CLINICAL EXAMINATION OF THE PATIENT WITH RENAL DISEASE

Dr. A.D. Zugravu

Spitalul Clinic de Nefrologie Dr. Carol Davila

WHY IS THE PATIENT COMING? Clinical presentation of renal disease

Asymptomatic patients (but an abnormality has been detected on clinical/lab exam); Symptoms or physical signs indicating underlying renal disease; Systemic disease known to be associated with renal involvement; Family history of an inherited renal disorder.
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SYMPTOMATIC PATIENTS
Disorders of micturition Disorders of urine volume Alterations of urine composition Pain Edema Impairment of renal function

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Spitalul Clinic de Nefrologie "Dr. Carol Davila"

Clinical examination
Not only the urinary tract, but a full clinical exam! Vital signs!!!
BP (supine/standing), both hands HR/pulse (supine/standing) RR (respiratory rate), respiratory pattern (Kssmaul = acidotic) temperature
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Fluid status!!!
BP (supine/standing) HR (supine/standing) skin turgor eyeball turgor pitting enlarged jugular veins painful hepatomegaly

Spitalul Clinic de Nefrologie "Dr. Carol Davila"

Inspection

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Spitalul Clinic de Nefrologie "Dr. Carol Davila"

Habitus cushingoid (prednisone!) Alterations of urine composition hematuria (red-brown u.), proteinuria (foamy, frothy u.), pyuria (cloudy u.), chyluria (milky u.), hysturia, pneumaturia. Edema Grossly enlarged kidneys (ADPKD, tumor) Ureters chronic obstructive nephropathy Bladder overdistention (thin pts.)
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Spitalul Clinic de Nefrologie "Dr. Carol Davila"

Palpation

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Spitalul Clinic de Nefrologie "Dr. Carol Davila"

Edema
Classification - location
Generalized:
renal cardiac hepatic

Stages
Pre-edema
daily weighing

Subcutaneous (4-5 L)
dependent pitting

Localised:
allergic inflammatory post traumatic

Serosal (5-7 L)
hydro-thorax, pericard, ascites

Visceral, anasarca (1520 L)

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Pitting edema

Renal (nephrotic) edema usually white, puffy, recently appeared, easily pitting
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Palpation of kidney - methods

Guyon Isral

Glnard

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Posterior renal points

costovertebral costomuscular rib, inferior They correspond to the kidney, pyelon and upper ureter.

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Spitalul Clinic de Nefrologie "Dr. Carol Davila"

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Giordano maneuver
Elicits pain originating from a distended pyelon Warn the patient, then suddenly hit the lombar region; better executed starting from the midthorax, going downward towards the buttocks (to exclude the it hurts everywhere syndrome)
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Uretheral points

1. superior ureteral point (Bazy)-pyelon 2. middle ureteral point (Halle)-lombar ureter 3. inferior ureteral point (Pasteau) - accessible only through rectal/ vaginal examination!

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Spitalul Clinic de Nefrologie "Dr. Carol Davila"

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Enlarged bladder, palpation

Bladder capacity ~ 150 mL (pelvic organ, palpable only through rectal/vaginal exam + abdominal hand). Distended bladder > 300 mL (obstruction/neurological dysfunction) becomes an abdominal organ, palpable with the cubital side of the left hand.
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Male external genitalia

Penile urethra foreign bodies, calculi, strictures, inflammation, polyps; opening: normal/hypo-/epispadias Testes:
(orchi)epididimitis enlarged, painful, erythema spermatic cord usually not painful, like a match; inflammation painful; TB moniliform neoplasia hard, not painful hydrocele fluid in vaginalis testis (transillumination) varicocele- right (sentinel) - look for a right Grawitz/retroperitoneal tumor
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Normal

Phymosis

Paraphymosis

Hydrocele

Hydrocele, transillumination

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Spitalul Clinic de Nefrologie "Dr. Carol Davila"

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Prostate examination
Prostate -usually 3x3 - 4x4 cm, chestnut-shaped, distinct median groove Abnormalities: enlarged; no median groove; hard nodule; painful area. Seminal vesicles palpable usually when chronically inflammation (non-specific/ tuberculosis)
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Vaginal examination
Check for uterine prolapse! Check for neoplasia! Urethral meatus:
polyps ( hematuria, frequency) strictures calculus

Developmental abnormalities- vulva, vagina Inflammation of Bartholin/Skene glands

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Percussion

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Distended bladder dullness, upper convexity Ascites shifting dullness, upper concavity (fluid wave,) Enlarged cardiac dullness pericarditis, CHF Grossly enlarged kidneys (ADPKD)
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Auscultation

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Spitalul Clinic de Nefrologie "Dr. Carol Davila"

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Arterial bruits:
abdominal aorta ( palpable aneurysm) femoral arteries (groins) renal arteries (anterior - periumbilically, bilaterally; posterior under the rib cage, in the loin, laterally in the flank) carotids + palpation of peripheral pulses bowel sounds

Heart murmurs Pericardial rub = EMERGENCY!

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Abdominal auscultation

Pericardial rub = emergency

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Spitalul Clinic de Nefrologie "Dr. Carol Davila"

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Emergencies in the renal patient

Malignant or severe hypertension Acute renal failure with oligoanuria Acute glomerulonephritis (in childhood) Severe water and electrolyte disorders, particularly hyperkalaemia Renal colic and any acute urinary tract obstruction Cardiovascular and respiratory emergencies: not only myocardial infarction, acute pulmonary oedema, aortic dissection, etc., but also uraemic pericarditis, pulmonary embolism in the nephrotic patient, severe haemoptysis in a patient with the Goodpasture's syndrome Acute thrombosis of arteriovenous fistula Severe haemorrhage such as gastrointestinal bleeding in patients with acute renal failure, severe bleeding after renal biopsy or from arteriovenous fistula, acute rupture of a transplanted kidney, intracranial haemorrhage due to ruptured aneurysm in polycystic kidney disease Fever such as that due to upper urinary tract infection or to septicaemia of any other origin; or fever in immunodepressed patients
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Thank you
Prof. Tiberiu Nanea, MD, PhD, Caritas Clinical Hospital (my semiology attending) Assist. Prof. Simona Stancu, MD, PhD (my attending in Nephrology, mentor) Prof. Gabriel Mircescu (our boss, mentor, line drawings) Charlie Goldberg, UCSD ( photographs) and many more
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