examination of the renal patient
DESCRIPTION
Examination of the Renal Patient. Peter 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 - PowerPoint PPT PresentationTRANSCRIPT
![Page 1: Examination of the Renal Patient](https://reader035.vdocuments.site/reader035/viewer/2022062217/56813187550346895d97fac0/html5/thumbnails/1.jpg)
Examination of the Renal PatientPETER LATHAM
FY2
![Page 2: Examination of the Renal Patient](https://reader035.vdocuments.site/reader035/viewer/2022062217/56813187550346895d97fac0/html5/thumbnails/2.jpg)
Plan 30 minutes
Treat it as a mock final
What to expect before finals
History
Examination
Investigations
Management
Common Questions
![Page 3: Examination of the Renal Patient](https://reader035.vdocuments.site/reader035/viewer/2022062217/56813187550346895d97fac0/html5/thumbnails/3.jpg)
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
![Page 4: Examination of the Renal Patient](https://reader035.vdocuments.site/reader035/viewer/2022062217/56813187550346895d97fac0/html5/thumbnails/4.jpg)
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
![Page 5: Examination of the Renal Patient](https://reader035.vdocuments.site/reader035/viewer/2022062217/56813187550346895d97fac0/html5/thumbnails/5.jpg)
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
![Page 6: Examination of the Renal Patient](https://reader035.vdocuments.site/reader035/viewer/2022062217/56813187550346895d97fac0/html5/thumbnails/6.jpg)
Roles of the Kidney
All symptoms arise from the different roles of the kidney, failing
![Page 7: Examination of the Renal Patient](https://reader035.vdocuments.site/reader035/viewer/2022062217/56813187550346895d97fac0/html5/thumbnails/7.jpg)
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
![Page 8: Examination of the Renal Patient](https://reader035.vdocuments.site/reader035/viewer/2022062217/56813187550346895d97fac0/html5/thumbnails/8.jpg)
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?’
![Page 9: Examination of the Renal Patient](https://reader035.vdocuments.site/reader035/viewer/2022062217/56813187550346895d97fac0/html5/thumbnails/9.jpg)
3. Acid Base balance Kidney key role in the longterm control of pH
Excretes H+ and reabsorbs HCO3
Acidosis key symptoms – N&V
![Page 10: Examination of the Renal Patient](https://reader035.vdocuments.site/reader035/viewer/2022062217/56813187550346895d97fac0/html5/thumbnails/10.jpg)
4. Electrolyte Balance Key role in retaining sodium and excreting potassium
Hyperkalaemia – lethargy, muscle paralysis, chest pain
Hyponatraemia – muscle cramps, anorexia, N&V
![Page 11: Examination of the Renal Patient](https://reader035.vdocuments.site/reader035/viewer/2022062217/56813187550346895d97fac0/html5/thumbnails/11.jpg)
5. Erythropoietin Produces EPO
Anaemia is common throughout patients with CKD
Symptoms – lethargy, pallor, cold peripheries, chest pain, dizziness
![Page 12: Examination of the Renal Patient](https://reader035.vdocuments.site/reader035/viewer/2022062217/56813187550346895d97fac0/html5/thumbnails/12.jpg)
PmHx Open question (could ask them for a cause?)
ASK SPECIFICALLY FOR
Diabetes
HTN
Childhood infections
![Page 13: Examination of the Renal Patient](https://reader035.vdocuments.site/reader035/viewer/2022062217/56813187550346895d97fac0/html5/thumbnails/13.jpg)
Drugs, Operations, Allergies Drugs – NSAIDs
Ops – Transplant
![Page 14: Examination of the Renal Patient](https://reader035.vdocuments.site/reader035/viewer/2022062217/56813187550346895d97fac0/html5/thumbnails/14.jpg)
Sx Smoking
Smoking
Smoking
Smoking
Alcohol
Work with dyes
![Page 15: Examination of the Renal Patient](https://reader035.vdocuments.site/reader035/viewer/2022062217/56813187550346895d97fac0/html5/thumbnails/15.jpg)
Fx PCOS
Artheriopaths
![Page 16: Examination of the Renal Patient](https://reader035.vdocuments.site/reader035/viewer/2022062217/56813187550346895d97fac0/html5/thumbnails/16.jpg)
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?’
![Page 17: Examination of the Renal Patient](https://reader035.vdocuments.site/reader035/viewer/2022062217/56813187550346895d97fac0/html5/thumbnails/17.jpg)
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……’
![Page 18: Examination of the Renal Patient](https://reader035.vdocuments.site/reader035/viewer/2022062217/56813187550346895d97fac0/html5/thumbnails/18.jpg)
End of Bed Well or unwell
Breathing comfortably at rest (compensating for acidosis)
Colour – pallor (anaemia)
Can you see a fistula?
![Page 19: Examination of the Renal Patient](https://reader035.vdocuments.site/reader035/viewer/2022062217/56813187550346895d97fac0/html5/thumbnails/19.jpg)
Hands Pallor, perfusion
Gouty Tophi
Lindsay’s nails
Pulse
Fistula????
Offer Blood pressure
![Page 20: Examination of the Renal Patient](https://reader035.vdocuments.site/reader035/viewer/2022062217/56813187550346895d97fac0/html5/thumbnails/20.jpg)
Face Pallor in Conjunctiva, Xanthelasma
Offer Fundoscopy – Hypertension retinopathy, End-organ damage
Assess JVP
![Page 21: Examination of the Renal Patient](https://reader035.vdocuments.site/reader035/viewer/2022062217/56813187550346895d97fac0/html5/thumbnails/21.jpg)
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
![Page 22: Examination of the Renal Patient](https://reader035.vdocuments.site/reader035/viewer/2022062217/56813187550346895d97fac0/html5/thumbnails/22.jpg)
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
![Page 23: Examination of the Renal Patient](https://reader035.vdocuments.site/reader035/viewer/2022062217/56813187550346895d97fac0/html5/thumbnails/23.jpg)
Offer Cardiovascular Exam
Neuroexam (PCKD)
![Page 24: Examination of the Renal Patient](https://reader035.vdocuments.site/reader035/viewer/2022062217/56813187550346895d97fac0/html5/thumbnails/24.jpg)
Investigations Bedside Tests
Blood pressure in both arms, lying and standing
ECG – hyperkalaemia!!!
Urine dip – Protein! Albumin Creatinine ratio (or protein creatinine ratio)
WEIGHT
![Page 25: Examination of the Renal Patient](https://reader035.vdocuments.site/reader035/viewer/2022062217/56813187550346895d97fac0/html5/thumbnails/25.jpg)
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
![Page 26: Examination of the Renal Patient](https://reader035.vdocuments.site/reader035/viewer/2022062217/56813187550346895d97fac0/html5/thumbnails/26.jpg)
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)
![Page 27: Examination of the Renal Patient](https://reader035.vdocuments.site/reader035/viewer/2022062217/56813187550346895d97fac0/html5/thumbnails/27.jpg)
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
![Page 28: Examination of the Renal Patient](https://reader035.vdocuments.site/reader035/viewer/2022062217/56813187550346895d97fac0/html5/thumbnails/28.jpg)
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
![Page 29: Examination of the Renal Patient](https://reader035.vdocuments.site/reader035/viewer/2022062217/56813187550346895d97fac0/html5/thumbnails/29.jpg)
Surgical Transplant and immunosuppression
![Page 30: Examination of the Renal Patient](https://reader035.vdocuments.site/reader035/viewer/2022062217/56813187550346895d97fac0/html5/thumbnails/30.jpg)
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
![Page 31: Examination of the Renal Patient](https://reader035.vdocuments.site/reader035/viewer/2022062217/56813187550346895d97fac0/html5/thumbnails/31.jpg)
Any Questions???