Renal History and Examination Flashcards
Common presenting complaints of renal disease.
Dyspnoea
Leg swelling
Nausea/Vomiting
Upper Airway Symptoms
Constitutional symptoms
Lower UT symptoms
Flank pain
History of dyspnoea.
Exercise tolerance
Triggers
Relieving factors
Diurnal variation
Orthopnoea
PND
Associated symptoms
History of leg swelling.
Site
Severity
Time of onset
Amount of fluid intake
History of Nausea/Vomiting.
Triggers
Relieving factors
Able to keep food down?
UT Frequency
Associated symptoms
Bowel frequency
History of ENT.
Nasal secretions
Sinusitis
Epistaxis
Haemoptysis
Sore throat
Visual disturbances
Hearing loss
History of constitutional symptoms.
Fever
Joint pains
Muscles aches
Weight changes
Lethargy
Night sweats
Pruritus
History of lower UT symptoms.
Dysuria
Frequency
Quantity of urine
Colour of urine
Frothiness
Haematuria
History of flank pain.
Duration
Radiation
Associated symptoms
Intensity
Aggravating/relieving factors
What should you ask patients on dialysis?
Mode of RRT (APD/CAPD/Assisted PD/UHD/HHD)
What access?
When last dialysed?
PMH of renal disease.
All is relevant but specifically…
Previous AKI
Requiring dialysis?
CKD stage if known
Cause of CKD/ESRF
CVS risk factors (DM/HTN/Hypercholesterolaemia)
Recurrent UTI?
Childhood infections
Surgery
Cancer
What else do you want to ask in a history of renal patient?
Drugs (especially NSAIDs)
Allergies
FH for renal, cardiac, diabetes and HTN.
Smoking
Occupation
Recent foreign travel
Daily activities
Alcohol
Performance status
General inspection on examination of a renal patient.
Any obvious discomfort or pain
Dyspnoea
Colour/cyanosis
Resp rate
Tremor
O2
Vomit bowl
Dialysis machines
IV access
General inspection of hands.
Clubbing
Peripheral cyanosis
Uraemic flap
Cogwheel rigidity
General inspection of arms.
Arteriovenous fistula (Size, colour, thrill)
General inspection of face.
Anaemia
Rashes (malar rash as in SLE)
Swelling (SVCO from haemodialysis access)
General inspection of neck..
JVP
Haemodialysis tunnelled/non-tunnelled lines
Previous access scars
What is this?
A tunnelled aka “Perm-cath” line.
What is this?
A non-tunnelled aka “Vas-Cath” line.
Explain assessment of fluid balance status in renal patient.
Check BP
Listen to heart sounds for murmurs or added sounds
Check pulse for character and rate.
Auscultation of the chest;
Fine crackles for pulmonary oedema.
Decreased air entry and dull percussion with reduced vocal resonance for pleural effusion.
Check urine output
Sacral oedema
Peripheral oedema
Lying and standing BP
What to look for on abdominal examination.
PD tube?
Palpable polycystic kidney?
Enlarged cystic liver?
Scars from previous surgery
Palpable transplanted kidney?
Indwelling catheter?
Signs of advanced renal disease.
Brown nails
Discoloration of the skin from uraemia (yellow-brown)
Under-nutrition leading to muscle wasting
“Uraemic frost” which is urea from sweat crystallises on the skin.
Hyper-reflexia
Pericardial rub
GI ulceration and bleeding.
Give broad classes of renal function tests.
Bloods
Urine
Imaging
What bloods are done to check renal function?
FBC for anaemia, infection and allergic reactions
Haematinics (Iron/Folate/B12 def.)
U&Es - Potassium, Urea, Creatinine and Bicarbonate
Bone profile - Calcium, Phosphate, PTH and ALP
CRP
HbA1c
What urine tests are done to assess renal function?
Urine dipstic to check for infection (leuko and nitrites) as well as check for glomerular pathology (blood and proteins)
Urine Protein:Creatinine ratio - quantifies the amount of protein in the urine
Urine Albumin:Creatinine ratio - quantifies the amount of albumin to monitor Diabetic nephropathy
Urine microscopy, culture and sensitivity.
What is looked for on imaging?
US KUB is done (Kidney, ureter bladder)
Peri-nephric collection
Size of kidneys
Corticomedullary differentiation
Hydronephrosis
Why are you doing venous blood gases in renal patients?
To assess Acid-Base balance
Metabolic acidosis
Metabolic alkalosis
Causes of metabolic alkalosis.
Diarrhoea
Vomiting
Primary hyperaldosteronism
Tubular transporter defects
Diuretics
Hypokalaemia
Acidosis due to increased acid (High anion gap)
Lactic acidosis
Ketoacidosis
Toxin (Ethylene glycol, methanol, isoniazid, aspirin, salicylate)
Renal failure
Acidosis due to reduced alkali (Normal anion gap)
GI losses of HCO3
Renal loss of HCOs (renal tubular acidosis, mineralcorticoid def. (Addison’s))
Toxins such as ammonium chloride and acetazolamide.
