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CLINICAL EXAMINATION OF THE CLINICAL EXAMINATION OF THE PATIENT WITH RENAL DISEASEPATIENT WITH RENAL DISEASE
Dr. A.D. ZugravuDr. A.D. Zugravu
Spitalul Clinic de Nefrologie “Dr. Carol Davila”
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WHY IS THE PATIENT COMING?WHY IS THE PATIENT COMING?Clinical presentation of renal diseaseClinical presentation of renal disease
Asymptomatic patients (Asymptomatic patients (but an abnormality but an abnormality has been detected on clinical/lab examhas been detected on clinical/lab exam););Symptoms or physical signs indicating Symptoms or physical signs indicating underlying renal disease;underlying renal disease;Systemic disease known to be associated Systemic disease known to be associated with renal involvement;with renal involvement;Family history of an inherited renal Family history of an inherited renal disorder. disorder.
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SYMPTOMATIC PATIENTSSYMPTOMATIC PATIENTS
Disorders of micturitionDisorders of micturition
Disorders of urine volumeDisorders of urine volume
Alterations of urine compositionAlterations of urine composition
PainPain
EdemaEdema
Impairment of renal functionImpairment of renal function
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Clinical examinationClinical examination
Vital signs!!!Vital signs!!!– BP (supine/standing), BP (supine/standing),
both handsboth hands– HR/pulse HR/pulse
(supine/standing)(supine/standing)– RR (respiratory rate), RR (respiratory rate),
respiratory pattern respiratory pattern (K(Küssmaul = acidoticüssmaul = acidotic))
– temperaturetemperature
Fluid status!!!Fluid status!!!– BP (supine/standing)BP (supine/standing)– HR (supine/standing)HR (supine/standing)– skin turgorskin turgor– eyeball turgoreyeball turgor– pittingpitting– enlarged jugular veinsenlarged jugular veins– painful hepatomegalypainful hepatomegaly
Not only the urinary tract, but a full clinical exam!
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InspectionInspection
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Habitus – cushingoid (prednisone!)Habitus – cushingoid (prednisone!)
Alterations of urine composition – Alterations of urine composition – hematuria (red-brown u.), proteinuria hematuria (red-brown u.), proteinuria (foamy, frothy u.), pyuria (cloudy u.), (foamy, frothy u.), pyuria (cloudy u.), chyluria (milky u.), hysturia, pneumaturia.chyluria (milky u.), hysturia, pneumaturia.EdemaEdemaGrossly enlarged kidneys (ADPKD, tumor)Grossly enlarged kidneys (ADPKD, tumor)Ureters – chronic obstructive nephropathyUreters – chronic obstructive nephropathyBladder overdistention (thin pts.)Bladder overdistention (thin pts.)
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PalpationPalpation
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EdemaEdema
Generalized:Generalized:– renalrenal– cardiaccardiac– hepatichepatic
Localised:Localised:– allergicallergic– inflammatoryinflammatory– post traumaticpost traumatic
Pre-edemaPre-edema– daily weighingdaily weighing
Subcutaneous (4-5 L)Subcutaneous (4-5 L)– dependentdependent– pittingpitting
Serosal (5-7 L)Serosal (5-7 L)– hydro-thorax, pericard, hydro-thorax, pericard,
ascitesascites
Visceral, anasarca (15-Visceral, anasarca (15-20 L)20 L)
Classification - location Stages
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Pitting edemaPitting edema
Renal (nephrotic) edema – usually white, puffy, recently appeared, easily pitting
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Palpation of kidney - methodsPalpation of kidney - methods
Guyon Israël
Glénard
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Posterior “renal points”Posterior “renal points”
costovertebralcostovertebral
costomuscularcostomuscular
rib, inferiorrib, inferior
They correspond to the They correspond to the kidney, pyelon and upper kidney, pyelon and upper ureter. ureter.
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Giordano maneuverGiordano maneuver
Elicits pain originating Elicits pain originating from a distended pyelon from a distended pyelon
Warn the patient, then Warn the patient, then suddenly hit the lombar suddenly hit the lombar region; better executed region; better executed starting from the mid-starting from the mid-thorax, going downward thorax, going downward towards the buttocks (to towards the buttocks (to exclude the ‘it hurts exclude the ‘it hurts everywhere’ syndrome)everywhere’ syndrome)
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Uretheral pointsUretheral points
1. superior ureteral point 1. superior ureteral point (Bazy)-pyelon(Bazy)-pyelon
2. middle ureteral point 2. middle ureteral point (Halle)-lombar ureter(Halle)-lombar ureter
3. inferior ureteral point 3. inferior ureteral point (Pasteau) - accessible (Pasteau) - accessible only through rectal/ only through rectal/ vaginal examination!vaginal examination!
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Enlarged bladder, palpationBladder capacity ~ 150 mL Bladder capacity ~ 150 mL (pelvic organ, palpable only (pelvic organ, palpable only through rectal/vaginal exam through rectal/vaginal exam + abdominal hand).+ abdominal hand).
Distended bladder > 300 mL Distended bladder > 300 mL (obstruction/neurological (obstruction/neurological dysfunction) becomes an dysfunction) becomes an abdominal organ, palpable abdominal organ, palpable with the cubital side of the with the cubital side of the left hand. left hand.
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Male external genitaliaMale external genitalia
Penile urethra – foreign bodies, calculi, strictures, Penile urethra – foreign bodies, calculi, strictures, inflammation, polyps; opening: inflammation, polyps; opening: normal/hypo-/epispadiasnormal/hypo-/epispadias
Testes:Testes:– (orchi)epididimitis – enlarged, painful, erythema(orchi)epididimitis – enlarged, painful, erythema– spermatic cord – usually not painful, like a match; spermatic cord – usually not painful, like a match;
inflammation – painful; TB – moniliforminflammation – painful; TB – moniliform– neoplasia – hard, not painfulneoplasia – hard, not painful– hydrocele – fluid in vaginalis testis (transillumination)hydrocele – fluid in vaginalis testis (transillumination)– varicocele- right (‘sentinel’) - look for a right varicocele- right (‘sentinel’) - look for a right
Grawitz/retroperitoneal tumorGrawitz/retroperitoneal tumor
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Normal Phymosis Paraphymosis
Hydrocele Hydrocele, transillumination
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Prostate examination
Prostate -usually 3x3 - 4x4 Prostate -usually 3x3 - 4x4 cm, chestnut-shaped, cm, chestnut-shaped, distinct median groovedistinct median grooveAbnormalities: enlarged; Abnormalities: enlarged; no median groove; hard no median groove; hard nodule; painful area. nodule; painful area. Seminal vesicles – Seminal vesicles – palpable usually when palpable usually when chronically inflammation chronically inflammation (non-specific/ tuberculosis)(non-specific/ tuberculosis)
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Vaginal examinationVaginal examination
Check for uterine prolapse!Check for uterine prolapse!
Check for neoplasia!Check for neoplasia!
Urethral meatus:Urethral meatus:– polyps (polyps (→ hematuria, frequency→ hematuria, frequency))– stricturesstrictures– calculuscalculus
Developmental abnormalities- vulva, vaginaDevelopmental abnormalities- vulva, vagina
Inflammation of Bartholin/Skene glands Inflammation of Bartholin/Skene glands
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PercussionPercussion
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Distended bladder – Distended bladder – dullness, upper dullness, upper convexityconvexityAscites – shifting Ascites – shifting dullness, upper dullness, upper concavity (fluid wave,…)concavity (fluid wave,…)Enlarged cardiac Enlarged cardiac dullness – pericarditis, dullness – pericarditis, CHFCHFGrossly enlarged Grossly enlarged kidneys (ADPKD)kidneys (ADPKD)
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AuscultationAuscultation
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Arterial bruits:Arterial bruits:– abdominal aorta (abdominal aorta (± palpable aneurysm± palpable aneurysm))– femoral arteries (groins)femoral arteries (groins)– renal arteries (anterior - periumbilically, renal arteries (anterior - periumbilically,
bilaterally; posterior under the rib cage, in the bilaterally; posterior under the rib cage, in the loin, laterally in the flank)loin, laterally in the flank)
– carotids + palpation of peripheral pulsescarotids + palpation of peripheral pulses– bowel soundsbowel sounds
Heart murmursHeart murmurs
Pericardial rub = EMERGENCY!Pericardial rub = EMERGENCY!
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Pericardial rub = emergency
Abdominal auscultation
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Emergencies in the renal patientEmergencies in the renal patient
Malignant or severe hypertension Malignant or severe hypertension Acute renal failure with oligoanuria Acute renal failure with oligoanuria Acute glomerulonephritis (in childhood) Acute glomerulonephritis (in childhood) Severe water and electrolyte disorders, particularly hyperkalaemiaSevere water and electrolyte disorders, particularly hyperkalaemiaRenal colic and any acute urinary tract obstruction Renal colic and any acute urinary tract obstruction Cardiovascular and respiratory emergencies: not only myocardial Cardiovascular and respiratory emergencies: not only myocardial infarction, acute pulmonary oedema, aortic dissection, etc., but also infarction, acute pulmonary oedema, aortic dissection, etc., but also uraemic pericarditis, pulmonary embolism in the nephrotic patient, uraemic pericarditis, pulmonary embolism in the nephrotic patient, severe haemoptysis in a patient with the Goodpasture's syndromesevere haemoptysis in a patient with the Goodpasture's syndromeAcute thrombosis of arteriovenous fistula Acute thrombosis of arteriovenous fistula Severe haemorrhage such as gastrointestinal bleeding in patients Severe haemorrhage such as gastrointestinal bleeding in patients with acute renal failure, severe bleeding after renal biopsy or from with acute renal failure, severe bleeding after renal biopsy or from arteriovenous fistula, acute rupture of a transplanted kidney, arteriovenous fistula, acute rupture of a transplanted kidney, intracranial haemorrhage due to ruptured aneurysm in polycystic intracranial haemorrhage due to ruptured aneurysm in polycystic kidney disease kidney disease Fever such as that due to upper urinary tract infection or to Fever such as that due to upper urinary tract infection or to septicaemia of any other origin; or fever in immunodepressed septicaemia of any other origin; or fever in immunodepressed patients patients
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Thank you…Thank you…
Prof. Tiberiu Nanea, MD, PhD, “Caritas” Prof. Tiberiu Nanea, MD, PhD, “Caritas” Clinical Hospital (my semiology attending)Clinical Hospital (my semiology attending)
Assist. Prof. Simona Stancu, MD, PhD (my Assist. Prof. Simona Stancu, MD, PhD (my attending in Nephrology, mentor)attending in Nephrology, mentor)
Prof. Gabriel Mircescu (our boss, mentor, Prof. Gabriel Mircescu (our boss, mentor, © line drawings© line drawings))
Charlie Goldberg, UCSD (Charlie Goldberg, UCSD (© photographs© photographs))
and many more…and many more…