Block - 9 - Patient-Doctor Handbook Renal & Urology

STAGE 2
PATIENT DOCTOR HANDBOOK
Renal & Urology
2014 UNIVERSITY OF MALAYA MEDICAL PROGRAMME

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Contents
INTRODUCTION (NOTES FOR TUTORS) ........................................................................................................ 4
Features of the program of the University of Malaya Medical Programme ........................................... 4
Patient Doctor Tutorials .......................................................................................................................... 4
Assessment .............................................................................................................................................. 5
Attendance ............................................................................................................................................ 8
Recommended reading ........................................................................................................................... 8
TIMETABLE GUIDE ....................................................................................................................................... 9
UROLOGY: ................................................................................................................................................ 9
Week 1: Male Sexual History & History taking and physical examination in prostate and urinary
tract disease; Prostate Disease............................................................................................................ 9
RENAL: ................................................................................................................................................... 10
Week 2: History and physical examination in acute kidney injury and Assessing hydration ; General
history in kidney disease ................................................................................................................... 10
Week 3: History and physical examination in Glomerular disease; History in acute kidney injury .. 10
Week 4: History and physical examination in chronic kidney disease .............................................. 11
Week 5: End-stage kidney disease: dialysis and transplantation; History of End-stage kidney
disease: dialysis and transplantation ................................................................................................ 11
COMMUNICATION SKILLS (HISTORY TAKING) ........................................................................................... 12
UROLOGY: .............................................................................................................................................. 12
Week 1: Male sexual history & History in prostate and urinary tract disease .................................... 12
RENAL: ................................................................................................................................................... 16
Week 2: General history in kidney disease ....................................................................................... 16
Week 3: History in acute kidney disease ........................................................................................... 18
Week 4: History in Chronic Kidney Disease ....................................................................................... 20
Week 5: History of End-stage kidney disease: dialysis and transplantation ..................................... 22
CLINICAL DIAGNOSTIC SKILLS (PHYSICAL EXAMINATION) ......................................................................... 24
UROLOGY: .............................................................................................................................................. 24
Week 1: History and physical examination in prostate and urinary tract disease ............................ 24
RENAL .................................................................................................................................................... 26
Week 2: History and physical examination in acute kidney injury and assessing hydration ............ 26
Week 3: History and physical examination in Glomerular disease ................................................... 27
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Week 4: History and physical examination in Chronic Kidney Disease ............................................. 28

Week 5: End-stage kidney disease: dialysis and transplantation ...................................................... 29
STRUCTURED CLINICAL EXERCISES ............................................................................................................ 30
Renal: Examination to determine Fluid Status....................................................................................... 30
Assessing Chronic Kidney Disease (Not on Dialysis): History .................................................................. 32

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INTRODUCTION (NOTES FOR TUTORS)

Features of the program of the University of Malaya Medical Programme
Problem-based learning with an emphasis on the development of clinical reasoning skills

Small group work
Early clinical contact to develop skills in communication and examination
Self-directed learning
Assessment with an emphasis on feedback
Integration of subjects and themes within and across years
Emphasis on evidence-based medical practice
The medical program is organised around four themes. These themes describe important professional
characteristics that students acquire during and after completion of the program. The four themes are:
Basic & Clinical Science

Community & Doctor
Patient & Doctor
Personal & Professional Development
Graduates of the University of Malaya Medical Programme will demonstrate:
Understanding of the therapeutic nature of the patient-doctor relationship and the impact on
that relationship of the individual characteristics of both patient and doctor.
The ability to listen and identify issues of concern to patients, families and carers and to
respond to those concerns, by whatever means necessary for effective communication.
The ability to elicit and interpret clinical symptoms and signs by interviewing and examining
patients systematically and with sensitivity, and to use this information to guide further
investigations.
The ability to perform important clinical procedures, particularly those vital in life-threatening
situations.
Ethical behaviour in meeting the needs of patients and families; concern for confidentiality and
respect for individual autonomy, enabling patients and their families to make informed
decisions in relation to their medical care.
Patient Doctor Tutorials

It is essential that the Objectives for this block are covered during the Patient Doctor tutorials at all
Clinical Schools as the assessment is based on these objectives. The Block Objectives can be found at
the beginning of each section, Communication Skills (History Taking), Clinical Diagnostic Skills
(Physical Examination) and Procedural Skills.
Suggested tutorial outlines have been provided for your use. It can be difficult to find suitable patients
for multiple groups of students for a specific topic each week and we therefore ask that you cover all of
the objectives for each tutorial during the block, but not necessarily in the order in which they are
listed.

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Working with patients in tutorials
Whenever possible, try to identify relevant patients for tutorials, but role-play can be used when no
patients are available. Particularly in Year 1, it is appropriate for students to examine 'normal' patients
i.e. those lacking clinical signs. You may elect to make one student responsible each week for
identifying one or more suitable patients for the following week's tutorial. Tutors who have patients
elsewhere (e.g. in general practice) may elect to hold some of their tutorials at that site. Please ensure
that your clinical school office is notified of any special arrangements.
Feedback
Skills are learned best when students have the opportunity to practise under supervision, with
feedback. Giving and accepting feedback on performance is a key skill. Feedback is most helpful
when it is concrete and specific, when it tackles one thing at a time and when it focuses on behaviours
that are remediable, with constructive advice about how the skill might be improved. This feedback is
based on your assessment of student progress in every tutorial. Acknowledging tasks done well
provides a less confronting opportunity to then discuss areas for improvement. The Clinical Exercises
are designed to provide a framework for constructive feedback.
It is also important to help your students to become skilled in accurate self-assessment and in peer
assessment. Feedback for learning is labelled as formative assessment. Its essential characteristic is
that it is intended purely for the benefit of the learner. Formative assessments give opportunities to
highlight areas for further practice or coaching.
At the end of each block students are asked to give feedback on their tutor. This feedback is collected
when students complete a Tutor Evaluation Form (provided by the clinical school) and is handed back
to the clinical school.
Assessment
All assessments of the Patient-Doctor Theme in Stage 1 are formative in nature. Formative
assessments are not used for decisions on student progress. They are designed to give students
feedback on performance and an opportunity to practise for the summative clinical assessment at the
end of Stage 2 (OSCE). The summative assessment is used to determine whether the student is
ready to progress to the next stage of the course.
Clinical Assessment Schedule:

Stage 1
Stage 2
Block 4 OSCE (Formative)

End of Block 10 OSCE (Summative)
Clinical schools make local arrangements for the assessments and advise tutors.

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Clinical Ward-Based Exercises (Required Formative Assessment)

Purpose (Information for students and tutors)
The Clinical Ward-Based Exercises are designed to give students in the early stages of their clinical
training guidelines for learning and practising basic clinical skills. These skills may include facets of
history taking, physical examination, interpretation of tests or performance of simple investigative
procedures. The syllabus for these will be delivered during the blocks
A selection of Clinical Exercises has been developed for each Block (except Block 1). They have been
selected by senior clinicians as being both key areas of expertise and appropriate to this stage of
student learning. It is expected that students would have basic competence in each of the assigned
exercises by the end of the Block. Assessment of one or two exercises per Block (see below for the
requirement for each Block) will be made by the tutor or a designated examiner and the results
recorded and retained by the clinical school. At the time of the assessment, feedback will be given to
the student about their performance.
Each Clinical Exercise has some attached explanatory notes. These are not intended as a detailed
syllabus but are there to bridge the gap between a students knowledge of underlying principles and
the application of this knowledge to a clinical problem.
Almost all the Clinical Exercises are designed so that they can be performed on normal subjects.
Where students or tutors have access to a patient with clinical signs then the exercise can be
extended to the examination of that patient but for the purposes of assessment a normal subject is
preferred. In general the Exercises should be used to help students develop familiarity with normal
findings so that they can detect abnormal signs later in their clinical career. They can mostly be
practised on friends or family members. Practising in pairs is very helpful.
Taking a good history or eliciting physical signs takes practice and students should have practised any
given exercise several times before it is assessed.
In general the assessment of the Clinical Exercises should take place in the second half of the term
and tutors may wish to set aside one tutorial for assessment. Alternatively a tutor may prefer to spread
the assessment exercises over the last few tutorials of the term. It is useful to watch other students
undergoing assessment as it is often easier to see flaws in others technique than to see flaws in you
own. The feedback from assessment should, however, only be provided by the tutor unless the
student being assessed specifically requests feedback from colleagues.
When an exercise has been completed the examiner should sign off the form and the student should
return this to the clinical school and retain a copy for their own records.
The results of the assessments of the Clinical Exercises will not contribute to the summative
assessment mark at the end of the year but their completion is required for progression.

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Requirements for each block:

Students are required to complete clinical ward-based exercises during Blocks 2 11. The number of
clinical exercises to be completed each Block is listed below:
Block
Number
2
3
4
5
6
7
8
9
10
11
Number of Clinical Exercises

Zero
Two
Two
Two
Two
Two
Two
One
One
Two
All clinical exercise MUST be conducted in the presence of a tutor.

Please contact Clinical School for further information.
OSCE: Observed Structured Clinical Examination

The OSCE consists of a variable number of stations requiring the student to demonstrate a particular
skill in a set time frame, in a structured exam situation (e.g. history taking or patient education with a
standardised patient, single system examination or a procedural skill this list is not exhaustive). Each
station has instructions about the task that the student is to perform, an examiner at each station and
usually a surrogate patient (occasionally the examiner may play this role). The student is asked to
perform the task and sometimes explain their findings while the examiner records the students
performance on a checklist. This takes 6 minutes. After this time in the formative OSCE the examiner
then provides feedback to the student for an additional 2 minutes. There is no feedback time in the
summative OSCE. Tutors might consider giving students a timed task to practise during a tutorial so
they become familiar with time constraints and students are encouraged to practise timed tasks
among their peers.
The Clinical Exercises provide a good preparation for the OSCE assessment and most OSCE stations
map to a clinical exercise.

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Attendance
Tutors are requested to keep a record of absences for each student (form provided in the back of each
Block Handbook). 100% attendance is requested, but naturally there will be some non-attendance
owing to illness etc. 90% attendance is considered the minimum requirement. Students cannot satisfy
the course requirements for Stages 1 & 2 unless attendance is satisfactory. Please advise the clinical
school office immediately if any of your students have any problems in relation to attendance at
tutorials.
Recommended reading
Lloyd M, Bor R. Communication Skills for Medicine London: Churchill Livingstone, 2nd Edition,
2004
th
Talley NJ, O'Connor S. Clinical Examination Churchill Livingstone, 6 Edition, 2009
Note this edition provides access to additional resources online.

Please check the web for any additional online resources.

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TIMETABLE GUIDE
The following is a suggested timetable for renal and lower urinary tract disease. F or detailed
discussions, see the subsequent pages.
NOTE:
It can be difficult to find suitable patients for multiple groups of students for a specific topic each week
and therefore you are asked to cover all of the objectives for each tutorial during the block, but not
necessarily in the order in which they are listed.
UROLOGY:
Week 1: Male Sexual History & History taking and physical examination in prostate and
urinary tract disease; Prostate Disease
a) Male Sexual Histroy

Communications:
Aim:
Introduce students to obtaining a relevant biological and psychosocial sexual history in males.
Objectives:
1. To learn to elicit a sexual history from a middle aged man that is relevant to a case scenario.
2. To learn to integrate biological and psychosocial aspects of a sexual history in a male patient.
b) History taking and physical examination in prostate and urinary tract disease
Find a patient with a lower urinary tract problem. Patients with prostatic disease or malignancy of the
lower urinary tract may often be found on the urology ward.
Communications skills (history taking): History taking and physical examination in prostate and
urinary tract disease
As always introduce yourself to the patient and tell them why you wish to talk to them.
Find out the symptoms they had before they came to hospital.
Do they have nocturia? How often did they have to pass urine at night?
Did passing urine hurt? Was their urine a normal colour?
How long have they had these symptoms and have they changed?
Clinical diagnostic skills (physical examination): Prostate disease

o Detection of bladder distension.
o Rectal examination of prostate (see Clinical Skills Centre sessions).
o Examination of the penis, testes and scrotum (see Talley and OConnor):
If they have an indwelling catheter your tutor will be able to describe the various catheters and
how they should be used.

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RENAL:
Week 2: History and physical examination in acute kidney injury and Assessing hydration ;
General history in kidney disease
Find a patient with Acute Kidney Injury. Such patients may be in intensive care or other acute
management areas. They may be in renal wards where they have been admitted for a renal biopsy or
assessment of their impaired kidney function.
Communications skills (history taking):
Seek permission to take a history from the patient and as always explain why you are there.
How or why did they seek help regarding their renal function? Was it found to be abnormal
when presenting with a seemingly unrelated problem?
What do they know about their kidney function?
Ask how they feel. Especially ask whether they are nauseous or anorexic.
Have they noticed any change in the frequency or regularity of passing urine? Did they have
nocturia that was not present before?
Did they pass blood or did their urine change colour?
Ask about their medications. Ask about occupation and exposure to toxins.
Refer to: The Renal System by Field, Pollock & Harris for further information.
Clinical diagnostic skills (physical examination):
How does the patient appear?
Assess their fluid status.
A full cardiovascular examination is usually appropriate.
This may be an opportunity to examine the urine.
Week 3: History and physical examination in Glomerular disease; History in acute kidney
injury
Find a patient with primary renal disease, ideally a patient who has a history of glomerulonephritis.
There will be many patients who have diabetes with secondary renal impairment. There will be others
with various forms of primary glomerulonephritis.
When and how did the patient find that they had kidney problems?
Try to find out how their underlying kidney disease affected them.
Ask about their appetite and their body weight.
Do they sleep well or poorly and are they able to carry out their work tasks or have they had to
change the work they did? What was the problem?
Ask about medicines? What do they take and how often?
Ask about complementary medicines.
While talking to the patient, make an assessment of their appearance.
Do they look sick or are they pale or abnormally pigmented? Ask yourself why this may be so.
Measure their blood pressure and make an assessment of the patients fluid status. Are they
oedematous?
Carry out a full cardiovascular examination.
A careful neurological examination is necessary.
This may be an opportunity to look at and test the urine. See if the patient can provide a urine
specimen.

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Week 4: History and physical examination in chronic kidney disease

Find a patient with Chronic Kidney Disease. Usually there will be a number of such patients in
hospital. Some will be receiving dialysis therapy and often will be willing to tell you the story of their
illness.
Ask how and when did they know that their kidneys were not working correctly? How did they
feel? Ask about their appetite, their exercise tolerance and their ability to carry out their normal
tasks.
Ask about their family & whether other members of the family have kidney problems.
While taking a history ask yourself how does the patient look? Do they look well or unwell; are
they pale or have abnormal pigmentation?
o Do they seem short of breath?
o Do they have obvious oedema?
Check their blood pressure and assess their fluid balance. Carry out a full cardiovascular
examination and a neurological examination. Look for evidence of chronic dialysis access (if
patient treated with dialysis arteriovenous fistula or catheter for haemodialysis or peritoneal
dialysis) and/or kidney transplant
If they are able to pass urine this may be an opportunity to test and look at the urine.
Week 5: End-stage kidney disease: dialysis and transplantation; History of End-stage kidney
disease: dialysis and transplantation
o Review the symptoms as discussed in communication tutorials.
o Causes and progression of Chronic Kidney Disease.
o Complications of Chronic Kidney Disease.
o Lifestyle and family implications of a chronic, uncertain disease course.
o Coping with dialysis.
o Physical examination for the complications of Chronic Kidney Disease e.g. sallow complexion,
anaemia, bruising, scratch marks etc.
o Dialysis and techniques of dialysis, include discussion and demonstration of arteriovenous (AV)
fistulae and central venous catheters used for haemodialysis and Tenckhoff catheters used for
peritoneal dialysis.

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COMMUNICATION SKILLS (HISTORY TAKING)

UROLOGY:
Week 1: Male sexual history & History in prostate and urinary tract disease
Male sexual history

Aim
o
Introduce students to obtaining a relevant biological and psychosocial sexual history in males.
Objectives
1. To learn to elicit a sexual history from a middle aged man that is relevant to a case scenario.
2. To learn to integrate biological and psychosocial aspects of a sexual history in a male patient.
Suggested Format
Group discussion and/or Role Play
Doctors often find the taking of a sexual history difficult for many different reasons, as a group discuss
some of the reasons why this might be so (eg embarrassment, lack of skills, being younger than the
patient, patient may not see relevance...)
Reflect on the communication skills and techniques that you have reviewed and practised in previous
tutorials. What skills may be useful in helping to overcome some of the difficulties described in the
above exercise?
e.g. Some skills and strategies
Identifying one's own discomfort with discussing sex and sexual activities.
Ensure a private setting.
Stress confidentiality.
Explain to patient why aspects of sexual history need to explored.
Seek patient's permission to obtain sexual history.
Reduce anxieties and discomfort wherever applicable.
Being non-judgmental with respect to lifestyle and sexual activities.
Others....?
Possible Role Play
Tutor and students should read through the following case history, and one student should interview
the tutor or another student as Peter. The student task is to obtain a sexual history.
Peter Lim is a 53 year old supervisor in a warehouse. Non-insulin dependent diabetes was diagnosed
five years ago. Peter is divorced and had not had sexual intercourse since that time. He recalls
having had a satisfying sex life with his former wife who left him three years ago because of
longstanding communication problems. His children are aged 28, 26 and 22.
Peter exercises infrequently and has difficulty complying with his prescribed diabetic diet. He weighs
112Kg and has not been able to lose weight, even though he sees a dietitian regularly. He drinks up to
four middies of beer at least three nights a week.
Peter has just commenced a sexual relationship with a 42 year old woman who works at the same
warehouse. Because one of his children is living with him, he finds that his sexual opportunities are
limited, but when his 22 year old son went away for the weekend recently, his girlfriend stayed with him.
They had gone out on Friday night after work and had a few drinks before and during dinner. When they
came home, Peter found it more difficult to get and sustain an erection than in the past and this is
worrying him a great deal. He was unable to engage in intercourse and the couple "just gave up". Peter

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reports that his libido is high and that he is very keen to solve this problem. On questioning he says that
he has not had a morning erection or masturbated for 'quite a long time'. He does not recall any
problems with ejaculation.
One of the students should now elicit a relevant history from the role play patient. Consider the
following elements of the sexual history
Urogenital history: changes in urinary flow and frequency, changes in erection and ejaculation
Sexual history: experience, responsiveness, libido, erectile or ejaculatory dysfunction,
masturbation, sexual penetration
Contraception: attitudes and practices
Medical history: STD, cardiovascular change, testicular problems, prostate problems,
medications taken
Psychiatric and psychological history: relationships, sexual abuse, body image problems
Drug and alcohol history: including nicotine, social and prescribed
Questions to ask include:
Is the patient sexually active?
How often does the patient engage in sexual activity?
Has there been any change over time?
Can the patient achieve a full or partial erection?
Is ejaculation normal?
Is the patient able to void normally?
Has there been any change over time?
Is the patient satisfied with his sexual functioning?
Does he have any specific concerns
After completion of the role play the patient should spend some time giving feedback to the student with
respect to their sensitivity, counselling skills and perceived relevance of the questions. Allow time for
general case discussion and history taking skills.
Additional notes on taking a sexual history can be found here:
http://www.gmp.usyd.edu.au/tutorials/z/5172/dtmmpdrres.doc

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History in prostate and urinary tract disease

Aim
Introduce students to the principles of history taking in patients with urinary tract disease.
Objectives
To learn the general principles of history taking in urology.
To learn to take a renal history, including systemic and structural problems.
To develop an understanding of the link between the symptoms and the pathophysiology of urinary
tract disease.
Suggested Activities
Discuss the symptoms that may be associated with urological disease.
Discuss the links between symptoms and pathophysiology in urinary tract disease.
Discuss:
o How might a patient describe these symptoms?
o How might you ask a patient about these symptoms?
Interview a patient with a history of urinary tract disease.
Find a patient with a lower urinary tract problem. Patients with prostatic disease or malignancy of the
lower urinary tract may often be found on the urology ward.
Do they have nocturia? How often did they have to pass urine at night?
Did passing urine hurt? Was their urine a normal colour?
How long have they had these symptoms and have they changed?
Background information for discussion
Symptoms of urinary tract disease can be grouped as follows:
Pain
o Renal pain due to stretching of the renal capsule is felt in the lumbar region of the back
o Renal colic due to spasm of the renal pelvis or ureter (such with a stone) begins in the loin and
radiates downwards and forwards to the iliac fossa, groin and genitalia. Note that longstanding
obstruction can be painless.
o Inflammation in the bladder gives a pain in the lower abdomen.
o Painful urination is called dysuria and may be due to cystitis, urethritis or trigonitis.
Altered patterns of urination
o Frequency
o Nocturia
o Urinary incontinence
Urgency and urge incontinence (intense urge to urinate followed by urine
leak e.g. with detrusor overactivity)
Stress incontinence (urine leak when coughing or straining)
Other forms of incontinence
o Enuresis and nocturnal enuresis
o Decrease in urinary flow, hesitancy, intermittency and dribbling. Hesitancy refers to difficulty in
initiation of micturition (or urination). Intermittency is a urinary flow which starts and stops.
o Double voiding (due to incomplete bladder emptying)
o Urinary retention (when acute, this is usually associated with pain; if chronic, it may be
symptomless).
Altered urinary appearance

o Red or pink urine may be due to blood (haematuria) or other pigments in the urine such as certain drugs, food dyes, beetroot or porphyrins (porphyria). Bleeding
anywhere along the lower urinary tract will give rise to red urine (with intact red cells
on microscopy). The lower the source of the blood and the faster the bleeding the
more bright red the colour will be.
o Haematuria secondary to glomerular disease may be distinguished from lower tract

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o
o
o
bleeding by the presence of predominantly dysmorphic red cells (appreciated best by

phase contrast microscopy), red cell casts or other abnormalities (granular or cellular
casts, proteinuria) in urine, as determined by microscopic examination.
Brown urine can be due to excessive loss of myoglobin or free haemoglobin in the
urine (no red cells seen on urine microscopy) or due to bleeding from the kidneys.
Foamy urine may indicate the presence of large amounts of protein.
Bacteria and white cells in infection give the urine a cloudy appearance, and the urine
may be malodorous.
Between Tutorials
Half the group should find a patient on the ward (Urology/Geriatrics/Gynecology) with urinary incontinence.
Take a detailed history and try to determine the type of incontinence and how you would further investigate it.
The other half of the group should find another patient on the ward with a urological cancer
(prostate/Kidney/Bladder/testicular). Take a detailed history and try to determine the stage of the cancer and
what treatment the patient has had up until now.
Discuss one patient from each group at the beginning of the following tutorial.
Resources
Smiths General Urology, Tanagho EJ, McAninch JW. McGraw Hill

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RENAL:
Week 2: General history in kidney disease
Aim
Introduce students to the principles of history taking in patients with renal disease.
Objectives
To learn the general principles of history taking in renal medicine.
To learn to take a renal history, including systemic and structural problems.
To develop an understanding of the link between the symptoms and the pathophysiology of renal disease.
Suggested Activities
Discuss the symptoms that may be associated with kidney disease.
Discuss the links between symptoms and pathophysiology in kidney disease.
Discuss:
o How might a patient describe these symptoms?
o How might you ask a patient about these symptoms?
o Interview a patient with a history of kidney disease.
o Find a patient with renal disease: this may be someone with acute kidney injury, a common
complication in hospital and therefore found on many different wards, or a patient with chronic kidney
disease, who are commonly found on the renal ward.
o Do they have nocturia? How often did they have to pass urine at night? Has their urine changed
appearance?
o Do they have any symptoms to suggest either fluid overload (shortness of breath, peripheral
oedema, increased weight) or dehydration (dizziness, palpitations, thirst)
o How long have they had these symptoms and have they changed?
o Do they have any risk factors for renal disease (e.g. diabetes, hypertension, recurrent UTI, family
history of renal disease, medications etc..)

The renal system is linked in its physiology and pathophysiology to many other systems in the body. Thus the
complications of renal disease and underlying causative conditions (such as diabetes) may overshadow
symptomatology arising from the kidneys and urinary tract per se. In kidney and urinary tract disease the
symptoms may be quite subtle until the problem is very advanced. Some patients will simply present with
abnormalities of routine urinalysis or serum biochemistry.
Symptoms of kidney and urinary tract disease can be grouped as follows:
Altered patterns of urination
Frequency
Nocturia
Urinary incontinence
Urgency and urge incontinence (intense urge to urinate followed by urine leak e.g. with detrusor
overactivity)
Stress incontinence (urine leak when coughing or straining)
Other forms of incontinence
Enuresis and nocturnal enuresis
Decrease in urinary flow, hesitancy, intermittency and dribbling. Hesitancy refers to difficulty in
initiation of micturition (or urination). Intermittency is a urinary flow which starts and stops.
Double voiding (due to incomplete bladder emptying)
Urinary retention (when acute, this is usually associated with pain; if chronic, it may be
symptomless).
Altered urinary appearance
Red or pink urine may be due to blood (haematuria) or other pigments in the urine - such as certain

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drugs, food dyes, beetroot or porphyrins (porphyria). Bleeding anywhere along the lower urinary tract
will give rise to red urine (with intact red cells on microscopy). The lower the source of the blood and
the faster the bleeding the more bright red the colour will be.
Haematuria secondary to glomerular disease may be distinguished from lower tract bleeding by the presence
of predominantly dysmorphic red cells (appreciated best by phase contrast microscopy), red cell casts or other
abnormalities (granular or cellular casts, proteinuria) in urine, as determined by microscopic examination.
Brown urine can be due to excessive loss of myoglobin or free haemoglobin in the urine (no red cells seen on
urine microscopy) or due to bleeding from the kidneys.
Foamy urine may indicate the presence of large amounts of protein.
Bacteria and white cells in infection give the urine a cloudy appearance, and the urine may be malodorous.
Altered urine volume
Oliguria is the name given to urine output of less than 400mls per day (patients might say they have passed
little urine that is dark in colour).
Anuria means no urine is passed (or less than 50mls per day).
Polyuria may be due to renal disease, ADH deficiency (diabetes insipidus) or osmotic diuresis, as in diabetes
mellitus. It should be distinguished from increased urinary frequency.
Oedema
This is an important presenting symptom in kidney disease. It is primarily due to an expansion of the interstitial
fluid due to an increase in total body sodium and water arising, for example, due to failure of the nephron to
adequately excrete sodium. In nephrotic syndrome, massive urinary protein loss may contribute due to loss of
interstitial (protein) oncotic pressure.
Breathlessness
Can be caused in renal disease by plasma volume expansion and pulmonary oedema, hypoproteinaemia due
to nephrotic syndrome causing pleural effusion, anaemia due mainly to failure of erythropoietin production, or
less commonly respiratory compensation (hyperventilation) of metabolic acidosis.
Uraemia
As renal failure progresses there are a range of symptoms related to retention of fluid and toxins, disruption of
hormone systems (including parathyroid hormone and vitamin D) and anaemia.
Nocturia (resulting from loss of ability to concentrate urine) is one of the earliest symptoms of chronic kidney
disease.
Impaired ability of kidneys to respond to changes in sodium and water balance.
Oliguria or anuria and oedema in late stages.
Anorexia, a metallic taste, vomiting, hiccups.
Fatigue, insomnia.
Itch, bruising.
Bone pain (osteodystrophy).
Shortness of breath.
Uraemic patients may also present with features of hypertension, congestive cardiac failure, ischaemic heart
disease, pericarditis, encephalopathy, sensorimotor peripheral neuropathy or gastrointestinal haemorrhage.
Many of these complications of kidney disease are late features seen in only a minority of patients.
Cardiovascular disease is very common in patients with chronic kidney disease.
Between Tutorials
Each student should interview a renal patient prior to the next tutorial, discussing with them the symptoms that
lead them to realise they have renal disease and any risk factors that may have contributed to their renal
problems. This could be discussed and patients compared for the first 10 or 15 minutes at the next tutorial.
Resources
Field M J, Pollock C A, Harris D C, The Renal System, Churchill Livingstone

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Week 3: History in acute kidney disease

Aim
Introduce students to the clinical features and pathophysiology of Acute Kidney Injury (AKI):
Objectives
To learn about the clinical syndrome of Acute Kidney Injury.
To learn a systematic approach to the assessment of patients with, or at risk of developing, Acute Kidney
Injury, including an approach to determining the cause or potential cause.
Suggested Activities/Format
The aetiology of Acute Kidney Injury can be considered in terms of prerenal, renal and postrenal causes
Discuss these causes - how you might recognise the patient at risk, and how you might ask about the
causes.
Discuss symptoms of Acute Kidney Injury and how to ask a patient about them.
Take a history from a patient with Acute Kidney Injury, eliciting details which may suggest the underlying
cause. Such patients may be in intensive care or other acute management areas. They may be in renal wards
where they have been admitted for a renal biopsy or assessment of their impaired kidney function.
Alternatively, take the history from a patient with any type of renal impairment, even chronic, if a patient with
Acute Kidney Injury is not available. In hospital, common places to find suitable patients include the renal ward
or clinics, the urology ward (e.g. acute urinary tract obstruction) or in the ICU.
o Seek permission to take a history from the patient and as always explain why you are there.
o How or why did they seek help regarding their renal function? Was it found to be abnormal when
presenting with a seemingly unrelated problem?
o What do they know about their kidney function?
o Ask how they feel. Especially ask whether they are nauseous or anorexic.
o Have they noticed any change in the frequency or regularity of passing urine? Did they have
nocturia that was not present before?
o Did they pass blood or did their urine change colour?
o Ask about their medications. Ask about occupation and exposure to toxins.
o Go over features of the history and test results to seek evidence for both the aetiology and the
severity of the kidney failure in this patient.
The aetiology of Acute Kidney Injury can be considered in terms of prerenal, renal and post-renal causes.
Prerenal causes often result in a reduction in kidney function that is initially reversible if the underlying
problem is treated early:
o Hypovolaemia e.g. extracellular fluid loss from haemorrhage, burns, pancreatitis, diarrhoea and
vomiting.
o Septic shock, cardiogenic shock or other conditions that cause renal hypoperfusion.
o Drugs causing decreased renal perfusion and/or oliguria: NSAIDS, ACE inhibitors,angiotensin
receptor blockers and diuretics.
Renal causes:
o 90% of patients with established Acute Kidney Injury have "acute tubular necrosis".
o Examples of common causes include:
Any prolonged and severe renal ischaemia or hypovolaemia (indicating the
progression from a potentially reversible pre-renal effect to the production of
established kidney damage).
Toxins such as drugs (aminoglycosides), radio contrast dyes or pigment (myoglobin
with rhabdomyolysis, free haemoglobin with acute haemolysis)
Pregnancy related conditions (including pre-eclampsia and eclampsia).
o Interstitial nephritis is much less common than acute tubular necrosis and is often caused by drugs
(NSAIDs, many antibiotics, proton-pump inhibitors).
o Acute severe glomerulonephritis is an uncommon cause of Acute Kidney Injury (crescentic or
rapidly progressive glomerulonephritis in adults, and post-streptococcal glomerulonephritis in
children).
o Vasculitis is an uncommon cause eg microscopic polyangiitis.
Postrenal causes:
o Obstruction to urethra, bladder outlet, or both ureters in abdomen or pelvis. Unilateral ureteric
obstruction may be difficult to recognize because the other side is unaffected.

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Obstruction may be:

intraluminal e.g. stone, pus, blood clot.
intramural e.g. stricture, tumour.
extramural or external e.g. tumour, retroperitoneal fibrosis.
o Intrarenal obstruction e.g. uric acid crystals or stones.
Often worsening kidney function is only detected by the routine or targeted measurement of serum creatinine.
However, possible symptoms include:
Falling urine output or oliguria in approximately half the patients (importantly, half have a normal urine
volume or polyuria).
Symptoms of dehydration or hypovolaemia in the case of a pre-renal problem.
Symptoms of fluid overload (e.g. oedema, CCF) if oliguria occurs.
Symptoms of uraemia (anorexia, nausea, vomiting, drowsiness, delirium).
Recently noted hypertension or worsening hypertension.
Rapid deep breathing causing apparent breathlessness (due to compensation for metabolic acidosis).
Brown urine due to pigment toxicity (rhabdomyolysis) or blood in urine (glomerulonephritis).
Haematuria and pain in the case of urinary tract obstruction.
A high index of suspicion about the development of Acute Kidney Injury is required in certain at risk situations,
such as after fluid loss or crush injury, exposure to nephrotoxins, etc. It is important to monitor the risk of
developing Acute Kidney Injury and to institute prompt treatment of the underlying problem where possible,
e.g. intravenous hydration of a dehydrated patient, cessation of nephrotoxic drugs.
It is important to identify the cause of Acute Kidney Injury so that appropriate treatment can be
instituted to prevent ongoing injury.
Simple investigations can often give important clues about the likely cause.
Urine microscopy, looking for an active sediment, which includes excessive red or white cells and granular
or cellular casts, and is often, in renal causes, accompanied by proteinuria. For example, pre-renal Acute
Kidney Injury is characterized by a benign urinary sediment, whereas granular and tubular cell casts may be
seen with acute tubular necrosis. With glomerulonephritis there may be microscopic haematuria, sterile pyuria
(excessive white cells with no organisms grown on culture) or cellular (red or white cells) casts, and often
moderate to heavy proteinuria. Interstitial nephritis will generally be accompanied by mild proteinuria,
microscopic haematuria and sterile pyuria. One third of patients with interstitial nephritis will have peripheral
eosinophilia and a rash.
Spot urinary Na+ will be < 20mmol/l if the cause is pre-renal, but > 40 mmol/l in established acute tubular
necrosis. (Spot refers to a single sample of urine, rather than a timed collection).
Culture of the urine to look for infection as a contributing factor.
Ultrasound of the kidneys and urinary tract to look for urinary tract obstruction (obstruction will cause
dilatation of the urinary tract) and to assess kidney size and echogenic texture (small echogenic kidneys
indicate chronic disease, whereas normal sized kidneys usually indicate an acute process. The exceptions to
this latter rule include polycystic disease and infiltrative diseases such as amyloid and myeloma where chronic
disease may be associated with large kidneys; In addition, diabetic kidney disease may also be associated
with large or normal-sized kidneys despite the presence of chronic disease). Ultrasound can also detect
masses within the kidney which may be malignant or benign, as well as cysts which are typically simple cysts
(benign) or less commonly complex (which may require further investigation with a CT scan)
Between Tutorials
Consider how you might explain to a patient with chronic kidney disease the risk factors associated with acute
kidney injury and how they should be avoided. Discuss this at the beginning of the next tutorial.
Resources

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Week 4: History in Chronic Kidney Disease

Aim
Introduce students to the clinical features and pathophysiology of Chronic Kidney Disease (CKD).
Objectives
To learn to elicit a history from patients with Chronic Kidney Disease
o to ascertain symptoms (if any present).
o to seek clues about the cause of the Chronic Kidney Disease..
o to assess the complications of Chronic Kidney Disease and its causes.
To learn the common causes of Chronic Kidney Disease
Understand which patients in general practice need screening for CKD and how this screening should occur.
To learn the pathophysiology underlying the symptoms of Chronic Kidney Disease.
To practice explaining the common symptoms of Chronic Kidney Disease to a patient in order to increase the
patients understanding.
To understand the principles of managing chronic kidney disease in order to slow its
progression.
Suggested activities/format
Discuss the above points with the student group.
Visit a patient with Chronic kidney disease in the renal ward.
Ask how and when did they know that their kidneys were not working correctly? How did they feel? Ask
about their appetite, their exercise tolerance and their ability to carry out their normal tasks. Ask about other
uraemic symptoms.
While taking a history ask yourself how does the patient look? Do they look well or unwell; are they pale or
have abnormal pigmentation?
Ask the patient what medications or lifestyle interventions have been introduced in order to treat their kidney
disease.
Ask if dialysis or transplantation has ever been discussed and if so are any preparations being made in this
regard
Present and then discuss the history findings.
Background Information for discussion
Presentations of Chronic Kidney Disease include:
Asymptomatic abnormalities on serum biochemistry (including elevated urea and creatinine).
Asymptomatic proteinuria/haematuria.
Hypertension.
Symptoms of the primary disease (causing kidney failure as a complication).
Symptomatic uraemia.
Chronic Kidney Disease is classified in stages, ranging from normal glomerular filtration rate with abnormal
urine (stage 1) to End Stage Kidney Disease (stage 5).
As kidney failure progresses there are a range of symptoms related to retention of fluid, salt and toxins;
disruption of hormone systems (including parathyroid hormone and vitamin D); and anaemia.
These start to appear during stage 3 disease, but are usually not marked until late stage 4 disease.
Nocturia (due to impaired urinary concentrating ability), polyuria, oedema and in late stages oliguria.
Impaired ability of kidneys to respond to excessive intake or loss of salt and water.
Anorexia, a metallic taste, vomiting, hiccups.
Fatigue, insomnia.
Itch (due to hyperphosphataemia and/or uraemia), bruising.
Bone pain, muscle aches, bone fractures.
Menstrual disturbances and impaired fertility.
Shortness of breath (due to fluid retention, anaemia, acidosis).
Bone symptoms, peripheral neuropathy and anaemia suggest strongly that the kidney failure is chronic rather
than acute.

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Common causes of Chronic kidney disease include:

Diabetes mellitus - the most common cause in Australia and worldwide.
Chronic glomerulonephritis, especially lgA disease and focal sclerosing glomerulonephritis.
Hypertension.
Polycystic kidney disease (inherited).
Vesico-ureteric reflux.
Analgesic nephropathy: this occurs due to regular intake of branded combinations of aspirin, phenacetin and
caffeine, such as Bex and Vincents powders. Although these are no longer available, occasional patients
with this condition are still seen.
Certain herbal medicines (e.g. containing aristolochic acid) can also cause Chronic Kidney Disease,
particularly in Asian countries.
Kidney stones are a common cause of Chronic Kidney Disease in some countries, particularly in the tropics.
Thus, important points to address in the history regarding the aetiology of the Chronic Kidney Disease include:
Is there a past history of diabetes?
Are there symptoms to suggest chronic glomerulonephritis, including ankle swelling, hypertension and
haematuria?
Is there a history of long-standing hypertension?
Repeated urinary tract infections (particularly as a child to suggest vesico-ureteric reflux)?
Kidney stones?
Family history of deafness (Alports syndrome) or kidney disease (polycystic kidney disease)?
Exposure to herbal medicines?
Combination analgesic intake?
The patients age and gender can be relevant (e.g. obstruction due to enlarged prostate in elderly males).
Complications of Chronic Kidney Disease
Abnormalities of calcium/phosphate metabolism and bone disease (renal osteodystrophy), which includes
secondary hyperparathyroidism and osteomalacia.
Resistant hypertension and hypertensive heart disease.
Chronic anaemia, mainly due to erythropoietin deficiency and not uncommonly relative iron deficiency.
Peripheral sensorimotor neuropathy.
Accelerated vascular disease (atherosclerosis), which is linked to abnormal calcium-phosphate metabolism,
as well as traditional vascular risk factors.
Skin pigmentation and pruritus.
Chronic Kidney Disease tends to progress, even when the initial cause has been treated. However, the
majority of patients die from cardiovascular disease before the kidney disease reaches end stage.
Between Tutorials
Two students should interview patients with chronic kidney disease prior to the next tutorial, and present their
interview at the beginning of the next tutorial. Think about how the patient was initially diagnosed and whether
current screening programs (see CKD management in general practice below) may have been able to
intervene earlier.
Resources
Chronic kidney disease: management in general practice
Clinical Exercise on Assessing Chronic Kidney Disease

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Week 5: History of End-stage kidney disease: dialysis and transplantation

Aim
Introduce students to the clinical features and pathophysiology of End Stage Kidney Disease (ESKD).
Objectives
To learn to elicit a history from patients with ESKD
o to ascertain symptoms (if any present).
o to seek clues about the cause of the ESKD.
o to assess the complications of ESKD and its causes.
To learn the common causes of ESKD
To learn the pathophysiology underlying the symptoms of ESKD.
To practice explaining the common symptoms of ESKD to a patient in order to increase the patients
understanding.
To understand the lifestyle and social challenges facing patients with End-Stage Kidney Disease (ESKD)
undergoing dialysis.
To understand the concepts behind who would be an appropriate transplant candidate.
Suggested activities/format
Discuss the above points with the student group.
Visit a patient with End Stage Kidney Disease in the renal ward or dialysis unit. Some will be receiving
dialysis therapy and often will be willing to tell you the story of their illness
Ask how and when did they know that their kidneys were not working correctly? How did they feel? Ask
about their appetite, their exercise tolerance and their ability to carry out their normal tasks.
Discuss features of the patient's history in the pre-dialysis period, and compare with the
patient's condition since dialysis was commenced.
What medications does the patient take and can they tell you what they are for?
Has transplantation been discussed with the patient? If the patient is on the transplant list, what
investigations did they need to have before they got on the list?
Present and then discuss the history findings.
Background Information for discussion
Common causes of End Stage Kidney Disease include:
Diabetes mellitus - the most common cause in Malaysia and worldwide.
Chronic glomerulonephritis, especially Systemic Lupus Erythematosus (SLE), lgA disease and focal
sclerosing glomerulonephritis.
Hypertension.
Polycystic kidney disease (inherited).
Vesico-ureteric reflux.
Analgesic nephropathy: this occurs due to regular intake of branded combinations of aspirin, phenacetin and
caffeine, such as Bex and Vincents powders. Although these are no longer available, occasional patients
with this condition are still seen.
Certain herbal medicines (e.g. containing aristolochic acid) can also cause Chronic Kidney Disease,
particularly in Asian countries.
Kidney stones are a common cause of Chronic Kidney Disease in some countries, particularly in the tropics.
Complications of ESKD
Abnormalities of calcium/phosphate metabolism and bone disease (renal osteodystrophy), which includes
secondary hyperparathyroidism and osteomalacia.
Resistant hypertension and hypertensive heart disease.
Chronic anaemia, mainly due to erythropoietin deficiency and not uncommonly relative iron deficiency.
Peripheral sensorimotor neuropathy.
Accelerated vascular disease (atherosclerosis), which is linked to abnormal calcium-phosphate metabolism,
as well as traditional vascular risk factors.
Skin pigmentation and pruritus.

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Management of End Stage Kidney Disease (ESKD) - haemodialysis, peritoneal dialysis, renal
transplantation.
The primary objective here is to appreciate the enormous impact that ESKD therapy and its complications
have on lifestyle, functional status and quality of life.
Useful questions to ask a patient about their dialysis:
What type of dialysis does the patient use? (haemodialysis, chronic ambulatory peritoneal dialysis,
automated peritoneal dialysis)
Where is haemodialysis performed? (home, satellite unit, hospital)
What kind of access does the patient use? (Peritoneal catheter, arteriovenous fistula, graft or central venous
catheter)
Does the patient still pass any urine? (an indicator of residual renal function)
What fluid restriction has been recommended?
How much weight does the patient gain between each haemodialysis session; how much fluid is lost each
day by peritoneal dialysis?
What dietary restrictions have been recommended?
What drugs have been prescribed (phosphate binders such as calcium containing drugs, erythropoietin, antihypertensives, active vitamin D (to suppress the parathyroid gland))
Is the patient on the renal transplant waiting list?
Between Tutorials
Think about some of the ways in which dialysis is unable to compensate for a patients renal disease, and how
these are managed. Discuss at the next tutorial.
Resources

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CLINICAL DIAGNOSTIC SKILLS (PHYSICAL EXAMINATION)

UROLOGY:
Week 1: History and physical examination in prostate and urinary tract disease
Aim
To introduce students to the symptoms and signs of prostate disease, and to the clinical features of disorders
of the male external genitalia.
Objectives
To understand the symptoms caused by prostatic enlargement and complications that may arise.
To learn to take a history relevant to prostatic enlargement.
To learn to recognize common disorders affecting the male genitals (hydrocele, testicular masses, and
varicocele).
Detection of bladder distension.
Rectal examination of prostate (see Procedural Skills sessions).
Examination of the penis, testes and scrotum (see Talley and OConnor):
o If they have an indwelling catheter your tutor will be able to describe the various catheters and how
they should be used.
Suggested Format/Activities
Group session to discuss the likely signs and symptoms of prostatic and genital disease.
Students should interview patients with prostatic disease or any genital disorder on urology ward.
Students should present their findings to the group and receive feedback.

History taking for prostatic problems
o Symptoms of progressive lower urinary tract obstruction:
Poor stream, hesitancy, intermittency, terminal dribbling, nocturia, frequency,
urgency, incontinence.
What effect does straining have on urinary flow? Straining reduces urinary flow in
prostatic hypertrophy, and increases urinary flow through a urethral stricture.
o Complications of prostatism (urinary retention, haematuria, infection, stones).
o Past history of urinary catheters, surgery to the urinary tract or neurological disorder.
o Drugs, especially those with anti-cholinergic effects that increase urinary retention (eg tricyclics) or
those with cholinergic effects that would increase incontinence.
History taking for diseases affecting the penis, testes and scrotum
o If a teenager or young adult presents with severe testicular pain for a few hours, think of torsion of
the testis. This requires urgent surgical exploration to save the testis.
o If an older man presents with testicular pain that has been present for a few days, epididymoorchitis is possible. Ask about:
Unprotected sex (suggesting sexual transmission of Chlamydia).
Dysuria, frequency of urination, urgency, suprapubic discomfort, fevers (suggesting
a retrograde spread of a bacterial infection from the urinary tract).
A recent history of mumps (for post-pubertal males).
o For painless testicular lumps in young men, ask about:
Previous surgery for undescended testis (a risk factor for testicular tumours) as well
as other symptoms of metastatic disease such as abdominal mass, supraclavicular
lymphadenopathy or gynaecomastia.
o For scrotal swellings, it is important to distinguish between swellings that are confined to the
scrotum, or hernias that descend down the inguinal canal. Ask:
Does the swelling go away overnight after bed-rest? Does the swelling get worse
with coughing or straining?

24 | P a g e
Physical examination
o Detection of bladder distension.
o Rectal examination of prostate (see Clinical Skills Centre sessions).
o Examination of the penis, testes and scrotum (see Talley and OConnor):
With regard to a scrotal swelling, can you get above it? If you can, then is the swelling solid or cystic (cysts
will trans-illuminate, a solid mass will not). If it is cystic, you will be able to feel the testis easily if it is a cyst of
the epididymis or a spermatocele, but you will not be able to feel the testis easily (except posteriorly) with a
hydrocele.
With regard to testicular swelling, is it painful or painless?
Between Tutorials
Find a patient on the ward with Lower Urinary Tract Symptoms. These patients may be found on the urology
ward, but are often also on the geriatrics ward. Take a history and try to work out what the cause of his
symptoms may be due to and how to investigate it.
Resources
Smiths General Urology, Tanagho EJ, McAninch JW. McGraw Hill

25 | P a g e
RENAL
Week 2: History and physical examination in acute kidney injury and assessing hydration
Aim
To introduce students to clinical examination for Acute Kidney Injury.
Objectives
To learn to take a renal history and perform a relevant examination in the setting of acute
deterioration of renal function.
To learn how to assess a patients hydration status
Group session: Discuss the components of an examination of the renal system.
Bedside teaching: Student(s) should examine one or more patients with Acute Kidney Injury, typically found
in the renal ward or Intensive Care Unit. They should then present their findings to the group and receive
feedback.
How does the patient appear?
Assess their fluid status.
A full cardiovascular examination is usually appropriate.
This may be an opportunity to examine the urine.
Students should consider the symptoms discussed in the generic skills tutorial this week, and elicit a
brief relevant history from the patient, covering the following:
Features suggestive of dehydration or over hydration.
Changes in urination pattern, eg nocturia, frequency, oliguria.
Factors precipitating an acute decline in kidney function.
Fever, loin pain, macroscopic haematuria, dysuria.
Features suggestive of acute uraemia.
Between Tutorials
Practice examining patients fluid status and discuss at the beginning of the next tutorial the signs that
were found and what they imply in regard to patients hydration status.
Resources
The Clinical Exercise Examination to determine Fluid Status

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Week 3: History and physical examination in Glomerular disease

Aim
Introduce students to the clinical features of glomerular disease.
Objectives
To recognise the range of presentations of glomerular disease (asymptomatic haematuria and proteinuria,
nephritic syndrome, nephrotic syndrome, renal impairment, hypertension).
To understand the origins of symptoms and signs in patients with glomerular disease.
Students should interview and examine patients being investigated or treated for suspected or known
glomerular disease, or patients with renal involvement in systemic disease (e.g. diabetes).
The results of urinalysis should be examined and their meaning discussed.
While talking to the patient, make an assessment of their appearance.
Do they look sick or are they pale or abnormally pigmented? Ask yourself why this may be so.
Measure their blood pressure and make an assessment of the patients fluid status. Are they oedematous?
Carry out a full cardiovascular examination.
A careful neurological examination is necessary.
This may be an opportunity to look at and test the urine. See if the patient can provide a urine specimen.
If the patient has had a renal biopsy discuss what pathology may have been expected to be found and then
compare to the actual pathology if possible
Consider how the results of a biopsy may have contributed to the patients management
Two important intrinsic renal clinical syndromes should be understood:
Nephritic syndrome, which is defined by the presence of haematuria/proteinuria, oliguria with reduced GFR,
and hypertension. It is due to glomerular infiltration with inflammatory cells (acute glomerulonephritis). The
inflammation results in haematuria and an active urinary sediment (granular or cellular casts), and then
oliguria and renal functional impairment. Hypertension results from salt and water retention and vasoactive
hormone release. Free haemoglobin in the urine may also result in a history of brown (tea/coke) coloured
urine.
Nephrotic syndrome is defined by the presence of heavy proteinuria, hypoalbuminaemia and oedema.
Characteristically it is accompanied by hypercholesterolaemia and risk of thrombosis and infection. Urinalysis
is a useful screening test and should show 3+ or 4+ proteinuria. Proteinuria should be confirmed by
measurement of urinary protein either by a timed collection (24 hour urine protein excretion) or by spot urine
protein concentration corrected for the urine creatinine concentration (urine protein to creatinine ratio). This is
rarely associated with Acute Kidney Injury but sometimes progresses to Chronic Kidney Disease (mainly in
adults with diabetes, membranous nephropathy and focal segmental glomerulosclerosis).
Between Tutorials
Draw up a table of clinical presentations with glomerular disease (isolated proteinuria, haematuria, nephrotic
syndrome, nephritic syndrome, rapidly progressive GN and CKD) and match these to pathological and
aetiological causes. Discuss at the next tutorial.
Resources

27 | P a g e
Week 4: History and physical examination in Chronic Kidney Disease

Aim
Introduce students to clinical examination for Chronic Kidney Disease.
Objectives
To develop an understanding of the clinical features of Chronic Kidney Disease, including the symptoms and
signs of its systemic complications.
Students should interview and examine patients with Chronic Kidney Disease, typically found in the renal
ward.
Students should present their findings to the group and receive feedback. While taking a history ask
yourself how does the patient look? Do they look well or unwell; are they pale or have abnormal
pigmentation?
Check their blood pressure and assess their fluid balance. Carry out a full cardiovascular examination and a
neurological examination. Look for evidence of chronic dialysis access (if patient treated with dialysis
arteriovenous fistula or catheter for haemodialysis or peritoneal dialysis) and/or kidney transplant
Discuss with the group whether renal replacement therapy is likely to be required soon and how the patient
may be prepared for this.
History taking
Clinical skills
Between Tutorials
Interview a patient with CKD and do a case presentation to the group at the next tutorial.
Resources

28 | P a g e
Week 5: End-stage kidney disease: dialysis and transplantation

Aim
Introduce students to clinical examination for End Stage Kidney Disease (ESKD).
Objectives
To develop an understanding of the clinical features of ESKD, including the symptoms and signs of its
systemic complications.
To learn about methods of managing patients with End Stage Kidney Disease (dialysis and transplantation).
Students should interview and examine patients with ESKD, typically found in the renal ward or Dialysis Unit.
Check their blood pressure and assess their fluid balance. Carry out a full cardiovascular examination and a
neurological examination. Look for evidence of chronic dialysis access (if patient treated with dialysis
arteriovenous fistula or catheter for haemodialysis or peritoneal dialysis) and/or kidney transplant
History taking
o Coping with dialysis.
Clinical skills
o Dialysis and techniques of dialysis, include discussion and demonstration of arteriovenous (AV)
fistulae and central venous catheters used for haemodialysis and Tenckhoff catheters used for
peritoneal dialysis.
Between Tutorials
Interview a patient with ESKD and consider whether they are appropriate for transplantation. Discuss
amongst the group why they may or may not be appropriate.
Resources

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STRUCTURED CLINICAL EXERCISES

Renal: Examination to determine Fluid Status
Please complete this form using black pen only.
DATE
NAME
MATRIC NO.
EXAMINER
SKILLS
POINTS
(0,1)
1. Observe mental state.

2. Look at the mucous membranes.
3. Check skin turgor.
4. Take pulse rate.
5. Take the blood pressure supine.
6. Take the blood pressure standing.
7. Check peripheral perfusion (temperature and pulses in limbs).
8. Assess the jugular venous pressure.
9. Auscultate the heart sounds
10. Auscultate the chest.
11. Examine the sacral oedema.
12. Examine the pedal oedema
13. Ask for body weight.
SCORING
Total out of 13 points
(8 or more points to pass)
PASS
FAIL (Must Re-sit CEx)
Signed:

30 | P a g e
Examination to determine Fluid Status

1. It essential to assess the state of hydration in all patients, particularly those with renal disease. Severe
dehydration can be a cause of acute renal failure and can cause an acute deterioration in patients with chronic
renal disease. Conversely over-hydration can result from intravenous fluids used to correct acute renal failure.
In general it is easier to clinically detect over-hydration than dehydration.
2. Marked changes in fluid status, either severe dehydration or severe fluid overload may cause an
encephalopathy which will present as delirium. This will produce agitation, motor restlessness, poor
concentration and, if severe enough, hallucinations.
3. Loss of fluid will produce drying of mucous membranes although this can be unreliable, particularly in
hospital patients receiving oxygen by mask.
4. Decreased fluid in the tissues will make them less elastic: a pinch of skin will be slower to relax in a
dehydrated patient, although this can also be unreliable in elderly patients who have reduced skin elasticity.
Sunken eyes may also reflect marked dehydration.
5. As circulatory volume decreases there will be constriction of the peripheral vasculature and peripheral
pulses will be decreased in amplitude.
6. Decreased intravascular volume will initially produce tachycardia. As volume depletion worsens the patient
will develop postural hypotension (a drop in systolic blood pressure of greater than 20 mm Hg on standing).
Chronic fluid overload may produce hypertension.
7. In fluid overload the JVP will be raised. The JVP is less useful in dehydration.
8. Fluid overload will eventually produce biventricular heart failure and this will be manifest as crepitations in
the lung bases and oedema of the sacrum (if bedbound) or the ankles (if ambulant). Oedema should be
assessed by pushing firmly with the pulp of the thumb for 3 seconds or so and looking for a residual pit.
9. Serial weight change is the best indicator of short term fluctuations in fluid status: If someone has gained
3kg over 24 hours it can only be fluid.

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Assessing Chronic Kidney Disease (Not on Dialysis): History

Please complete this form using black pen only.
DATE
NAME
MATRIC NO.
EXAMINER
SKILLS
POINTS
(0,1)
1. Introduction and statement of purpose

2. General well being:
a) Malaise and fatigue
b) Appetite and weight
c) Sleep
3. Causes of Chronic kidney Disease:
a) Glomerulonephritis (duration treatment)
b) Diabetes (duration, treatment)
c) Hypertension (duration, treatment)
4. Urinary Symptoms:
a) Difficulty passing urine
b) Frequency, dysuria, nocturia
5. Fluid Overload Symptoms:
a) Shortness of breath
b) Peripheral oedema
6. Ischemic Heart Disease:
a) Angina
b) Myocardial Infarction
7. Medication:
a) Review list
b) Estimate compliance
SCORING
Total out of 15 points
(9 or more points to pass)
PASS
FAIL (Must Re-sit CEx)
Signed:

32 | P a g e
Assessing Chronic Kidney Disease (Not on Dialysis): History

1. In any history-taking task you should introduce yourself and give the patient a brief overview of what you
are trying to achieve with the history.
2. Chronic Kidney Disease can produce widespread but often non-specific disturbances in body functions.
Patients with at least moderate disease commonly complain of tiredness, lack of energy and poor sleep. They
frequently sleep for only short periods during the night and daytime somnolence is common. Dreaming is
sometimes disturbing. Leg movements and restless legs occasionally overwhelm the patient. The cause of
these symptoms remains obscure and they are not always improved with dialysis. Correction of anaemia often
improves some or all of these symptoms, although some often remain.
3. In people under the age of 40, renal failure is most commonly due to immune mediated glomerulonephritis,
IgA nephropathy/SLE being the most common underlying disorder. In people over 40, diabetes has become
the most important cause of Chronic Kidney Disease and its incidence is increasing. Hypertension is also an
important contributor. In Malaysia, at the end of 2013 there were 31,637 patients undergoing dialysis therapy,
and over 6,222 commenced dialysis in 2013 61% with diabetes, 16% with hypertension and 3% with
glomerulonephritis/SLE as the cause of their kidney failure(BL Goh, LM Ong, YN Lim, (Eds) 21st Report of the
Malaysian Dialysis & Transplant Registry 2013, Kuala Lumpur 2014)
4. Renal failure is frequently accompanied by an alteration in urinary frequency and normal diurnal variation is
lost. Nocturia three or more times at night is common until the terminal stages of the disease. This probably
reflects a loss of renal mass that results in a reduction in concentrating power. Urine is therefore frequently
dilute (isosthenuria) as the kidney fails to adequately concentrate. Patients receiving dialysis therapy often
pass little urine and so nocturia ceases to be a problem.
5. Shortness of breath usually reflects fluid overload with or without anaemia. Patients are often thirsty and
crave cold drinks. People often adapt to their worsening renal function by doing less and so lessening their
symptoms.
6. Cardiac failure is common in Chronic Kidney Disease and often accompanied by ischaemic heart disease,
hypertension and fluid overload. Widespread vascular disease is also a common complication of Chronic
Kidney Disease.
7. Medication lists are an important source of information. The contents may reveal diagnoses missed in the
rest of the history (hyperlipidaemia, hypertension, gout). You should assess compliance by establishing the
patients familiarity with the medications and whether they use an aid such as pre-packaged medicines
(Webster pack).

33 | P a g e

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STAGE 2

PATIENT DOCTOR HANDBOOK

Renal & Urology

2014 UNIVERSITY OF MALAYA MEDICAL PROGRAMME

Week 4: History and physical examination in Chronic Kidney Disease ............................................. 28

2014 UNIVERSITY OF MALAYA MEDICAL PROGRAMME

INTRODUCTION (NOTES FOR TUTORS)

Problem-based learning with an emphasis on the development of clinical reasoning skills

Basic & Clinical Science

Graduates of the University of Malaya Medical Programme will demonstrate:

Patient Doctor Tutorials

2014 UNIVERSITY OF MALAYA MEDICAL PROGRAMME

Working with patients in tutorials

Clinical Assessment Schedule:

Block 4 OSCE (Formative)

Block 6 OSCE (Formative)

2014 UNIVERSITY OF MALAYA MEDICAL PROGRAMME

Clinical Ward-Based Exercises (Required Formative Assessment)

2014 UNIVERSITY OF MALAYA MEDICAL PROGRAMME

Requirements for each block:

Number of Clinical Exercises

All clinical exercise MUST be conducted in the presence of a tutor.

OSCE: Observed Structured Clinical Examination

2014 UNIVERSITY OF MALAYA MEDICAL PROGRAMME

Note this edition provides access to additional resources online.

2014 UNIVERSITY OF MALAYA MEDICAL PROGRAMME

a) Male Sexual Histroy

Clinical diagnostic skills (physical examination): Prostate disease

2014 UNIVERSITY OF MALAYA MEDICAL PROGRAMME

2014 UNIVERSITY OF MALAYA MEDICAL PROGRAMME

Week 4: History and physical examination in chronic kidney disease

2014 UNIVERSITY OF MALAYA MEDICAL PROGRAMME

COMMUNICATION SKILLS (HISTORY TAKING)

Male sexual history

2014 UNIVERSITY OF MALAYA MEDICAL PROGRAMME

2014 UNIVERSITY OF MALAYA MEDICAL PROGRAMME

History in prostate and urinary tract disease

Altered urinary appearance

2014 UNIVERSITY OF MALAYA MEDICAL PROGRAMME

bleeding by the presence of predominantly dysmorphic red cells (appreciated best by

2014 UNIVERSITY OF MALAYA MEDICAL PROGRAMME

Background information for discussion

2014 UNIVERSITY OF MALAYA MEDICAL PROGRAMME

2014 UNIVERSITY OF MALAYA MEDICAL PROGRAMME

Week 3: History in acute kidney disease

2014 UNIVERSITY OF MALAYA MEDICAL PROGRAMME

Obstruction may be:

2014 UNIVERSITY OF MALAYA MEDICAL PROGRAMME

Week 4: History in Chronic Kidney Disease

2014 UNIVERSITY OF MALAYA MEDICAL PROGRAMME

Common causes of Chronic kidney disease include:

2014 UNIVERSITY OF MALAYA MEDICAL PROGRAMME

Week 5: History of End-stage kidney disease: dialysis and transplantation

2014 UNIVERSITY OF MALAYA MEDICAL PROGRAMME

2014 UNIVERSITY OF MALAYA MEDICAL PROGRAMME

CLINICAL DIAGNOSTIC SKILLS (PHYSICAL EXAMINATION)

Background information for discussion

2014 UNIVERSITY OF MALAYA MEDICAL PROGRAMME

2014 UNIVERSITY OF MALAYA MEDICAL PROGRAMME

2014 UNIVERSITY OF MALAYA MEDICAL PROGRAMME

Week 3: History and physical examination in Glomerular disease

2014 UNIVERSITY OF MALAYA MEDICAL PROGRAMME

Week 4: History and physical examination in Chronic Kidney Disease