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4: H/P of Nephrology (Medicine & Surgery)

Macleod's Clinical Examination 13th Ed. l Nicolas Talley's clinical examination l Churchill's Pocketbook of Differential Diagnosis
by

OSCE 433

on 20 November 2015

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Transcript of 4: H/P of Nephrology (Medicine & Surgery)





SYMPTOMS AND DEFINITIONS

SYMPTOMS:

Pain
Voiding symptoms
Abnormalities in urine volume and composition




3: Past history
Ask about any previous history of renal system disease.
Also ask about:
Hypertension (which may cause or result from renal
disease)
Diabetes mellitus (associated with diabetic
Nephropathy and renovascular disease)
Vascular disease at other sites (which makes
Renovascular disease more likely)
Past history of urinary tract stones or surgery
Recurrent infections (particularly urinary infections
Which may be associated with renal scarring, and upper respiratory infections which may be associated with glomerulonephritis and/or vasculitis)
Anaemia (which may be due to CKD).

Bilharziasis.
􏱌 Endoscopy, catheterization, or other invasive procedures. 􏱌 Trauma.
􏱌 Stones.
􏱌 TB symptoms or diagnosis.
􏱌 Sexual transmitted disease.
􏱌 Blood disorder.
􏱌 Renal transplant.
4: Medication history
Renal failure affects drug metabolism and pharmaco- kinetics, and drugs may adversely affect renal function.
Take a full drug history, paying particular attention to drugs which accumulate in renal failure, such as digoxin, lithium, aminoglycosides, opioids and water- soluble beta-blockers, e.g. atenolol.
Drugs which may affect renal function include angiotensin-converting enzyme inhibitors, angiotensin receptor antagonists and NSAIDs. These drugs do not impair the function of normal kidneys, but further reduce glomerular filtration when the kidneys are underperfused. Ask about over-the-counter NSAIDs, which can dramatically reduce renal function in the context of systemic infection or hypovolaemia. Aminoglycosides, amphotericin, lithium, ciclosporin, tacrolimus and, in overdose, paracetamol are toxic to normal kidneys. Some drugs cause kidney failure indirectly: for example, cocaine and ecstasy can cause rhabdomyolysis and myoglobinuria leading to acute renal failure.
Warfarin.
􏱌 Heparin.
􏱌 AIDS drugs. 􏱌 Rifampicin.
Find out about your patients’ ideas, concerns and expectation (ICE).
End-stage renal disease requiring dialysis and/or transplantation has major implications for lifestyle, employment and relationships. Similarly, incontinence has major implications for daily living.
Smoking is a risk factor for atheromatous renal vascular disease, for nephropathy in diabetic patients and for urothelial cancers. Excess alcohol consumption is associated with hypertensive renal damage and increased incidence of IgA nephropathy.
Take a dietary history in patients with renal stones: include intake of water, calcium, e.g. milk and dairy products, and oxalate, e.g. chocolate, rhubarb, spinach and soya.
Assess dietary protein intake in patients with CKD to make sure it is not excessive.
Ask about salt (sodium) intake in patients with hypertension and CKD.
Some renal conditions are found in particular ethnic groups: for example, Balkan nephropathy (interstitial nephritis and urinary tract tumours, probably caused by fungal toxins in grain), systemic lupus erythematosus (SLE) with nephritis in the Far East, and severe hypertension or diabetes mellitus with renal failure in patients of African origin.
Marital Status.
􏱌 Sexual contact.
􏱌 Travel.
􏱌 Number Of relatives (for kidney donation).
Living and working in hot conditions with more concentrated urine may predispose to renal stone formation. Exposure to organic solvents may cause glomerulonephritis. Aniline dye and rubber workers have an increased incidence of urothelial cancer. Long- term exposure to lead and cadmium may cause renal damage.
THE PHYSICAL EXAMINATION
Physical examination may be normal, even with significant kidney disease.

Ask the patient to lie flat with his head on a pillow with his arms by his side to relax the abdominal muscles. Expose the abdomen fully.
Inspection
Look for distension (from the enlarged kidneys of APKD, or occasionally in obstructive uropathy) and suprapubically from bladder distension.
Look in the loins for scars of renal tract surgery and in the iliac fossae for those of transplant surgery. You may see a catheter for peritoneal dialysis or small scars left by one in the midline and hypochondrium.


Palpation

Use the fingers of your right hand. Start in the right lower quadrant and palpate each area systematically.
To detect lesser degrees of kidney enlargement; place your left hand behind the patient’s back below the lower ribs and your right hand anteriorly over the upper quadrant just lateral to the rectus muscle.
Firmly, but gently, push your hands together as the patient breathes out. Ask the patient to breathe in deeply; feel for the lower pole of the kidney moving down between your hands. If this happens, gently push the kidney back and forwards between your two hands to demonstrate its mobility. This is ballotting, and confirms that this structure is the kidney.
If the kidney is palpable, assess its size, surface and consistency.
Ask the patient to sit up. Palpate the renal angle (between the spine and 12th rib posteriorly) firmly but gently. If this does not cause the patient discomfort, firmly (but with moderate force only) strike the renal angle once with the ulnar aspect of your closed fist after warning the patient what to expect and note any discomfort.
The kidneys are normally mobile and move as much as 3 cm inferiorly during inspiration. It is usually easier to feel the right kidney, as it is lower than the left. Minor degrees of kidney enlargement are difficult to assess. In very thin subjects the lower pole of a normal right kidney may be palpable, but even very large kidneys may be impossible to feel in obese subjects. A markedly enlarged liver is difficult to differentiate from the right kidney, especially if APKD is associated with cystic disease of the liver.
Enlargement of one kidney may result from compen- satory hypertrophy due to renal agenesis, hypoplasia or atrophy, or surgical removal of the other kidney. It may also be due to a renal tumour or hydronephrosis. Enlargement of both kidneys occurs in APKD, amy- loidosis and in acute glomerulonephritis. A transplanted kidney is palpable as a smooth mass in either iliac fossa with an overlying scar.
Polycystic kidneys have a distinctive irregular nodular surface and vary in size from moderately enlarged to filling the whole of one side of the abdomen. Kidneys containing tumours are usually firm and irregular, and sometimes tethered to surrounding structures. Enlarged obstructed or hypertrophic kidneys have a smooth surface. Tenderness over the kidneys is most often due to acute pyelonephritis or acute urinary obstruction. A distended bladder is a smooth firm mass arising from the pelvis, which disappears after urethral catheterisation.
■ Measure the pulse and blood pressure (do not use an arm with an AV fistula for blood pressure measurement.
■ Assess the JVP.
■ Palpate the apex beat .
■ Auscultate for:
■ a mid-systolic ‘flow’ murmur
■ third or fourth heart sounds
■ pericardial friction rub.
■ Look for pitting oedema in the ankles, the sacrum, and the back of the thighs in recumbent patients

Blood pressure is often elevated in renal disease, but may be low with a postural drop in patients with tubulo- interstitial disease who lose sodium and water inappro- priately because of impaired tubular reabsorption. Pulsus paradoxus may be present with pericar- dial tamponade due to uraemic pericarditis, along with a raised JVP and low blood pressure. In the nephrotic syndrome, although oedema is present, the JVP is not usually raised and there are no added heart sounds, as the intravascular volume is often normal or reduced.
The apex beat may be displaced in fluid overload and heart failure, or heaving in patients with left ventri- cular hypertrophy or secondary to hypertension. ‘Flow’ murmurs are common in patients with ‘renal’ anaemia, particularly if the cardiac output is increased because of an AV fistula. Added heart sounds occur in fluid over- load and/or heart failure, and a pericardial friction rub may be present due to uraemic pericarditis.
Peripheral oedema usually signifies fluid retention and expanded extracellular fluid volume; the exceptions are in hypoalbuminaemia (decreased capil- lary oncotic pressure) and the use of vasodilator drugs, e.g. calcium channel blockers (increased capillary hydro- static pressure).
Assess the patient’s general appearance and conscious level. Is he well or ill?
Look for fatigue, pallor, breathlessness, uraemic complexion, cushingoid appearance and hirsutism.
Measure the temperature.
Look at the eyes for the conjunctival pallor of anaemia and across the cornea – for band keratopathy, and at the edge of the cornea – limbic calcification.
Note any bruising or excoriation.
Examine the hands for nail changes.
Ask the patient to hold out the arms and fully extend the hands. Look for a coarse flapping tremor (asterixis) developing after a few seconds.
Smell the patient’s breath for uraemic fetor.
Assess hydration by checking skin turgor, eyeball tone, JVP and presence of oedema .
Drug treatment may cause abnormalities: for example, cushingoid features with steroid therapy, hirsutism and gum hypertrophy related to ciclosporin, and warts and skin cancers due to immunosuppression in patients with a renal transplant.
CKD may be associated with a lemon-yellow coloration of the skin, and bruising and excoriation secondary to pruritus. These patients are often anaemic and have a urine-like smell on the breath (uraemic fetor). Nail changes include a brownish discoloration of the distal nail bed, leukonychia (white nails), Muehrcke’s nails (leukonychia striata; band-like pale discolorations) and Beau’s lines (transverse grooves or furrows on the nail plate) in chronic hypoalbuminaemia.

In untreated end-stage renal disease there may be altered consciousness and asterixis.
Note any surgically created arteriovenous (AV) fistula at the wrist or elbow which allows vascular access for haemodialysis.
Percussion of the kidneys is unhelpful.
Percuss for the bladder over a resonant area in the upper
Abdomen in the midline and then down towards the symphysis pubis. A change to a dull percussion note indicates the upper border of the bladder.
Auscultate for bruits arising from the renal arteries. Listen carefully over both loins posteriorly and in the epigastrium, using the stethoscope diaphragm. Renal artery bruits cannot be distinguished from those in adjacent vessels, e.g. the mesenteric arteries, but any abdominal bruits, diminished or absent femoral artery pulses and bruits increase the probability of coexistent atheromatous renal artery disease.
Test for ascites, which may be found in nephrotic syndrome or in patients having peritoneal dialysis.
In men examine the external genitalia and perform a rectal examination to assess the prostate for benign or malignant change.
In women, perform a vaginal examination to exclude pelvic malignancy and to assess prolapse and the integrity of the pelvic floor.


Young female:
always suspect
UTI.
Old male:
always suspect benign prostatic hyperplasia
(BPH)
and look for obstructive symptoms.
1: Presenting complaint
In Patient's Own Words .
Write The Duration .
Sort Them In Chronological Manner .
Example : Loin pain / 1 weak .
C-

Analysis Of Complaint :
SOCRATS :)
1- Pain :
Site , Onset , Course , Duration , Character , Radiation , Aggravating & Relieving Factors , Severity , Associated Symptoms .
2- Polyuria :
Onset , Course , Duration , Frequency , Volume , Associated Symptoms .
3- Dysuria :
Onset , Course , Duration , Associated Symptoms .
4- Hesitancy / Urgency / Urine Retention :
Onset , Course , Duration , Associated Symptoms .
5- Incontinence :
Onset , Course , Duration , Related To Neurological Problem ? , Associated Symptoms .
6- Discharge :
Onset , Course , Duration , Color , Amount , Odour , Consistency , Itching .


2- History Of Presenting Illness ( HPI ) :
A-
The Patient Is Known Case Of ....... ( Chronic Disease ) .
B-
The Patient Was Well Till / On Usual Status Till ......... ( Hours - Days - Weeks - Months ) Back When
He/She Started To Has ................... ( Complaint ) .

1: Pain
EX: Renal colic:
• Site –
unilateral, in the renal angle and flank area
• Onset –
sudden
• Character –
usually very severe and sustained, may vary cyclically in intensity
• Radiation –
may radiate to the iliac fossa, the groin and the genitalia, especially the testes
• Associated features –
patient is usually restless and nauseated, and often vomits
• Timing –
may last for several hours or even days, until the obstructing body reaches the bladder,
when symptoms usually resolve
• Exacerbating/relieving factors
– analgesia with non-steroidal anti-inflammatory drugs (NSAIDs) or opioids is required
• Severity –
variable, but often very severe and incapacitating.
• Similar –
distinguish from intestinal or biliary colic, appendicitis, torsion of an ovarian cyst, ruptured ectopic pregnancy. Test the urine for blood; haematuria (visible or non-visible) is usual and, if absent, casts doubt on the diagnosis .
2: Voiding symptoms
Lower urinary tract symptoms may be:
1: During the storage phase of micturition
2: During the voiding phase of micturition
3: After micturition
4: With incontinence.
3: Abnormalities in urine volume and composition
1: Obstuctive:
(RIDIPH)
Retention
2: Irritative:
(UFNDI)
Urgency
B: Surgery
The history
Incomplete empty
Dribbling
Intermittent stream
Hesitancy
Frequency
Nocturia
Dysuria
Incontinence
History
Focused history of hematouria
General urology History
1 : Age
(some pathologies cluster in certain ages like BPH).
2: Place of residency
(some infectious agents like schstosomiasis found in rural areas).
3: Occupation
(It is imporat in bladder cancer due to exposure in the work place to carcinogens such as benzidine and Naphthylamine).
4: Smokig:
(Cigarette smoking is the strongest risk factor for transitional cell carcinoma).
Symptoms
A:
Systemic symptoms (fever,fatigue,malise,decrease appetite ...)
B:
Upper urinary symptoms (flank pain , mass)
C:
Lower urinary symptoms,LOTs
1: Obstructive (RIDIPH)
2: Irritative UFNDI)
Systemic review
1: When it begin
2: Is this the first time
3: Is it there every time you micturate
4: How many times per day
5: Painful or painless
(SOCRAT)
6: Gross or microscopic
7: Does it come in the beginning or at the end or throught the micturation
8: The colour (bright dark)
9: Clotted or fresh
10 : Shape of clot (elongated or rounded)
11: Do you have blood diseases
12: Any other eeding sites
13: Ask about risk factores (smoking-UTI-stones-trauma-bladder cancer-family history for urinary history-diet)
14: Past medical and surgical history
15: Medication history
16: Social history
17: Blood transfusion and allergic history
18 Systemic review
Special nots
1:
The timing f the urin is very important, in the beginning usually means urethral, while at the end usually means bladder and throughout means before like kidney
2:
The shape of clots give indication to its site elongated clots means upper urinary whie rounded means lower urinary.
• Measure the respiratory rate .
• Percuss the chest to detect pleural effusions. • Auscultate for bilateral basal lung crackles indicating fluid overload or heart failure.
Respiratory examination
Nervous system
The renal system
Medicine & Surgery
A: Medicine
The history
Voiding symptoms
URINARY INCONTINENCE
HISTORY:
Stress incontinence: History of multiple childbirth. Difficult delivery. Recent prostatectomy. History of loss of urine during coughing and straining.
Urge incontinence: The patient is unable to maintain urinary continence in the presence of frequent and persistent urges to void. Recent prostatectomy. Recurrent attacks of cystitis with dysuria and frequency. Past history of pelvic radiotherapy. History of TB. History of ureteric colic. Persistent suprapubic discomfort and haematuria associated with stone. Haematuria associated with tumour.
Overflow incontinence: History of spinal injury involving lumbar vertebra (sacral centre, cauda equina). History of pelvic surgery, e.g. abdominoperineal resection of rectum with damage to pelvic nerves. History of diabetes. History of prostatism with chronic retention with overflow. The patient may still be able to void reasonably normally but feels the bladder is not emptying and leakage continues.
Neurological: With upper motor neurone lesions there may be a history of spinal trauma affecting the cord above the sacral centre. History of head injury, CVA, multiple sclerosis or syringomyelia.
Anatomical: Ectopia vesicae will be obvious at birth with an abdominal wall defect and the ureter opening into exposed bladder mucosa on the lower abdominal wall. Duplex ureter may be associated with an ectopic opening of the ureter into the vagina. Vesicovaginal fistula may follow pelvic surgery or pelvic radiotherapy. It may occasionally be the presenting symptom of pelvic malignancy. Rarely ureterovaginal fistula may occur from an erosion of a ureteric calculus into a vaginal fornix. With duplex ureter, vesicovaginal fistula or ureterovaginal fistula, urine dribbles from the vagina continuously.
Other: Nocturnal enuresis occurs in up to 5% of 10-year-old children. Bed-wetting after puberty usually indicates the presence of an unstable bladder or other pathology.
A: Storage symptoms
Frequency –
micturating more often with no increase in the total urine output.
Urgency –
a sudden strong need to pass urine. Urgency is due to either overactivity in the detrusor muscle or abnormal stretch receptor activity from the bladder (sensory urgency). Incontinence may occur.
Nocturia –
waking more than twice at night to void.
Storage symptoms are usually associated with bladder, prostate or urethral problems, e.g.
lower urinary tract infection, tumour, urinary stones or obstruction from prostatic enlargement, or are a consequence of neuro- logical disease.
D: Incontinence
Involuntary release of urine may occur with a need to void (urge incontinence), result from an increase in intra-abdominal pressure (stress incontinence) or be a combination of both (mixed incontinence). Urge incontinence occurs when the detrusor is overactive. Stress incontinence occurs in women due to weakness of the pelvic floor, usually following childbirth. Continual incontinence implies a fistula between the bladder and either the urethra or the vagina due to complications of obstetric delivery, pelvic surgery, radio- therapy, tumour or trauma. Such fistulas are a major public health problem for women in many underdeveloped countries due to inadequate obstetric care and a high incidence of impacted labour. Enuresis is incontinence during sleep, and common in childhood. In adults it suggests bladder outlet obstruction or abnormalities of the wakening mechanism.
B: Voiding phase symptoms
Hesitancy is difficulty or delay in initiating urine flow. In men over 40 this is commonly due to bladder outlet obstruction by prostatic enlargement. In women these symptoms suggest urethral obstruction from stenosis or in association with genital prolapse
C: After micturition
Dribbling and incomplete emptying are caused by bladder neck obstruction, but if they are associated with storage symptoms, may indicate abnormal detrusor function.
Polyuria:
is an abnormally large volume of urine, and is most commonly due to excessive fluid intake. Rarely, this is a manifestation of psychiatric disease (psycho- genic polydipsia). Polyuria also occurs when the kidneys cannot concentrate urine. Causes may be extrarenal, e.g. diuretic drugs; hyperglycaemia with glycosuria causing an osmotic diuresis; lack of arginine vasopressin (AVP) from the pituitary gland in cranial diabetes insipidus, or failure of aldosterone secretion by the adrenal gland in Addison’s disease. Renal causes occur when the kidney tubules fail to reabsorb water appropriately in response to AVP. This occurs in nephrogenic diabetes insipidus, usually due to genetic mutation in the tubular AVP receptor.

Oliguria:
is a reduction in urine volume to <800 ml/day. It may be appropriate with a very low fluid intake, but may also indicate loss of kidney function. The minimum urine volume needed to excrete the daily solute load varies with diet, physical activity and metabolic rate, but is at least 400 ml/day. Acute renal failure is usually associated with oliguria, although 20% of patients have non-oliguric acute renal failure.

Anuria:
is the total absence of urine production. Exclude urinary tract obstruction, which may be lower (bladder neck or urethral obstruction causing acute urinary reten- tion) or upper, e.g. a ureteric stone in a patient with a single functioning kidney.

Pneumaturia:
is passing gas bubbles in the urine, is rare. It may be associated with faecuria, when faeces are voided. It suggests a fistula between the bladder and the colon, from a diverticular abscess, cancer or Crohn’s disease.
Proteinuria - Haematuria.
6: Social history
7: Occupational history
Personal data:
D:
Volume change: (Polyuria, Oligouria, Anuria).
E:
Urine discoloration (red, orange with drugs like Rifampicin or food like beetroot).
THE PHYSICAL EXAMINATION
Examination sequence
Cardiovascular examination
Past medical/ Surgical history.
Medication history (Rifampicin, anticoagulant).
Famiy history
Social history
Allergic history
Blood transfusion
Abnormal findings
Abdominal examination
Percussion
Auscultation
Abnormal findings
Abnormal findings
Abnormal findings
In CKD, respiratory compensation for the associated metabolic acidosis may lead to an increased respira- tory rate and deep sighing respirations. Pleural effusions may be present due to fluid overload or hypoalbuminaemia.
• Assess level of consciousness.
• Test sensation and the tendon reflexes.
• Examine the optic fundi
Abnormal findings
Altered consciousness or even coma is a feature of very advanced CKD, as is peripheral neuropathy. Retinal infarcts are seen in vasculitis or SLE, and retinopathy is an important finding in diabetes mel- litus and hypertension.
PUTTING IT ALL TOGETHER
In renal disease, blood-and urine tests and appropriate imaging are essential for definitive diagnosis. Although some kidney conditions are primary, e.g. many forms of glomerulonephritis, others are secondary to systemic conditions, e.g. diabetes, autoimmune disorders and systemic vasculitis, adverse drug reactions, malig- nancies such as lymphoma, and infections including septicaemia.
Most kidney disease is painless. However, pain may arise from the kidney capsule (loin pain), the ureter (ureteric colic) or the bladder/urethra.
Renal angle (between the 12th rib and the spine) or loin pain is due to stretching of the renal capsule or renal pelvis.
Causes include infection, inflammation or mechanical obstruction.
Constant loin pain, with systemic upset, fever, rigors and pain on voiding, suggests infection of the upper urinary tract and kidney (acute pyelonephritis).
Chronic dull, aching loin discomfort may occur with chronic renal infection and scarring from vesicoureteric reflux, adult polycystic kidney disease (APKD) or chronic urinary tract obstruction. Chronic obstruction may, however, be painfree. Dull loin pain also occurs in renal stone disease and some forms of glomerulonephritis, e.g. IgA nephropathy. It can be difficult to distinguish between renal pain and musculoskeletal conditions, e.g. osteoarthritis of the spine.
Ureteric colic (‘renal colic’) is caused by acute obstruction with distension of the renal pelvis and ureter by a stone, blood clot or, rarely, a necrotic renal papilla.
Patients with loin pain–haematuria syndrome complain of chronic unilateral or bilateral loin discomfort of varying severity. Characteristically they have non- visible haematuria and episodic visible haematuria.
Dysuria (voiding pain) is pain during or immediately after passing urine, often described as a ‘burning’ sensation felt at the urethral meatus or suprapubically.
Strangury describes slow and painful discharge of small volumes of urine related to involuntary bladder contractions.
Frequency is a desire to pass urine more often than usual.
The most common cause of the above symptoms is infection and/or inflammation of the bladder (cystitis). Prostatitis and urethritis produce similar symptoms. Prostatitis may cause perineal and rectal pain at the same time. Pain localised to the penis indicates local pathology, e.g. an inflammatory stricture, stone or, rarely, tumour.
Testicular and epididymal pain may be felt primarily in the groin and lower abdomen. Tenderness and swell- ing of the testis may be due to acute epididymo-orchitis; in pubertal boys and young men consider torsion of the testis, and be careful to distinguish these conditions from a strangulated inguinal hernia d
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