Renal Examination
Shorts - Renal examination
Stem
"Haematuria"
"Proteinuria"
Introduction
Impression of mental status (uremic or hypertensive encephalopathy, depression of chronic disease)
Surrounds (Dialysate)
Well v Unwell
Colour
Growth
- short (CKD)
- Thin (CKD)
- obese (Steroids)
Tanner: delay (CKD)
Nutrition: poor muscle bunk, subcutaneous fat (CKD)
Dysmorphism:
Hemihypertrophy (Wilms)
Skin
- sallow (CKD)
- palour (↓EPO, HUS)
- Jaundice (hepatorenal syndrome ie liver failure > splanchnic vasodilation > ↓TPR > renal hypoperfusion > ↓GFR)
- bruising, petechia (uremic platelet dysfunction)
- Scratch marks (uremic pruritus)
- uremic frost (uncontrolled Uremia)
- hirsute (hair in adult male distribution > steroids)
- hypertrichosis (excess hair outside adult male distribution > CSA)
Upper limb
Pulse
- ↑ (dehydration, HF in CKD)
Hands, nails (vasculitis)
Nails
- brown lines (CKD)
Palm
- Crease palour (CKD/HUS)
Wrists
- Flare, tender (CKD MBD)
AV Fistula (CKD)
Asterixis (CKD)
BP plotted for age and height
Lymph nodes (CMV, lymphoma)
Shoulder power (proximal myopathy: CKD, steroids)
Head and neck
Face
- Malar flush (SLE)
- Cushingoid facies
- periorbital oedema
Eyes
- Conjunctival palour (EPO, HUS)
- Scleral jaundice (hepatorenal, HUS)
- Band keratopathy (hypercalcemia)
- Aniridia (Wilms)
- Cataract (Steroids)
- Uremic retinopathy
- Retinitis pigmentosa (nephronophthitis)
Ears
- Hearing (Alport, Aminoglycosides, congenital rubella)
Nose
- NG
Mouth
- dry (dehydration)
- uraemic breath
- gum hypertrophy (CSA)
Neck
- JVP (fluid overload, cardiorenal syndrome)
- cervical adenopathy (CMV, lymphoma in immunosuppressed)
- CVC
Chest
Anterior
Abdomen
Inspection
Lower limbs
Inspection
- Muscle bulk, SC fat
- valgus at knees (CKD MBD)
- Flare at ankle (CKD MBD)
Palpation
- oedema (fluid overload/CRS)
Hips
- Power for proximal weakness (steroids) or squat
- ROM for SCFE (CKD MBS)
Reflexes down (Uremic peripheral neuropathy)
Gait
- limp (SCFE)
- Foot slap (uremic PN)
Urinalysis
Blood
Protein
Specific grav
Nitrites
pH
Glucose
Temperature chart
- infection
- transplant rejection
Neuro exam if HTN or Nephrotic
Ix
Renal US
- large with cysts ?AR/ADPKD (associated liver changes usually discrimination)
- cyst no parenchyma MCDK (large at birth involute over time, asymptomatic if other kidney normal
- small with cysts nephronophthisis
Stem
"Haematuria"
"Proteinuria"
Introduction
Impression of mental status (uremic or hypertensive encephalopathy, depression of chronic disease)
Surrounds (Dialysate)
Well v Unwell
Colour
Growth
- short (CKD)
- Thin (CKD)
- obese (Steroids)
Tanner: delay (CKD)
Nutrition: poor muscle bunk, subcutaneous fat (CKD)
Dysmorphism:
Hemihypertrophy (Wilms)
Skin
- sallow (CKD)
- palour (↓EPO, HUS)
- Jaundice (hepatorenal syndrome ie liver failure > splanchnic vasodilation > ↓TPR > renal hypoperfusion > ↓GFR)
- bruising, petechia (uremic platelet dysfunction)
- Scratch marks (uremic pruritus)
- uremic frost (uncontrolled Uremia)
- hirsute (hair in adult male distribution > steroids)
- hypertrichosis (excess hair outside adult male distribution > CSA)
Upper limb
Pulse
- ↑ (dehydration, HF in CKD)
Hands, nails (vasculitis)
Nails
- brown lines (CKD)
Palm
- Crease palour (CKD/HUS)
Wrists
- Flare, tender (CKD MBD)
AV Fistula (CKD)
Asterixis (CKD)
BP plotted for age and height
Lymph nodes (CMV, lymphoma)
Shoulder power (proximal myopathy: CKD, steroids)
Head and neck
Face
- Malar flush (SLE)
- Cushingoid facies
- periorbital oedema
Eyes
- Conjunctival palour (EPO, HUS)
- Scleral jaundice (hepatorenal, HUS)
- Band keratopathy (hypercalcemia)
- Aniridia (Wilms)
- Cataract (Steroids)
- Uremic retinopathy
- Retinitis pigmentosa (nephronophthitis)
Ears
- Hearing (Alport, Aminoglycosides, congenital rubella)
Nose
- NG
Mouth
- dry (dehydration)
- uraemic breath
- gum hypertrophy (CSA)
Neck
- JVP (fluid overload, cardiorenal syndrome)
- cervical adenopathy (CMV, lymphoma in immunosuppressed)
- CVC
Chest
Anterior
- Tachypnoea (acidosis in CKD)
- Rib rosary (CKD)
- Precordium
- Cardiomegaly (fluid overload, cardiorenal syndrome)
- Murmur (anaemia)
- Pericarditis (uremic pericarditis)
- percuss - effusion
- auscultation - creps
- Scar/Nephrostomy/pyelostomy
- Sacral oedema
Abdomen
Inspection
- Intervention (PD cath, gastrostomy, ureterostomy, vesicostomy, ileal conduit
- Colostomy (VACTERL)
- Transplant scar (central in young, 'hockey stick' iliac fossa in older
- Swelling (ascites, PD fluid)
- Prune belly (urinary tract dilation, renal dysplasia, cryptorchidism, lack of abdominal muscle)
- (note if incidental correlation with tanner)
- Musculature (Prune belly syndrome)
- Tenderness (peritonitis)
- Kidney (increased with polycystic kidneys, hydronephrosis)
- Transplanted kidney (size, consistency, tenderness)
- Lymph nodes (CMV, lymphoma from immunosuppression)
- "I would check for cryptorchidism" (Prune Belly)
- Bladder (retention)
- Kidneys including transplant (artery stenosis)
Lower limbs
Inspection
- Muscle bulk, SC fat
- valgus at knees (CKD MBD)
- Flare at ankle (CKD MBD)
Palpation
- oedema (fluid overload/CRS)
Hips
- Power for proximal weakness (steroids) or squat
- ROM for SCFE (CKD MBS)
Reflexes down (Uremic peripheral neuropathy)
Gait
- limp (SCFE)
- Foot slap (uremic PN)
Urinalysis
Blood
Protein
Specific grav
Nitrites
pH
Glucose
Temperature chart
- infection
- transplant rejection
Neuro exam if HTN or Nephrotic
Ix
Renal US
- large with cysts ?AR/ADPKD (associated liver changes usually discrimination)
- cyst no parenchyma MCDK (large at birth involute over time, asymptomatic if other kidney normal
- small with cysts nephronophthisis