Examination of the
Renal Patient
P E T ER L AT HA M
F Y2
Plan
30 minutes
Treat it as a mock final
What to expect before finals
History
Examination
Investigations
Management
Common Questions
What are the ‘classic’ Renal Cases?
• PCKD
• CRF
• Renal Transplant
In the hospital all the time for dialysis
Most will have some sort of sign
Still the chance to get something more exotic BUT the theme will always be around Renal Failure
History
No presenting compliant to work with!!
‘This man is on dialysis. Please find our more.’
‘This lady is known to the Renal Physicians. Please find out more.’
Classic Chronic Disease history
History
Introduction
Timeline
PC – lethargy, HTN, Blood Test, Kidney problems as a child, family history of kidney disease
From diagnosis – how have they progressed – when started dialysis, what types etc
Bring it back to the present
Screen for complications
Stay focussed – keep it renal
Roles of the Kidney
All symptoms arise from the different roles of the
kidney, failing
1. Calcium Homeostasis
Can’t convert to active form of Vitamin D (calcitriol) and can’t reabsorb Calcium
Renal Patients can suffer from hypocalcaemia and hypercalcaemia depending on whether the
are secondary or tertiary Hyperparathyroidism
Hypo – cramps, tingling peripherally
Hyper – Bone pain, constipation, kidney stones
2. Blood pressure and Fluid Homeostasis
Excretion of water is key
If not – it accumulates
Peripheral Oedema – ‘ankles swelling’
Pulmonary Oedema – orthopnea ‘how are you lying flat?’
3. Acid Base balance
Kidney key role in the longterm control of pH
Excretes H+ and reabsorbs HCO3
Acidosis key symptoms – N&V
4. Electrolyte Balance
Key role in retaining sodium and excreting potassium
Hyperkalaemia – lethargy, muscle paralysis, chest pain
Hyponatraemia – muscle cramps, anorexia, N&V
5. Erythropoietin
Produces EPO
Anaemia is common throughout patients with CKD
Symptoms – lethargy, pallor, cold peripheries, chest pain, dizziness
PmHx
Open question (could ask them for a cause?)
ASK SPECIFICALLY FOR
Diabetes
HTN
Childhood infections
Drugs, Operations, Allergies
Drugs – NSAIDs
Ops – Transplant
Sx
Smoking
Smoking
Smoking
Smoking
Alcohol
Work with dyes
Fx
PCOS
Artheriopaths
ICE
Do ICE early but not too early
Tricky because they will clearly have a good Idea what is going on!!
All about wording
‘First had symptoms – did you have any Idea what was going on?’
‘What concerns you the most about your current condition’
‘Has the care you have received met your expectations?’
Examination
Examiner – ‘What is exam would you like to do?’
Essentially a GI/General Exam
Talk to them, be confident, take control
‘What I would like to do……’
End of Bed
Well or unwell
Breathing comfortably at rest (compensating for acidosis)
Colour – pallor (anaemia)
Can you see a fistula?
Hands
Pallor, perfusion
Gouty Tophi
Lindsay’s nails
Pulse
Fistula????
Offer Blood pressure
Face
Pallor in Conjunctiva, Xanthelasma
Offer Fundoscopy – Hypertension retinopathy, End-organ damage
Assess JVP
Abdomen
Inspect and comments (Transplant scars in flanks)
Palpate – as per GI exam, ballot kidneys
Percuss – liver, spleen and bladder
Auscultate – renal bruits, and offer lung bases
Ankles for oedema
Fistula
No different to anything other examination
Inspect – signs of infection, wound breakdown, aneurysms
Palpitate (careful!), again signs of inflammation, should feel vibration
Auscultate – bruits to confirm function
Offer
Cardiovascular Exam
Neuroexam (PCKD)
Investigations
Bedside Tests
Blood pressure in both arms, lying and standing
ECG – hyperkalaemia!!!
Urine dip – Protein! Albumin Creatinine ratio (or protein creatinine ratio)
WEIGHT
Bloods
FBC – Anaemia
U&E – urea and creatinine
Bone – Calcium and phosphate
LFTs – ALP raised due to renal bone disease
Parathyroid Hormone
VBG or ABG - acidosis
Imaging
AxR – suspecting renal calculi
USS – non-invasive, size, shape, Structural abnormalities
CT – stones BUT always mention use of contrast
MRA – preferable if suspecting Renal Vascular Disease
Special Tests –Renal Biopsy (rarely done due to complications)
Management - Conservative
Lots of MDT players
Renal Physicians
Renal Specialist Nurse
Dieticians
GP – most should be managed in primary care
Immunisations
Psychological support
Patient education – diet, symptoms of decompensation
Management - Medical
Best Medical care
Control Hypertension
Reduce Cardiovascular risk – statins, antiplatets
Bone disease – calcium and vitamin D supplements
Anaemia – EPO injections
Stringent Diabetic Control
Avoid all nephrotoxins especially NSAIDs
Surgical
Transplant and immunosuppression
Questions
Try to think about these in your thinking time
Definition
Epidemiology
Pathophysiology
Risk Factors/Causes
Indications for treatment
Acute on Chronic Presentations – Hyperkalaemia, Pulmonary Oedema, Acute Kidney Injury
Any Questions???