Clinical Skills- Kidney, and Abdominal Aorta Flashcards
Describe the location and surface anatomy of the kidney
On the Transpyloric plane (L1)- passes throught he tips of the 9th costal cartilage. i.e. where the lateral margins of each erector spinae muscle meets the costal margin
The kidney is in the posterior abdominal wall. The right kidney is slightly lower than the left (NOT IN ALL PTS)
On a supine pt, the transpyloric plane guides you to th ehilia of the kindeys
Describe the path of the urerters. And suggest how you’d locate it on a lumbosacral radiograp[h
From hilia of kidneys descends vertically downwards into iliac fossa.
In AP radiographs, it lies cose to the tips of transverse process of L2-L5 and sacroiliac joints.
CT scan below shows left ureter labelled 79
Draw out the surface marking of the kidneys and ureters either on a paper or on a partner. Give ALL the relevant details
Draw transpyloric plance from anterior abdominal wall to the posterior. Can also do this by marking L1 vertebrae on the back and drawing a line
Mark the hilia of the kidney which is about 4-5cm from posterior median line.
Path of ureter: draw a line from each hilia down to the posterior superior iliac spine- (the PSIS is a skin dimple on the posteiorr surface of the trunk). This line runs along the tips of the transverse process of L vertebraes
how do you locate the L1 vertebrae on the back?
Find T12 first- this located halfway between inferior angle of scapula and highest point of iliac crest at scapular line (medial border of scapula or lateral border of erector spinae).
Then go one vertebrae down
Describe the dimensions of the kidney and how they are located
9-12cm long and 5-7cm wide broad- depends on body size.
Superior poles of kidneys are covered by the 12th ribs.
Inferior poles are about 3-4 cm above the iliac crests- below the 12th ribs
How do you palpate the kidneys
Pt to be supine. You can only palpate lower poles.
Use biminual palpation to palpate kidneys through anterior abdominal wall:
Keep left hand underneath flank with fingers in renal/costocophrenic angle.
Use right hand to palpate kidney by pressing the upper quandrant down deeply below the costal margin.
Tell pt to take a deep breath to capture the kidney between two hands
How do you ballot the kidney (pushing the kidney back and forth)
Palpate it first.
Keep Left hand in renal angle. Right hand should be in deep palpation parallel to laterail border of abs
swiftly flex the index and middle fingers (at MCP) of the LEFT hand to push the lower pole of kidney to strike the right hand
draw out the surface landmark for the abdominal aorta?
A line drawn from xiphosternal joint (T8/9) through umbilicus to the supracristal plane (L4 where it bifurcates)
Describe the death rate of an AAA
kills around 100k a year.
pts are mostly aymptomatic and mortlaity from surgery is 5%
A ruptured AAA has a 90% mortality rate
How do you palpate the AA pulse.
What should should expect?
Use both hands with palms facing downwards and press deeply into anterior abdominal wall.
The orientation of the fingers should be pointing towards the epigastrium and the ulnar fingers should be parallel to the costal margins.
Easier to palpate in a thin person
Normally you’d feel a oulsation under your fingers. however suspect an AA if the pulsation was a pulsatile and expansile (pushes up agaisnt fingers) mass
How do you detect vascular bruits? and what do they suggest fro each site
Auculation in specific areas. You’d hear the specific sound for it.
The follwing areas of hearing them alongside bowel sound are:
- Over the renal arteries - 2cm superior and laterally (on both sides), bruits would suggest renal artery stenosis
- Over the liver - bruits would suggest a liver tumour
- Over the iliac arteries - bruits would suggest artery stenosis
- Over the aorta - bruits would suggest AAA
What is shfiting dullness used for? How do you perform it?
Used for detection of ascites. Acsites is accumulation of fluid in peritoneal cavity and can be cuased by liver cancers and heart failures.
Examination:
Percuss from midline to flank and note where it changes from resonant to dull (due to fluid). Mark the spot and turn the patient to the opposite side.
Wait for 10s and then percuss the dullness spot, if it changes to resonant then the fluid has moved. therefor there’s ascites
What is abdominal thrills used for? Descirbe how you do it
Another test for ascites especially if the abdomen is tensely distended.
Place palm of hand against flat side of pt abdomen. Then flick a finger of the other hand against opposite side of the abdomen.
if you feel a flcik then ask assitant to place edge of hand on midline of abdomen so that the flick is only transmitted via the ascites.
if you still feel it then ascites is present (abdominal thrills)
how do you fund the renal angle?
The angkle between osoterior median line and lower bod=rder of 12th rib
What are the 3 most common places for renal stones to sit
Pelvic uteric junction
Where ureter cross over the sacro-iliac joint
vesicoureteric joint
This is due to the natural narrowings of the ureters at that point.
How does renal stones present?
Renal colic- often unilateral. This is excruciating intermittent pain.
This originates at flank and radiate towards suprapubic area.
Ureteric colic- pain but raidates across the path of the ureters; i.e. into the region of genitalia and inner thigh.
Physical exmaination is unremarkable except for flank tenderness.
whatn are the hallmarks of renal calculi in a axial abdominal CT
Radio-opaque spot- stone
Enlargement of rebal pelvis- due to backflow of urine
What are the management options for renal calculi
Analgeisics and fluids first
Pt can pass the stone if it permits or undergo surgery like:
- Shockwave lithiotripsy
- Ureteroscopy and insertion of stent
what is AAA (specific value) and what don pts present with?
Abnormal dilation of the aorta to atleast 1.5 times it’s normal diameter
Pts are mostly asymptomatic but can present with:
- abdominal pain and back pain
- awareness of abdominal pulsation
- Observation of ripple in water when they are in a bath
What are the treatment options for AAA and explain all the relevant details including any associated risk
Open surgery or Endovascular stenting
Open-
- surgically opening the abdomen, clamping the aorta and grafting the aneurysm site
- There are higher short term risk of this procedure but it’s a definite solution.
Stenting:
- insert a graft by inserting a stent through femoral artery
- lower short term risk and hospital stay.
- However, a higher rate of further surgery required..
Long term risk for both is the same.
what factors affect the decision to operate on an AAA?
Size- 5.5cm or larger
Rate of growth- more than 4 cm and growing by at least 1cm per year.
what does this CT scan show
AAA
What planes are this US and what do they show
Top- transverse
Bottom- longitudinal
They show AAA
What do pts with a ruptured AAA present with?
what shouild you do with these pts?
Triad of back/flank pain, hypotension and a pulsatile expansile abdominal mass.
On exmaination: cold and sweaty, weak and thready pulse. Pulsantile-expansile mass could be tender and have a bruit.
SURGICAL EMERGENCY- control BLEED FIRST before repairing aneurysm.
