Examination of the Renal PatientPETER LATHAM

FY2

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

QuestionsTry 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???