Renal & Endocrine assessment Flashcards
Renal Ass: Gen appearance x 6
General appearance
- pallor & tiredness
- breathlessness
- hydration status
- bruising
- itching, scratch marks
- evidence of oedema
Renal Ass: Sys Ass; hands x 2 & 1+3, arms x 4, & legs x 2
Hands:
- asterixis
- anaemia - palmar crease pallor
- nail features;
- Beau’s lines; grooves that run across the nail (infections, AMIs, trauma)
- splinter haemorrhages; under nails (trauma, bac* endoC, systemic Dx, diabetes, Raynaud, etc)
- pigmentation changes in nails; brown line/muehrcke’s line (multiple transverse white lines parallel to lunula of fingernail)
Arms:
- check pulse & BP
- arteriovenous fistulae
- carpel tunnel syndrome
- peripheral neuropathy
Legs:
- oedema
- peripheral neuropathy
Renal Ass: Sys Ass; face & neck x 6, eyes x 4
Face & Neck:
- jaundice
- pallor
- raised JVP
- carotid artery bruits
- gingival hyperplasia (overgrown gums)
- uraemia fetor (urine like odour on breath = uraemia)
Eyes:
- hypertensive retinopathy (seen on fundoscopy)
- diabetic retinopathy (fundoscopy)
- band keratopathy (corneal degradation - visible REFER on!!)
- anaemia/jaundice
Renal Ass: Sys Ass; lungs x 2, heart x 2, & abdo x 4
Lungs:
- hyperventilation
- crackles: pulmonary oedema
Heart:
- pericardial friction rub
- extra heart sounds
Abdo:
- inspect for scars
- palpate kidneys & bladder
- auscultate renal artery bruits
- renal exam - prostate enlargement GP only - REFER
Renal Sys Ass: inspect:ausc*:palpate:percuss
Inspect:
- flanks & abdo for discolouration, bruising or redness (Cullen or Grey-turner signs)
Auscultate (before touching!!:
- renal artery bruits
Palpate:
- identify any masses/tenderness around kidneys
- all 4 quadrants
- bladder distension - may be palpable
- assess for AAA & aorta position
Percuss:
- percuss full abdo, distended bladder will be dull
Specific tech: kidney strike
- Pt sitting/lateral
- non-dominant hand over kidney
- dominant hand strikes other w fist shaped
- costovertebral tenderness = kidney infection/inflammation
Renal Ass: common investigations x 2 & results x 3
POC testing:
- UA - simple dipstick
- blood tests- iStat
Bloods:
Serum creatinine:
- end product of muscle and protein metab*
- filtered & excreted by kidneys = excellent ind* of functioning
- levels vary; gender, age, muscle mass
- renal Dx results in increased levels (no common pathological cond)
- levels only increase once 50% of funct* is lost!!
Blood Urea Nitrogen (BUN):
- renal excretion of urea nitrogen (byprod* protein metab) by liver; kidneys then responsible for filtering & excreting
- most often interp together w serum C = overall kidney function
- BUN levels NOT specific to kidney Dx - only suggest dysfunction
Ratio BUN:serum C:
- determines whether dehydration or lack of renal perf* are causing elevated BUN
- dehydration/hypo-perf* = BUN rises more rapidly than serum C
- rising at same rate = ratio normal
- elevated serum C:BUN ratio suggests renal dysfunction of other cause
Endocrine Ass: History x 7, PM & FHx x 6, & Exam x 4
History:
- tiredness
- weakness
- lack of energy or drive
- changes in appetite/thirst
- changes in body shape/size
- problems w libido/menstrual issues
- changes in skin; dryness, oiliness, acne, thinning or thickening of hair
PMHx & FHx:
- prev surgeries or radiation involving endocrine glands
- menstrual Hx
- pregnancy
- growth & development in childhood
- FHx; auto-immune Dx, diabetes, cardiovascular Hx
- full drug Hx: will identify common iatrogenic endocrine probs
Exam:
- full general exam is essential!
- perform; weight, height BMI
- full vitals; HR, BP, temp, BGL, & ECG
- tailor rest of exam per suspected Dx
Endocrine Ass: hyperthyroidism Hx x 9, gen insp* x 7
History:
- Hx of thyroid problems
- FHx thyrotoxicosis
- ever taken amiodarone/thyroxine
- recent exposure to iodine
- palpitations?
- noticed any; insomnia, irritability, hyperactivity?
- any; weight loss, diarrhoea, increased stool freq, increased sweating or heat intolerance
- any muscle weakness?
- any eye problems; double vision, grittiness, redness, pain behind eyes
General inspection:
- weight loss, anxiety
- Hands - fine tremor, nails for onycholysis (nail separating from nailbed - often ring finger), clubbing, palmar erythema, warmth, sweatiness
- Arms - proximal myopathy
- Eyes - exopthalmos, thyroid stare, lid retraction, lid lag, ptosis
- Neck - thyroid enlargement, goitre
- Chest - gynaecomastia, systolic flow murmurs, CCF
- Legs - pretibial myxoedema, proximal myopathy, hyper-reflexia
Endocrine Ass: hypothyroidism; Hx x 8, & gen insp* x 6
History:
- cold intolerance
- muscle pain
- oedema
- constipation
- hoarseness of voice
- memory loss
- depression
- weight gain
General inspection:
- mental or physical sluggishness
- Hands - peripheral cyanosis, swelling of skin, cool & dry, hypercarotenaemia of palms, palmar crease pallor, sensory loss
- Face - skin (but not sclera) appears yellow, skin generally thickened, alopécie, vitiligo (Michael’s hands), periorbital oedema, loss or thinning of outer 3rd of eyebrow, xanthelasmata (cholesterol deposits; skin & eyes), thinning of scalp hair, swelling of tongue, coarse speech, bilateral nerve deafness
- Thyroid gland - goitre
- Chest - pericardial effusion, pleural effusion
- Legs - non-pitting oedema, peripheral neuropathy, altered Achilles reflex
Endocrine Ass: pan hypopituitarism; Hx x 6, & gen insp* x 8
Usually due to space occupying lesion
History:
- lethargy, weakness, fatigue, headaches, visual disturbances
- weight loss or gain, poor appetite
- constipation
- cold weather intolerance
- decreased libido/oligomenorrhoea
- reduced exercise tolerance
General inspection:
- short stature
- Skin - pallor of skin, fine-wrinkled skin, lack of body hair
- complete absence of secondary sexual characteristics
- Face - multiple skin wrinkles around eyes, forehead - transfrontal hypophysectomy scars (post removal of tumours)
- Eyes - visual field defects
- Chest - skin pallor, decreased nipple pigmentation
- Genitals - loss of pubic hair
- Legs - decreased ankle reflexes
Endocrine Ass: acromegaly; def & gen insp* x 11
Definition: excessive secretion of growth hormone; typically eosinophilic pituitary adenoma
General inspection:
- Hands - wide spade-like shape, increased sweating & warmth of palms, thickened skin, osteoarthritis, median nerve entrapment
- Arms - proximal myopathy, ulnar nerve thickening
- Axillae - skin tags & greasy skin
- Face - large supraorbital ridge, thickened lips, enlarged tongue, splayed teeth, malocclusion (bite alignment probs), prognathism (over/under bite; maxillary Vs mandibular)
- Eyes - visual field defects
- Neck - enlarged thyroid, hoarse voice
- Chest - coarse body hair, gynaecomastia, arrhythmias, cardiomegaly, CCF
- Back - kyphosis
- Abdo - hepatic, splenic & renal enlargement, testicular atrophy
- Lower limbs - osteoarthritis, pseudo gout, foot drop
- UA & BP; glucosuria and HTN
Endocrine Ass: Cushing’s syndrome; Hx x 7, & gen insp* x 7
Due to chronic excess of glucocorticoids
History:
- recent weight gain
- easy to bruise
- thinning of skin
- issues with acne
- agitation or insomnia
- muscle weakness
- diabetes diagnosis
General inspection:
- Hands - skinfold thickness should be >1.8mm on back of hand
- Standing - moonlike facies, central obesity, thin limbs, bruising, excessive pigmentation on the extensor surfaces
- Back - buffalo hump (fat deposition in intra-scapular area), bony tenderness of vertebral bodies
- Face & Neck - plethora, moon-shaped face, acne, hirsutism (facial hair growth in masculine pattern), telangiectasias (spider veins), supraclavicular fat pads, periorbital oedema
- Adbo - purple striae, adrenal masses, hepatomegaly
- Legs - oedema, bruising, poor wound healing
- UA & BP; glucosuria and HTN
Endocrine Ass: Addison’s Dx; def & gen insp* x 4
Definition: adrenocortical hypofunction w reduction in secreations of glucocorticoids & mineralocorticoids
General inspection:
- cachexia
- pigmentation of; palmar creases, elbows, gums, buccal mucosa, scars
- vitiligo
- BP; postural hypotension
Endocrine Ass: diabetes pathology x 3
HbA1c if not done recently
eGFR - assess nephropathy
UA - microalbuminaemia AND ACR = albumin:creatinine ratio
Endocrine Ass: Diabetes; presentations x 4
Acute presentations;
- 2-6 wks Hx of triad; polyuria, thirst, & weight loss
- ketonuria - often present in younger people & may progress to DKA
Sub-acute presentations:
- onset may be several months/years, esp older Pts
- standard triad present
- additional symptoms; lack of energy, visual blurring, pruritus vulvae or balanitis (itchy/swollen vulvae or head of penis)
Asymptomatic diabetes:
- glucosuria may be detected on routine exam
- more common in elderly due to glucose tolerance
- if found; req further investigation
Complications as presenting feature:
- staphylococcal skin infections
- retinopathy noted during visit to optician
- polyneuropathy causing tingling/numbness to feet
- erectile dysfunction
- arterial Dx
