The patient may have no history of psoriasis.

Whilst an adverse drug reaction could present in an identical way, psoriasis is a “better” answer.

The patient is put on penicillin orally 250mg QDS for 1 week. He then starts passing small volumes of urine. His urine is described as “orangey brown” . He continues taking anti inflammatories.What is the most likely explaination for this?

Rheumatic fever
Secondary to penicillin
Interstitial nephritis Secondary to anti inflammatory medication
Post infective Glomerulonephritis
None of the listed answers

Post infective Glomerulonephritis

Penicillin is the standard treatment for guttate psorias.

This is classical of post streptococcal Glomerulonephritis! Orange brown urine/ low urine volumes: think acute renal failure.

IN this situation he has had a recent streptococcus infection causing guttate psoriasis. For an exam: post streptococcal: think post strep GN.

Urinalysis would probably show blood and protein. The management is generally supportive without the use of prednisolone or a renal biopsy, unless there is renal impairment etc.

Which blood test is most likely to support the likely diagnosis?

ASOT
ANA
DsDNA antibody
ESR
Immunoglobulins and electorophoresis
None of the listed answers

ASOT or anti streopolysin O titre is an antibody titre to streptococci. This would help to confirm that his sore throat was indeed caused by a strep infection and is not a “red herring”.

Other tests post strep infection are: anti DNAse B.

Remember: rheumatic also occurs post strep infection…

46 year old woman

A 46 year old woman presents to her GP with a note from an insurance medical that he has been found to have microscopic haematuria on urinalysis. There were no other abnormalities on the urinalysis.

They sent a “mid stream urine” to the lab but you do not have the result.
If she has dipstic positive haematuria what would you expect the MCS of the MSU to show?

It will show macroscopic blood
She is highly likely to have increased red cells in her urine
SHe may not have RBC’s in her urine as microscopy is less sensative than urinalysis
She will definately have RBC’s on urine microscopy
None of the listed answers are correct.

She is highly likely to have increased red cells in her urine

Microscopic haematuria is microscopic. This means you can’t see it! It has many causes which will be covered shortly. But!

A dipstic will pick up about 15-20,000 rbc/ml

Abnormal RBC’s in the urine are when RBC’s are above about 12500/ml

I.e. an MSU is more sensitive.

Dipstic testing does have a false positive rate so she will not “definitely” have blood in her urine.

So there is a small possibility of having microscopic haematuria not detectable by dipstic.

Remember she could be menstruating…

She has a repeat urinalysis at the surgery. Which other 2 investigations from the following list would you consider most relevant to the microscopic haematuria?

(PLEASE PICK 3 ANSWERS)

DEXA scan
Cholesterol
Chest Xray
Blood Pressure
Haemoglobin
U&E’s
CRP
Ultrasound renal tract
Renal Biopsy

Blood Pressure
Haemoglobin
CRP

The key questions are:

1) does she have impaired renal function: if so things need to be done urgently. Hypertension causing renal end organ damage is also common, treatable, and dangerous.

2) does she have normal renal function (i.e. does she have renal impariment/ Chronic Kidney Disease)

3) Are there any structural abnormalities of her renal system e.g. stone disease/ malignancy

You would NOT jump into a biopsy at this stage prior to arranging other investigations: The fact she has no protein in her urine goes against a glomerulonephritis.

To pick up a bladder malignancy an ultrasound is relatively insensitive. A cystoscopy is needed.

Her GP arranges all of the previously listed investigations including RF/ BP and USS renal tract which are all normal.

Her repeat urinalysis shows

Blood: 2+

Protein: Negative

Glucose: Negative

Leucocytes Negative

Ketones Negative

She feels well in herself. A detailed history from GI/ GU/ Resp/ Derm/ CNS and a detailed clinical examination is entirely normal. The patient feels its not significant. She has had a comprehensive set of blood tests specifically relating to the haematuria.

What would you recommend?

Do nothing
Repeat the urinalysis in 3 months along with the above tests: then plan investigations accordingly
Cystoscopy
None of the interventions listed here

Cystoscopy

You always need to consider the possibility of a renal or bladder tumour causing the symptoms. This may be asymptomatic. As such the first line tests would include a cystoscopy (bladder) and USS (bladder and kidneys). Other causes include:

Renal stones
Glomerulonephritis
Renal cyst
Infection
Drugs (e.g. gold, cyclophosphamide)
ADAPKD (autosomal dominant adult polycystic kidney disease)
Benign causes

Renal Patient OSCE Stations

18 year old male

21 year old female

42 year old man

46 year old woman