RENAL EXAMINATION.pptx

GENERAL EXAMINATION
CLINICAL SYMPTOMS
On observation kindly check for symptoms like:
1. Decreased level of consciousness: seen in end-stage renal disease (ESRD).
2. Obvious scars: check previous abdominal surgery.
3. Pallor: Suggestive of underlying anaemia (e.g. erythropoietin deficiency).
4. Shortness of breath: may be due to pulmonary oedema secondary to advanced renal disease.
5. Oedema: typically presents as swelling of the limbs (e.g. pedal oedema) and abdomen (i.e. ascites). In the context of a renal system examination, possible causes could include nephrotic syndrome and end-stage renal disease (due to anuria).
6. Cachexia: muscle loss that is not entirely reversed with nutritional supplementation associated with end-stage renal failure due to protein-energy wasting (PEW).
7. Uraemic complexion: a yellow colour of the skin caused by uraemia in advanced chronic kidney disease.
8. Cushingoid appearance: facial puffiness and weight gain may be due to the use of high dose corticosteroids for renal transplant immunosuppression or glomerulonephritis.

1. RENAL EXAMINATION Presented by PANKAJ SINGH RANA

2. GENERAL EXAMINATION Decreased level of consciousness:  seen in end-stage renal disease (ESRD). Pallor : S uggestive of underlying anaemia (e.g. erythropoietin deficiency). Shortness of breath:  may be due to pulmonary oedema secondary to advanced renal disease. Oedema:  typically presents as swelling of the limbs (e.g. pedal oedema) and abdomen (i.e. ascites). In the context of a renal system examination, possible causes could include nephrotic syndrome and end-stage renal disease (due to anuria). Cachexia:  muscle loss that is not entirely reversed with nutritional supplementation associated with end-stage renal failure due to protein-energy wasting (PEW).

3. PHYSICAL EXAMINATION EYES Conjunctival pallor pallor  in conjunctiva  suggestive of  anemia . Anaemia is common in patients with  chronic renal failure due  to  erythropoietin   deficiency. Band keratopathy Band keratopathy  is a corneal disease caused by the  deposition of calcium  in the  central   cornea . In renal patient it is generally seen with chronic hypercalcaemia. Periorbital oedema Periorbital oedema  (swelling around the eyes) is a common clinical feature of  nephrotic   syndrome (defined by massive proteinuria responsible for hypoalbuminemia, with resulting hyperlipidemia , edema )

4. Band keratopathy Periorbital oedema

5. FACE Skin colour and skin lesions Inspect the patient’s  complexion  and note any  skin lesions : Yellowish complexion  (also known as a  uraemic   complexion ): associated with chronic renal failure. Uraemic frost:  crystallized urea deposits found on the skin of patients with chronic kidney disease who are chronically uraemic . Skin lesions:  seen in renal immunosuppression patients (e.g. squamous cell carcinoma, basal cell carcinoma, herpetic gingivostomatitis ).

6. Uraemic frost Yellowish complexion

7. Hearing aid Hearing loss seen in Alport   syndrome . Alport syndrome is a genetic disorder characterised by  glomerulonephritis ,  end-stage kidney disease  and  hearing loss .

8. MOUTH Gingival hypertrophy Gingival hypertrophy  is an  increase in the size of the gingiva  seen in gingival disease as well as certain medications such as  ciclosporin . Uraemic fetor Uraemic fetor (foul odour)  is a  urine-like (i.e. ammonia) smell of the breath  typically associated with  end-stage renal disease .

9. NECK Jugular venous pressure  (JVP) indicate an indirect measure of central venous pressure. internal jugular vein (IJV) reflects the right atrial pressure. Internal jugular vein situated between the earlobe and medial end of clavicle under medial aspect of sternocleidomastoid muscle. JVP interpretation An  elevated JVP  indicates  increased central venous pressure  secondary to  fluid   overload commonly seen in chronic kidney disease patient .

10. HANDS Pallor :  indicative of underlying anaemia (e.g. erythropoietin deficiency). Gouty tophi:  nodular masses of monosodium urate crystals deposited in the soft tissues of the body, common in advanced chronic kidney disease. Tremor:  seen in patient taking immunosuppressive medications (e.g. tacrolimus, ciclosporin ) in renal transplant patients.

11. Nail signs Koilonychia :  spoon-shaped nails, associated with iron deficiency anaemia (e.g. erythropoietin deficiency ). Leukonychia:  whitening of the nail bed, associated with hypoalbuminaemia (e.g. end-stage renal disease, nephrotic syndrome ).

12. Splinter haemorrhages:  a longitudinal, red-brown haemorrhage under a nail that looks like a wood splinter. Causes include local trauma, infective endocarditis (e.g. dialysis catheter-associated infections), sepsis, vasculitis and psoriatic nail disease . Beau’s lines:  one or more palpable transverse ridges in the nail plate extending across the nail associated, in some cases, with malnutrition and systemic disease.

13. Arms Arteriovenous fistula Assess for an  arteriovenous (AV)   fistula   Wrist  (radio-cephalic fistula) antecubital   fossa  ( brachio -cephalic or brachio-basilic fistula) synthetic PTFE graft  in the  antecubital   fossa  (now commonplace in haemodialysis).

14. Arteriovenous fistula Check functioning of fistula by palpating of the AV fistula for a  thrill  and  auscultate  for a  bruit

15. PERIPHERAL AND SACRAL OEDEMA Assess the patient’s  lower legs  and  sacrum  evidence of  pitting oedema  which may suggest  hypoalbuminaemia or fluid overload  (e.g. end-stage renal disease, nephrotic syndrome).

16. SYSTEMIC EXAMINATION

17. INSPECTION Scars :   Scars suggestive of renal pathology Rutherford-Morrison (‘hockey-stick’) scar:  suggestive of a previous renal transplant. Bilateral iliac fossae scars:  suggestive of a simultaneous pancreas-kidney transplant (for a patient with type 1 diabetes). Umbilical scar:  suggestive of previous peritoneal dialysis catheter insertion. Flank scar:  suggestive of a previous nephrectomy .

18. Renal transplant inspection Renal transplant  patients frequently appear in OSCEs, as they are stable and have specific clinical signs: Abdominal scar : right or left iliac fossa (Rutherford-Morrison scar) Palpable mass underneath scar : this is the transplanted kidney Signs of previous dialysis : AV fistula, peritoneal dialysis scar

19. PALPATION LIGHT PALPATION OF ABDOMEN Lightly palpate  each of the  nine abdominal regions , assessing for clinical signs suggestive of renal disease: Tenderness:   note the abdominal region(s) involved and the severity of the pain. Masses:  large or superficial masses (e.g. hernias, palpable renal transplant) may be noted on light palpation. Renal transplant Renal transplant  patients frequently appear in OSCEs, as they are stable and have specific clinical signs: Abdominal scar : right or left iliac fossa (Rutherford-Morrison scar) Palpable mass underneath scar : this is the transplanted kidney Signs of previous dialysis : AV fistula, peritoneal dialysis scar

20. DEEP PALPATION OF ABDOMEN Palpate each of the nine abdominal regions again, this time applying  greater pressure  to identify any  deeper masses . If any  masses  are identified during deep palpation, assess the following characteristics: Location:  renal masses are typically palpable in the flank. Size and shape:  assess the approximate size and shape of the mass. Consistency:  assess the consistency of the mass (e.g. enlarged polycystic kidneys may be irregular in their consistency). Mobility:  renal masses will be fixed and they’ll move superiorly and inferiorly with respiration.

21. Causes of enlarged kidneys Bilaterally enlarged, ballotable kidneys can occur in polycystic kidney disease or amyloidosis. A unilaterally enlarged, ballotable kidney can be caused by a renal tumour.

22. PERCUSSION Shifting dullness Percussion  can also be used to assess for the presence of  ascites  by identifying  shifting dullness : 1.  Percuss from the umbilical region to the patient’s left flank if dullness is noted it may be related to ascites. 2. Now shift patient to right side and wait for 30 seconds   3. R epeat percussion over the same area. 4.  If ascites is present, the area that was previously dull should now be resonant (i.e. the dullness has shifted).

23. AUSCULTATION Listen for bruits Auscultate  over the  renal arteries  to identify  vascular   bruits  suggestive of turbulent blood flow: Auscultate 1-2 cm superior to the umbilicus and slightly lateral to the midline on each side. A bruit in this location may be associated with renal artery stenosis (a possible cause of hypertension and renal failure).