Renal Clinical Medicine (except MDM) Flashcards
The percussion note for the liver should be ______
The percussion note for the spleen should be ______
The percussion note for the liver should be dull
The percussion note for the spleen should be resonant/tympanic*
*Note: The area where you percuss for the spleen (lowest intercostal space in the left anterior axillary line) should be resonant/tympanic because it is a lung field. An enlarged spleen will be dull, as it displaces the air-filled lungs, stomach, and/or colon
The renal medulla should be _______echoic compared to the liver
The renal medulla should be hyperechoic compared to the liver
(hyperechoic = whiter)
Which sections of the kidney are dilated?
Collecting system
(The dark structures filled with fluid = the collecting system)
Diagnosis = hydronephrosis
Which special tests are used to assess for ascites?
Shifting dullness
Fluid wave
Where will edema go in a mobile patient?
What about a patient who is hospitalized/lying down?
Dependent areas
Mobile -> legs
Bedrest -> sacrum, back of legs
Describe the changes to the IVC with normal breathing
-
Inspiration
- -> Increased abdominal pressure
- -> Compression of the IVC
-
Expiration
- -> Decreased abdominal presusre
- -> Expansion of the IVC
What does focal bacterial pyelonephritis look like on ultrasound?
Increased blood flow to places that are infected, decreased blood flow to other places
The liver sapan should be no more than ____cm
The liver sapan should be no more than 12 cm
What lab findings are consistent with hypovolemia?
- Elevated BUN/Cr
- Hemoconcentration (rise in hematocrit or albumin)
- Elevated specific gravity of urine
- Hypernatremia
Which of the following is TRUE regarding the administration of desmopressin prior to renal biopsies, according to a study published by Manno et al.?
- There was no difference in the rates of hematomas detected after renal biopsy in the group of patients who received desmopressin compared to placebo
- Patients who received desmopressin prior to renal biopsy required fewer blood transfusions compared to the patients who received a placebo
- Patients who received desmopressin had fewer clinically significant bleeding complications compared to patients who received a placebo
- There was no statistically significant difference in the hemoglobin concentrations of the patients who received desmopressin compared to the patients who received a placebo
D. There was no statistically significant difference in the hemoglobin concentrations of the patients who received desmopressin compared to the patients who received a placebo
(But it is thought that it might be helpful in uremic patients)
Where should you percuss for the spleen?
Lowest intercostal space in the left anterior axillary line
Area should be resonant/tympanic (lung field)
An enlarged spleen will be dull, as it displaces the air-filled lungs, stomach, and/or colon
In an ultrasound, which tissues reflect the most sound waves?
Denser tissue - will appear white/hyperechoic
What will an “hyperechoic” tissue look like on ultrasound?
Why?
Hyperechoic = white
More dense tissue, reflects more sound waves
Ex: bone
The cortex of the right kidney should be _______echoic compared to the liver
The cortex of the right kidney should be hypoechoic compared to the liver
(hypoechoic = darker)
What are the contraindications for renal biopsy?
Biggest risk = bleeding
Contraindications if people have conditions that put them at an even higher risk of bleeding
- Uncontroleld HTN
- Bleeding diathesis, recent antiplatelet or anticoag therapy, severe thrombocytopenia
Also…
- Active renal or perirenal infection
- Atrophic kidneys
- Bilateral renal cysts
- Hydronephrosis
- Solitary kidney
What happens when there is too little volume in the extracellular space?
- Hypotension
- Hypoperfusion of vital organs
- Lactic acidosis
- Death :(
What skin findings may be indicative of volume depletion?
Axillary dryness
Dry tongue
Dry nasal and oral mucous membranes
Poor skin turgor
What conditions increase a patient’s bleeding risk during kidney biopsy?
Anemia
Thrombocytopenia
Hypertension
Obesity
What are the signs of volume depletion?
Signs = found on physical exam
- Weight drop
- Hypotension or orthostatic hypotension
- Tachycardia or orthostatic tachycardia
- Dry mucous membranes
- Dry axilla
- Poor skin turgor
- Poor capillary refill time
Which special test is used to assess for acute cholecystitis?
Murphy’s Sign
Place fingers under the right costal margin. Ask the patient to take a deep breath. A sharp increase in pain when inspiration stops indicates a positive Murphy’s sign for acute cholecystitis
What ultrasound setting do you use to look at blood flow through the kidney?
Doppler
A renal stone would generally appear
- Anechoic with posterior acoustic shadowing
- Hyperechoic with posterior acoustic enhancement
- Hypoechoic with no relative change in the appearance of structures deep to it
- Anechoic with posterior acoustic enhancement
- Hyperechoic with posterior acoustic shadowing
E. Hyperechoic with posterior acoustic shadowing
What physical exam maneuvers are used to detect ascites?
Shifting dullness
Fluid wave
What is the most common cause of ascites?
Cirrhosis of the liver
Fluid accumulates in the intraperitoneal space
How will using JVP >10 instead of JVP >9 affect specificity and sensitivity for detecting volume overload?
Using JVP >10 will increase specificity but decrease sensitivity
- More patients with a “positive finding” will actually have volume overload
- However, more patient swith a “negative finding” will have volume overload, and these patients will be missed
Select the correct statement:
- High frequency transducer provides deeper tissue penetration with better image resolution compared to a low frequency transducer
- High frequency transducer provides superficial tissue penetration with better image resolution compared to a low frequency transducer
- Low frequency transducer provides deeper tissue penetration with better image resolution compared to a high frequency transducer
- Low frequency transducer provides superficial tissue penetration with better image resolution compared to a high frequency transducer
B. High frequency transducer provides superficial tissue penetration with better image resolution compared to a low frequency transducer
What pathology does this ultrasound show?
Hydroureternephrosis
Collecting system + ureters both dilated
What are the complications to watch out for during and after kidney biopsy?
Bleeding
- Perinephric
- Into the retroperinoneum - can lose a ton of blood here
- Subcapsular
- Collecting system
Other
- Arteriovenous fistula
- Basically bypasses the kidney
- Pseudoaneurysm
- Page kidney
- Subcapsular hematoma that puts rpessure on the kidney and worsens renal function
Which of the following is NOT considered to increase a patient’s baseline risk of bleeding after renal biopsy according to a study published by Corapi et al.?
- Systolic blood pressure ≥130 mmHg
- Creatinine ≥2 mg/dL
- Hemoglobin concentration <12 g/dL
- Pediatric patient
D. Pediatric patient
What are the indications for renal biopsy?
When we need to make a diagnosis or provide information that guides treatment
Ultrasound can help rule things out or indicate that a biopsy is necessary
What is the correct order for the abdominal exam?
Inspection
Palpation
Percussion
Auscultation
- Inspection
-
Auscultation
Check for aortic and renal bruits, bowel sounds!! These things are affected by percussion and palpation, so do them first - Percussion
You need to know where to palpate the liver, good to get a sense if there are any other areas that might need extra palpation - Palpation
Light then deep
How do you evaluate a patient’s abdominojugular reflux (aka hepatojugular reflux)?
- Push on the liver for 15-30 seconds
- -> Increased venous return to the right heart
- If there is a sustained rise of >4 cm 10 seconds after releasing the liver, the test is positive
- High specificity
- Low sensitivity
- => If this happens, the patient is volume overloaded, but if it doesn’t happen the patient might still be volume overloaded
What happens when there is too much volume in the extracellular space?
- Peripheral edema
- Pulmonary edema
- Death :(
What defines orthostatic hypotension>
A decrease of 20 mmHg systolic or 10 mmHg diastolic within 3 minutes of sitting up from lying down or sitting
How should a patient be prepared for renal biopsy?
- Minimize bleeding complications
- Platelet count ≥50k
- Normal PT/PTT (INR ≤1.5)
- BP controlled
- Desmopressin
- May improve platelet function in uremic patients but statistical significant is not proven
Relative to the liver, the kidney cortex should generally appear
B. Hypoechoic
Medulla may appear hyperechoic
What conditions result in loss of hypotonic fluid?
Sweating
Excessive urination
How are renal arteriovenous fistulas and renal artery pseudoaneurysms treated?
Deploy coils to occlude damaged artery
This stops the bleeding and decreases risk of complications, but the patient loses function in the portion of the kidney that was supplied by that artery
What’s the difference between a symptom and a sign?
A symptom is subjective – elicited during the history, based on how the patient feels
A sign is objective – found during the physical exam
What pathology does this ultrasound show?
Hydronephrosis
What signs of volume depletion are more likely to appear in children?
- Tachypnea
- Poor capillary refill
- Normal <2 seconds
- Poor skin turgor
- Normal:
- Men <2 seconds
- Women <3 seconds
- Elderly <4 seconds
- Normal:
What are the signs of volume overload?
Sign = found on physical exam
- Jugular venous distention
- S3 appreciated
- Peripheral edema
- Ascites
What defines orthostatic tachycardia?
Pulse increase of 30 bpm or more when going from sitting -> standing
Very sensitive for volume depletion from blood loss, but a patient who is volume depleted for other reasons may not have orthostatic tachycardia
How can we distinguish between the aorta and the IVC on ultrasound?
- Location?
- Compressibility?
- Walls?
- Branches?
- Respiratory variation?
- IVC
- Location: Pt right
- Compressibility: Yes
- Walls: Thin
- Branches: None
- Respiratory variation: Compress on insp, expand on exp
- Aorta
- Location: Pt left
- Compressibility: No
- Walls: Thick
- Branches: Yes
- Respiratory variation: No
What will an “anechoic” tissue look like on ultrasound?
Why?
Anechoic = black
Less dense tissue reflects fewer sound waves
Ex: fluid
What conditions might cause volume overload?
- Heart failure
- Ascites (free fluid in the peritoneal cavity)
- Renal failure
Which sections of the kidney are dilated?
Collecting system and ureters are both dilated
(the dark structures filled with fluid
What is the purpose of light vs. deep palpation?
Light = detect tenderness and areas of muscular spasms and rigidity
Deep = determine organ size, presence of abdominal masses
Which of the following is not a sign of ascites?
- Protuberant abdomen
- Hepatomegaly
- Flank dullness
- Shifting dullness
- Fluid wave
b. Hepatomegaly
Which of the following is an EFFECT of volume depletion?
A. Vertigo
B. Melena
C. Oliguria
D. Polyuria
E. Tachycardia
C. Oliguria
Kidney retains more salt, and hence more water
What are the symptoms of volume overload?
Symptom = reported by the patient
- Weight gain
- Leg swelling
- Shortness of breath, dyspnea on exertion
- Orthopnea, paroxysmal nocturnal dyspnea
- Nocturea
What condiditons result in loss of isotonic fluid?
- Vomiting
- Diarrhea
- Blood loss (Laceration, GI bleed, bone fracture)
Fluid loss from ECF only
A renal core biopsy performed as part of the work-up of kidney disease should be obtained from the
- Hilum
- Medulla
- Corticomedullary junction
- Cortex
- Capsule
D. Cortex
Describe the technique for renal biopsy
- Ultrasound guided
- Avoid hilum and collecting system
- Target the lower pole
- Obtain renal cortex
- Part of the kidney that contains the glomeruli
What is Murphy’s sign?
What does it indicate?
A clinical test to assess cholecystitis
Place fingers under the right costal margin. Ask the patient to take a deep breath. An increase in tenderness when inspiration stops indicates a positive Murphy’s sign
=> acute cholecystitis
A structure containing simple fluid would appear
- Anechoic with posterior acoustic shadowing
- Hyperechoic with posterior acoustic enhancement
- Hypoechoic with no relative change in the appearance of structures deep to it
- Anechoic with posterior acoustic enhancement
- Hyperechoic with posterior acoustic shadowing
D. Anechoic with posterior acoustic enhancement
Rebound tenderness is a sign of ______
Peritoneal irritation
What is anasarca?
Edema in the whole body
Which special tests are used to asses for appendicitis?
- Obturator sign
- Rotate the leg internally at the hip
- Increased abdominal pain indicates appendicitis
- Psoas sign
- Place hand above the patient’s right knee, ask the patient to flex their right hip against resistance
- Increased abdominal pain indicates a positive sign
Which fo the following is not a sign of peritonitis?
- Voluntary guarding
- Involuntary guarding
- Rebound tenderness
- Percussion tenderness
a. Voluntary guarding
