Examination of the Renal Patient

1. Examination of the Renal Patient Peter Latham FY2

2. Plan • 30 minutes • Treat it as a mock final • What to expect before finals • History • Examination • Investigations • Management • Common Questions

3. 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

4. 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

5. 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

6. Roles of the Kidney • All symptoms arise from the different roles of the kidney, failing

7. 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

8. 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?’

9. 3. Acid Base balance • Kidney key role in the longterm control of pH • Excretes H+ and reabsorbs HCO3 • Acidosis key symptoms – N&V

10. 4. Electrolyte Balance • Key role in retaining sodium and excreting potassium • Hyperkalaemia – lethargy, muscle paralysis, chest pain • Hyponatraemia – muscle cramps, anorexia, N&V

11. 5. Erythropoietin • Produces EPO • Anaemia is common throughout patients with CKD • Symptoms – lethargy, pallor, cold peripheries, chest pain, dizziness

12. PmHx • Open question (could ask them for a cause?) • ASK SPECIFICALLY FOR • Diabetes • HTN • Childhood infections

13. Drugs, Operations, Allergies • Drugs – NSAIDs • Ops – Transplant

14. Sx • Smoking • Smoking • Smoking • Smoking • Alcohol • Work with dyes

15. Fx • PCOS • Artheriopaths

16. 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?’

17. 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……’

18. End of Bed • Well or unwell • Breathing comfortably at rest (compensating for acidosis) • Colour – pallor (anaemia) • Can you see a fistula?

19. Hands • Pallor, perfusion • Gouty Tophi • Lindsay’s nails • Pulse • Fistula???? • Offer Blood pressure

20. Face • Pallor in Conjunctiva, Xanthelasma • Offer Fundoscopy – Hypertension retinopathy, End-organ damage • Assess JVP

21. 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

22. 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

23. Offer • Cardiovascular Exam • Neuroexam(PCKD)

24. Investigations • Bedside Tests • Blood pressure in both arms, lying and standing • ECG – hyperkalaemia!!! • Urine dip – Protein! Albumin Creatinine ratio (or protein creatinine ratio) • WEIGHT

25. 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

26. 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)

27. 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

28. 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

29. Surgical • Transplant and immunosuppression

30. 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

31. Any Questions???