1 exclinic nefrologie

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”

12.06.200612.06.2006 Spitalul Clinic de Nefrologie "Dr. Carol Davila"Spitalul Clinic de Nefrologie "Dr. Carol Davila" 22

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.


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


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!


InspectionInspection


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.)


PalpationPalpation


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


Pitting edemaPitting edema

Renal (nephrotic) edema – usually white, puffy, recently appeared, easily pitting


Palpation of kidney - methodsPalpation of kidney - methods

Guyon Israël

Glénard


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.


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)


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!


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.


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


Normal Phymosis Paraphymosis

Hydrocele Hydrocele, transillumination


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)


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


PercussionPercussion


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)


AuscultationAuscultation


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!


Pericardial rub = emergency

Abdominal auscultation


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


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…

1 exclinic nefrologie

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