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Clinical Exam Flashcards

1
Q

What are the signs of uraemia?

A

Uraemic tinge/fetor

Hiccups

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2
Q

What to look out for in a patient with kidney problem for general appearance?

A
  1. Uraemic signs - fetor/tinge/hiccups
  2. Acidosis - hyperventilation
  3. Hypocalcemia - tetany (Chvostek/Trosseau), twitching, myoclonic jerks
  4. Fluid balance - signs of dehydration & fluid overload (JVP, pulmonary oedema, ascites, peripheral oedema)
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3
Q

What are signs of hypocalcaemia?

A

Calcium > muscle not working > twitching, myoclonic jerks, tetany (Chvostek sign, Trousseau sign)

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4
Q

As part of fluid balance check, what should you measure during exam?

A

The patient’s weight

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5
Q

How to check for fluid balance?

A
  1. AKI due to dehydration: look for signs of dehydration - dry mucous membranes, reduced skin turgor, postural hypotension
  2. Fluid overload: JVP, signs of pulmonary oedema, ascites, peripheral oedema
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6
Q

How to check for urinary incontinence?

A

Look for stains on bed or patient’s clothing before balloting the kidneys.

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7
Q

What do Muehrcke’s (mew-rook’s) nails indicate?

A

Nephrotic syndrome/hypoalbuminemia

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8
Q

What do Mee’s lines indicate?

A

Renal failure

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9
Q

What to look for in the hands after general appearance?

A
  1. Nail changes: e.g. Muehrcke’s lines (hypoalbuminemia), Mee’s lines (renal failure), half-and-half nails (CKD), capillary refill*
  2. Anemia - palmar crease pallor
  3. Asterixis - severe CKD
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10
Q

How do half-and-half nails look like?

A

Distally its red, proximally its white colour.

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11
Q

What cause anaemia in CKD?

A
  1. Chronic disease

2. Lack of erythropoietin prdtion

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12
Q

What is the difference between an AV fistula and a shunt?

A

AV fistula is an anastomosis between an artery and a vein (direct connection)
Whereas a shunt is an extra graft extending between the artery and vein

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13
Q

Why are dialysis patients more prone to carpal tunnel syndrome?

A

Due to AV fistula and uraemic neuropathy.

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14
Q

What is a sign of carpal tunnel syndrome in dialysis patients? However do patients usually present with such specific numbness? If not then what do they present with.

A

Numbness over the median nerve distribution - radial side 3 fingers.
Often present with numbness of the whole hand.

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15
Q

After examining the hands and moving up to the arms in renal patients, what should you look for?

A

in the arms:

  1. scars - signifying previous thrombosed shunts
  2. AV fistulas/shunts
  3. check for signs of CTS i.e. numbness
  4. Scratch marks/excoriations
  5. Bruising
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16
Q

Scratch marks and excoriations on a renal patient indicates what?

A

Uremic pruritis > uremia > renal failure

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17
Q

Why do patients with kidney dysfunction have bruising on their arms?

A

Nitrogen retained in the body affects platelet aggregation resulting in bruising

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18
Q

What are the signs of vasculitis in renal patients?

A

Vasculitis may present as:

  1. sensory or motor neuropathy e.g. weakness, diminished sensation
  2. palpable purpura
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19
Q

What additional exams would you like to do to complete the renal exam?

A
  1. Neurological exam: specifically for peripheral neuropathy (sensation, reflexes)
    2.
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20
Q

What does rash indicate as the cause of renal disease?

A

SLE and systemic sclerosis

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21
Q

After examining the arm and moving to face, what signs to look out for in the renal patient?

A
  1. Rash: indicate SLE, systemic sclerosis
  2. Conjunctival pallor (indicative of anaemia)
  3. Eyes: band keratopathy (hyperparathyroidism), conjunctival pallor
  4. Mouth: gingival hyperplasia (calcineurin inhibitors), uremic fetor
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22
Q

What is band keratopathy and how is it related to renal disease?

A

Band keratopathy is a white smudge across the eyes (caused by calcium deposition). Get this because of secondary/tertiary hyperparathyroidism. Secondary hyperparathyroidism is caused by hypocalcemia of renal disease and low vitamin D levels.

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23
Q

Why do patients with CRF get hyperphosphatemia, hypocalcemia, and secondary hyperparathyroidism.

A

Because impaired kidneys cannot properly excrete phosphate, calcium phosphate forms binding to all the calcium and decreasing serum calcium. Parathyroid hormone secretion increases to correct the hypocalcemia.

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24
Q

What do normal kidneys do to Vitamin D? How does this relate to hyperparathyroidism and its sign on clinical examination?

A

Normal kidneys convert vitamin D into its active form. With impaired renal function, active vitamin D levels decrease, stimulating parathyroid secretion. Patient may have band keratopathy (calcium deposition in eyes) as a result of parathyroid hormone increasing calcium absorption.

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25
While inspecting the face, what do you want to look for in the mouth that can suggest that this is a post-transplant patient on a particular class of drugs?
Gingival hyperplasia is the result of taking calcineurin inhibitors (e.g. tacrolimus and cyclosporin), which are immunosuppressant drugs used for post-renal transplant.
26
What does a scar at the jugular vein suggest in a renal patient?
This patient has been on haemodialysis before as access was obtained to the jugular vein for 'VasCath'.
27
After examining the face of a renal patient, what signs are there to look for in the neck?
1. JVP - fluid status 2. Jugular vein access - haemodialysis 3. Scars - parathyroidectomy for tertiary hyperparathyroidism
28
What is tertiary hyperparathyroidism?
When secondary hyperparathyroidism is sustained for prolonged period till serum calcium levels become elevated.
29
Signs and Ix results of CKD-MBD are?
Bone pain, fractures | Vascular calcification on imaging, hypercalcemia
30
What are signs on examination that the patient has CKD rather than AKI?
1. Small kidneys instead of enlarged i.e. not ballotable with the exception of PCKD, diabetic nephropathy, myeloma and amyloidosis which are chronic kidney diseases but result in large kidneys) 2. Associated with renal osteodystrophy (CKD-MBD) 3. Peripheral neuropathy means chronic 4. Anaemia (of chronic disease)
31
After examining the neck and moving on to the chest exam of a renal patient, what should you look for? Wat are the 2 main organs associated with kidney disease?
Heart and Lungs: 1. Congestive cardiac failure, fluid overload, pulmonary oedema 2. Lung infection (CKD causes immunosuppression and so do post-transplant drugs)
32
Why does pericarditis occur in renal disease and what's its most dangerous complication?
Kidneys impaired > can't remove metabolic toxins > pericarditis and pericardial effusion > accumulates enough > becomes cardiac tamponade = fatal
33
How can you look for signs of pericarditis and its associated complication cardiac tamponade in a renal patient?
Pericarditis - pericardial friction rub | Cardiac tamponade - haemodynamic compromise, breathless, tachy, hypotension
34
How to assess haemodynamic stability? Why is it important in patients who present to ED with possible AKI?
1. Oliguria 2. Cap refill time 3. Vitals - temperature, HR, RR, BP The cause of AKI may be renal hypoperfusion which will manifest as signs of inadequate organ perfusion like oliguria and low cardiac output like cap refill time and tachycardia.
35
After inspecting the chest, move on to the abdomen of the renal patient, what should you look for?
1. Observe for Tenckhoff catheter suggestive of peritoneal dialysis 2. Scars: dialysis, transplant, nephrectomy 3. Palpate for distension, mass, tenderness and enlarged bladder 4. Ballot kidneys: feel for enlargement 5. Percuss for ascites (shifting dullness) and enlarged bladder
36
What are the different scars visible on the abdomen of a renal patient?
1. Peritoneal dialysis scars: usually at lower abdomen near the midline small enough for cathether to go through 2. Kidney transplant scars: right and left illiac fossae, moon-shaped down each side 3. Nephrectomy scars: posteriorly
37
After inspecting the abdomen, move on to the genitals, what are you looking for in a renal patient?
1. Genital oedema: can be caused by fluid overload in kidney disease
38
Why is it relevant to palpate for a triple AAA (abdominal aortic aneurysm) in renal patients?
Fibrosis around the aneurysm may cause ureteric obstruction and thus kidney disease.
39
Renal colic is a sign pointing towards what disease?
Kidney stones
40
When palpating a possible renal mass in the abdomen, what discriminating factors should you feel for and what disease do they suggest?
1. Enlarged mass close to the skin - transplanted kidneys 2. Mass enlarged in the forward direction - more likely enlarged kidneys VS 3. Mass enlarged at the back, posteriorly - more likely a perinephric abscess
41
What are the possible causes of abdominal distension in a renal patient?
1. Peritoneal dialysis fluid 2. Ascites from fluid overload / nephrotic syndrome 3, Polycystic kidneys
42
Post-renal transplant patient, when palpating you should ask the patient about _? Because?
Tenderness | Because it suggests transplant rejection
43
When palpating the abdomen for distension/masses, tenderness should be asked too particularly for _ and at _?
Tenderness shld be enquired for transplanted kidneys and at the loin.
44
When palpating the abdomen of a renal patient, shun bian palpate which other organ? Why?
Palpate the liver too for hepatomegaly as a result of hepatic cysts, as this can be associated with PCKD.
45
When balloting the kidneys, ask the patient to?
Breathe in and out and feel the kidneys move.
46
What are the 3 organs in the abdomen that can be enlarged in kidney disease?
Kidneys, duh - polycystic etc. Bladder - urinary retention Liver - hepatic cysts associated with PCKD
47
How to percuss for an enlarged bladder?
Percuss from top to down the midline noting when the percussion note changes from resonant to dull; this point marks the point of the bladder > is it high? > distended.
48
What are the causes of unilateral ballotable kidney?
1. Hydronephrosis (lvl of obstruction above bladder) 2. Polycystic kidney disease, renal cyst 3. Renal cell carcinoma 4. Renal abscess 5. Renal vein thrombosis 6. Hyperfunctioning of remaining kidney post-nephrectomy or congenital absence of one kidney
49
What are the causes of bilateral ballotable kidneys?
1. Polycystic kidney disease 2. Hydronephrosis (obstruction at or below level of bladder) 3. Renal cell carcinoma 4. DM nephropathy > compensatory renal hypertrophy 5. Infiltrative diseases e.g. amyloidosis, lymphoma
50
When palpating a renal mass, what features should be noted?
1. Size (spreaded fingers 14cm) 2. Consistency (hard, soft) 3. Surface (nodular, smooth) 4. Shape (kidney-shaped, irregular) 5. Tender? 6. Are you able to get ABOVE the mass?
51
Why is it important when palpating an abdominal, possibly renal, mass to try and get above it?
If cannot get above it, it is connected to some other structure e.g. hernia connected to colon If can get above it, it's a solid organ structure e.g. kidney
52
Once abdominal mass is felt, should ask patient to do what to feel if mass moves with _?
Respiration | Breathe in and out
53
How will a splenic mass feel different from a renal mass?
Splenic mass will have a distinct splenic notch, kidneys do not.
54
When mass is felt, if it is a renal mass, percussing over it will sound _? Because?
Resonant | Because of overlying bowel loops
55
Auscultate in a renal exam for?
Bowel sounds and renal bruits.
56
Determine the cause of a renal mass - what signs can you check?
1. Renal abscess: positive Murphy's sign, tenderness 2. PCKD: hepatosplenomegaly, signs of ESRF 3. RCC: cachexia 4. Diabetic nephropathy: diabetic dermopathy
57
Abdominal exam for renal mass - what are the general steps?
Inspection Palpation Percussion Auscultation
58
What are the signs of ESRF?
1. Uraemia - scratch marks, bruising, asterixis 2. Fluid overload - raised JVP*, unable to lie flat, ascites, bibasal inspiratory crepitations, peripheral oedema 3. Conjunctival pallor, sallow appearance 4. AVF/AVG
59
When examining a patient with ballotable kidney(s), what additional exam should you request for?
1. Vitals 2. Urinalysis: haematuria, glycosuria 3. Fundoscopy: diabetic or hypertensive retinopathy 4. APKD: CVS (MVP) + neurological exam (3rd nerve palsy, focal neuro deficit)
60
Cerebral aneurysms are associated with which kidney disease?
APKD
61
Differentials for bilaterally enlarged kidneys
1. APKD 2. Early diabetic nephropathy 3. Bilateral hydronephrosis (obstruction below bladder)
62
For completion's sake, what exams should be suggested after examining the kidneys?
1. Temperature chart for fever 2. Blood pressure chart for hypertension 3. Fundoscopy for hypertensive changes 4. Cardiovascular exam - MVP & AR (APKD)
63
What can cause a unilaterally enlarged kidney?
1. RCC 2. Hydronephrosis / pyonephrosis 3. Acute renal vein thrombosis 4. Hyperfunctioning of a single remaining kidney
64
What can cause bilaterally enlarged kidneys?
1. APKD 2. Hydronephrosis 3. Endocrine: Acromegaly, DM 4. Infiltrative: amyloidosis, lymphoma 5. Rare: VHL, tuberous sclerosis

Nephrology (9 decks)

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