THE RENAL SYSTEM SIGNS AND SYMPTOMS

1. THE RENAL SYSTEM SIGNS AND SYMPTOMS

2. HISTORY TAKING = IMPORTANT ROLE PRIOR HISTORY PAST MEDICAL HISTORY ACUTE INFECTIONS CHRONIC INFECTIONS TOXIC SUBSTANCES MECANICAL SECUNDARY TO OTHER DISEASESR BOLI FAMILY HISTORY

3. PAST MEDICAL HISTORY ACUTE INFECTIONS (Especially ? HEMOLITIC STREPTOCOCCUS) TONSILITTIS; SCARLET FEVER POSTSTREPTOCOCCAL SYNDROME; PNEUMONIA ENDOCARDITIS CHRONIC INFECTIONS TUBERCULOSIS SIFILIS MALARIA AMILOYDOSIS

4. PAST MEDICAL HISTORY TOXICS DRUGS: aminoglycosides, amphotericin, lithium, ciclosporin and tacrolimus, paracetamol (in overdose), non-steroidal anti-inflammatory drugs (underperfused kidney), METALS: COPPER, CHROMIUM, MERCURY DIETARY: Calcium-rich food. INCOMPATIBLE BLOOD TRANSFUSION MECANICAL CRUSHING TRAUMAS; RENAL EMBOLISM or THROMBOSIS; EXTRINSIC COMPRESSIONS SECUNDARY TO OTHER DISEASES Hypertension, Diabetes, PARATHYROIDS diseases

5. FAMILY HISTORY RENAL MALFORMATIONS POLYCYSTIC KIDNEY DISEASE CYSTINURIA INSIPIDUS DIABETES RENAL TUBULAR ACIDOSIS TUBULAR NEPHROPATIES

6. SIGNS AND SYMPTOMS RENAL PAIN DIURESIS disturbances MICTURITION disturbances URINE ABNORMALITIES RENAL EDEMA GENERAL MANIFESTATIONS

7. RENAL PAIN RENAL COLIC CHRONIC LOIN PAIN PERINEAL PAIN STRANGURY

8. RENAL COLIC ONSET: SUDDEN TRIGGERS: VIBRATIONS, PHYSICAL ACTIVITY, RAPID WALKING LOCATION: RENAL ANGLE (usually UNILATERALLY); RADIATION: LOINS?FLANKS?FOSSAS?GROINS?GENITALIA; INTENSITY and DURATION: SEVERE, SUSTAINED AGRAVATED by: PALPATION, COUGH, SNEEZING AMELIORATED by: HEAT ASSOCIATED with: RESTLENESS, PALOR, COLD SWEATING NAUSEA, VOMITINGS TACHYCARDIA, ANGINAL PAIN, ILEUS, MICTURITION disturbances

9. RENAL COLIC

10. RENAL COLIC CAUSES: KIDNEY STONES BLOOD CLOTS PUS CLOTS PAPILLARY NECROSIS NEOPLASTIC TISSUE URETERAL STRICTURES KIDNEY PTOSIS KIDNEY MALFORMATIONS EXTRINSIC ACUTE OBSTRUCTIONS

11. RENAL COLIC DIFFERENTIAL DIAGNOSIS : APPENDICULAR COLIC ILEITIS BILIARY COLIC PANCREATITIS, DUODENAL ULCER GENITALS DISEASES VERTEBRAL PAIN MUSCULAR PAIN ACUTE ABDOMEN

12. CHRONIC RENAL PAIN

13. CHRONIC RENAL PAIN CAUZE: GLOMERULONEPHRITIS INTERSTITIAL NEPHRITIS RENAL INFARCTUS EXTRARENAL INFLAMMATIONS RENAL MALFORMATIONS POLYCYSTIC KIDNEY DISEASE RENAL PTOSIS

14. PELVIC PAIN

15. STRANGURY

16. DIURESIS DISTURBANCES POLYURIA OLIGURIA ANURIA NOCTURIA DIURESIS = INGESTA – (0,5-1L) SWEATINGS BREATHING METABOLISM DEFECATION

17. DIURESIS DISTURBANCES - POLYURIA PASSING A LARGER VOLUME OF URINE THAN NORMAL PHYSIOLOGICAL: - COLD ENVIRONMENT - EMOTIONAL STRESS - LIQUID INGESTION (ALCOHOL) PATHOLOGICAL: - INFECTIONS - ACUTE RENAL FAILURE - CHRONIC RENAL FAILURE - HEART RHYTHM DISTURBANCES - DIURETICS - DIABETES MELITUS - DIABETES INSIPIDUS - psychogenic polydipsia (polydipsia = excessive drinking)

18. DIURESIS DISTURBANCES - OLIGURIA DIURESIS < INGESTA – 1000 Passing a smaller volume of urine than normal REDUCE URINE VOLUME until 400 – 500 ml/day CAUSES: PHYSIOLOGICAL: - EXCESSIVE HEAT EXPOSURE - INTENSE SWEATINGS - LACK OF FLUIDS INGESTION - “DRY” DIET

19. DIURESIS DISTURBANCES - OLIGURIA CAUSES: PATHOLOGICAL: - COLICA RENALA - OBSTRUCTII TUBULARE - NEFROPATII INTERSTITIALE - PIELONEFRITE - IRA - IRC - VARSATURI - Sd. DIAREEICE - RETENTII HIDROSALINE - hipoTA - ENDOCRINE: ADH, PROGESTERON

20. DIURESIS DISTURBANCES - ANURIA DIURESIS < 150 ml/24 ore always PATHOLOGICAL - ACUTE RENAL FAILURE - CHRONIC RENAL FAILURE - persistent HYPOTENSION - severe HYPOVOLEMIAS - severe HIDROELECTROLITICS IMBALANCES - severe BLOOD ACID-BASE IMBALANCES

21. DIURESIS DISTURBANCES - NOCTURIA REVERSAL OF NORMAL DAY/NIGHT VOIDING PATTERN NORMAL RATIO DAY:NIGHT = 3:1 CAUSES: RENAL – POLYURIA – INCOMPLETE URINARY TRACT OBSTRUCTION EXTRARENAL – HEART FAILURE – LIVER CIRRHOSIS

22. MICTURITION DISTURBANCES FREQUENCY RARE MICTURITIONS DYSURIA PAIN ON URINATION URINARY RETENTION URINARY INCONTINENCE URGENCY

23. FREQUENCY Increased frequency of micturition without an increase in the total urine volume CAUSES: POLYURIA – ALCOHOL, FLUIDS INGESTION – EDEMAS – DIABETES INSIPIDUS – DIABETES MELITUS – KIDNEY FAILURE DECREASED CAPACITY OF THE BLADDER – CYSTITIS – BLADDER STONES – BLADDER TUBERCULOSIS – TUMORS – PELVIC COMPRESSION pregnancy, tumors, cysts

24. FREQUENCY CAUSES: IMPAIRED EMPTYING OF THE BLADDER – obstruction of bladder neck, proximal urethra DECREASED CORTICAL INHIBITION OF BLADDER CONTRACTION LOSS OF PERIPHERAL NERVE SUPPLY TO BLADDER

25. RARE MICTURITION MICTURITION numbers ? 3/day OLIGURIA INCREASED BLADDER CAPACITY MEGALOCYSTIS (MEGABLADDER, MEGACYSTIS) BLADDER DIVERTICULI

26. DYSURIA DIFFICULTY VOIDING Delay in initiating urine flow (HESITANCY) Impaired urine flow Reduced force of the urinary stream Double voiding (need to pass urine again within a few minutes of micturition) Post-micturition dribbling

27. DYSURIA NB: DIFFERENTIAL with PAIN ON URINATION – pain in DYSURIA has lombar location and it is due to vesico-ureteric reflux CAUSES: BLADDER: tumors, stones BLADDER NECK: UNDER BLADDER: – URETHRAL: strictures – PROSTATIC: benign hypertrophy, carcinoma EXTRA BLADDER – PELVIC TUMORS – NEUROLOGICAL DISEASES

28. PAIN ON URINATION PREMICTURITION: BLADDER NECK conditions MICTURIONAL: INITIALLY: bladder neck, proximal urethra TERMINALLY: cystitis CONTINUOUS: urethritis POSTMICTURION: prostatitis

29. URINARY RETENTION COMPLETE INCOMPLETE

30. ACUTE COMPLETE URINARY RETENTION OF SUDDEN ONSET SYMPTOMS: - urge to micturition - strangury - restlessness, anxiety SIGNS: - inspection: bulging hypogastrium - palpation: tender, elastic, in tension, well defined mass - percussion: dullness with convex upper edge sometimes associated with dribbling incontinence ! differential with ANURIA ? URINARY CATHETERIZATION !

31. CHRONIC COMPLETE URINARY RETENTION OF SLOW ONSET, IN EVOLUTION OF INCOMPLETE URINARY RETENTION SIGNS and SYMPTOMS: - FREQUENCY - DYSURIA - CHRONIC STRANGURY - DRIBBLING INCONTINENCE

32. INCOMPLETE URINARY RETENTION IMPAIRED EMPTYING OF THE BLADDER WITH RESIDUAL URINE IN THE BLADDER SYMPTOMS: - dysuria, frequency clinical examination: Normal ? BLADDER DISTENTION

33. URINARY RETENTION CAUSES URETHRAL BLADDER NECK BLADDER PROSTATIC EXTRAURINARY (vicinity) EXTRAURINARY (at distance) NEUROLOGICAL

34. EXAMINATION OF THE URINE HAEMATURIA PYURIA PROTEINURIA PNEUMATURIA CHYLURIA

35. EXAMINATION OF THE URINE

36. HAEMATURIA The presence of red blood cells in the urine due to bleeding from the kidneys or urinary tract CAN BE: MICROSCOPIC (1000–1mil. erythrocytes/ml/min) MACROSCOPIC ( >1mil. erythrocytes/ml/min) Color of the haematuria: RED or BROWN CAN LEAD to CLOTS and HAEMATIC DEPOSITS

37. HAEMATURIA CAUSES PRERENAL: HEMORRHAGIC conditions: coagulopathies thrombopathies, vasculopathies RENAL: glomerulonephrites, interstitial nephrites, tuberculosis, tumors, traumas, renal stones, polycystic kidney disease hypertensive nephrosclerosis, acute tubular necrosis, renal ischaemia (renovascular disease) schistosomiasis, urinary tract infection reflux nephropathy and renal scarring POSTRENAL: URETER: stones, tumor, inflammation, vascular malformation, traumas BLADDER: tumor, stones, inflammation, polyp, foreign objects URETHRO-PROSTATIC: tumor, stones, inflammation strictures, foreign objects, malformation

38. HAEMATURIA 3 CUPS TEST: INITIAL ? URETHRA, PROSTATE TERMINAL ? BLADDER TOTAL ? KIDNEYS and URETER

39. HAEMATURIA DIFFERENTIAL CONCENTRATED urine – increased specific gravity CONJUGATED BILIRUBIN RED-BROWN – normalized when heated ? URATES – drugs: L-Dopa RED – DRUGS (rifampicin, metronidazol) – FOOD: beetroot, blackberries

40. HAEMATURIA DIFFERENTIAL Like PORTO wine – free haemoglobin – myoglobin (traumatisme) like BURGUNDIA wine (darker shade overtime) – porphyrins Blood from other sources than urinary tract (menorrhagia, metrorrhagia, traumas)

41. PYURIA PRESENCE OF PUS CELL IN THE URINE CAN BE: MICROSCOPIC = LEUCOCYTURIA MACROSCOPIC - changes in urine aspect: LOSS of LUSTRE, TRANSPARENCY, MUCUS FRAGMENTS, PUS DEPOSITS - changes in odor of the urine

42. PYURIA CAUSES PRERENAL: septicemia, hematogenous dissemination of other systemic infections RENAL: tuberculosis, infected kidney stones, tumors, malformations, POSTRENAL: STONES NEOPLASMS MALFORMATION CYSTITIS INVASIVE UROLOGICAL MANEUVERS BENIGN HYPERTROPHY/CANCER PROSTATE

43. PYURIA DIFFERENTIAL CLOUDY urines URATES, PHOSPHATES Clarifies when HEATED/ACID adding CHYLURIA URETHRITIS VAGINITIS

44. PROTEINURIA PRESENCE OF PROTEINS IN THE URINE QUANTITY MICROALBUMINURIA 30-300 mg/day MEDIUM 300mg – 3.5 g/day HIGH > 3.5 g/day

45. PROTEINURIA CAUSES PRERENAL (normal glomerular filter) High protein levels in the blood (transfusions) Plasma cell dyscrazias RENAL abnormal glomerular permeability, decreased tubular reabsorbtion, tubular secretion GLOMERULOPATHIES, TUBULOPATHIES POSTRENAL Massive epithelial desquamations + leucocyturia

46. PROTEINURIA URINE PROTEIN ELECTROPHORESIS (UPEP) GLOMERULAR SELECTIVE NONSELECTIVE TUBULAR ABNORMAL PROTEINS

47. GLOMERULAR PROTEINURIA SELECTIVE mostly ALBUMIN GLOMERULOPATHIES with potential reversible evolution NONSELECTIVE ALL PLASMA PROTEINS SEVERE, IRREVERSIBLE GLOMERULOPATHIES

48. TUBULAR PROTEINURIA UPEP ? – TAMM-HORSFALL – ?2 MICROGLOBULIN CAUSES TUBULAR INJURY of any cause CHRONIC KIDNEY FAILURE PYELONEPHRITIS HYPERTENSION

49. ABNORMAL PROTEINURIA EXCESS OF LIGHT CHAINS CAUSES: MULTIPLE MYELOMA ESSENTIAL MACROGLOBULINEMIA AMYLOIDOSIS LYMPHOMAS

50. “PHYSIOLOGICAL” PROTEINURIA Only ALBUMIN Of transient character CAUSES: FEVER CHILLS EXERCISE EXTENDED ORTHOSTATISM INTERMITTENT PROTEINURIA CONGESTIVE HEART FAILURE

51. GENERAL MANIFESTATIONS FEVER SKIN and APPENDAGES OF SKIN RESPIRATORY changes DYSPNEA, KUSSMAUL BREATHING CARDIOVASCULAR changes URAEMIC PERICARDITIS RHYTHM and CONDUCTION abnormalities MYOCARDIAL CONTRACTION changes HYPOTENSION

52. GENERAL MANIFESTATIONS GASTROINTESTINAL NAUSEA, VOMITINGS ALTERED BOWELL HABIT HALITOSIS NEUROLOGICAL SOMNOLENCE, RESTLENESS, COMA SENSORIAL or MOTOR abnormalities PERIPHERAL NEUROPATHY

53. RENAL SYSTEM PHYSICAL EXAMINATION GENERAL PHYSICAL EXAMINATION SKIN and SKIN APPENDAGES: PALLOR, LEMON-YELLOW COMPLEXION, DRY SKIN ITCHING, SCRATCH MARKS “UREMIC FROST” UREMIDES “BROWN LINE” PIGMENTATION OF NAILS RENAL EDEMA

55. LOMBAR REGION, ABDOMEN and GENITALIA EXAMINATION I. INSPECTION

56. LOMBAR REGION, ABDOMEN and GENITALIA EXAMINATION I. INSPECTION LOMBAR REGIONS ABNORMAL BULGING/RETRACTION; SKIN CHANGES BULGING + INFLAMMATION: PERINEPHRITIC ABCESS VERTEBRAL MUSCLES CONTRACTURE: renal colic ABDOMEN BULGING OF THE FLANKS THIN patients, CHILDREN UNI or BILATERAL In: KIDNEY CYSTS, TUMORS HYPOGASTRIC BULGING BLADDER DISTENTION GENITALIA

57. LOMBAR REGION, ABDOMEN and GENITALIA EXAMINATION II. KIDNEY PALPATION KIDNEYS ARE NOT PALPABLE EXCEPTION RIGHT KIDNEY in THIN, WELL RELAXED WOMEN TEHNIQUES OF EXAMINATION: BOTH HANDS: 2 METHODS ONE HAND (A) GUYON Place your left hand behind the patient's back below the lower ribs. Place your right hand over the upper quadrant anteriorly just lateral to the rectus muscle. Firmly, but gently, push your two hands together as the patient breathes out. Then ask the patient to breathe in deeply. You may feel the lower pole of the kidney moving down between the hands. Balloting = gently push the kidney back and forwards between your two hands (B) Same as the previous Patient is sitting in RIGHT LATERAL DECUBITUS for LEFT KIDNEY and LEFT LATERAL DECUBITUS for RIGHT KIDNEY PALPATION.

58. KIDNEYS PALPATION

59. LOMBAR REGION, ABDOMEN and GENITALIA EXAMINATION II. KIDNEY PALPATION (C) ONE HAND place your left thumb in the right hypocondrium/ right thumb in the left hypocondrium the other four fingers are placed in the costovertebral angle try to catch the kidney between thumb and fingers and palpate it with your thumb in CHILDREN, VERY SLENDER PATIENTS

60. LOMBAR REGION, ABDOMEN and GENITALIA EXAMINATION II. KIDNEY PALPATION ENLARGED: unilaterally: PTOSIS, COMPENSATORY HYPERTROPHY, NEOPLASM, CYSTS bilaterally: POLYCYSTIC KIDNEY ISEASE (PKD) uni or bilateralLY: HYDRONEPHROSIS, PYONEPHROSIS SHAPE: ”BEAN” changes in: PKD, TUMORS, PYONEPHROSIS MOBILITY: slightly mobile pathological: PTOSIS CONSISTENCY: firm, elastic HARD in TUMORS, SLIGHTLY INCREASED in PKD, SOFT in PYO and HYDRONEPHROSIS SURFACE: smooth, regular IRREGULAR: TUMORS, PKD, PYONEPHROSIS TENDERNESS: NON TENDER on palpation

61. LOMBAR REGION, ABDOMEN and GENITALIA EXAMINATION II. PALPATION OF POINTS OF MAXIMUM TENDERNESS POSTERIOR COSTOVERTEBRAL: < formed by XII rib with the spine correspond to: KIDNEYS, UPPER PORTION OF URETER COSTOLOMBAR: LOWER and OUTER than the previous ANTERIOR SUBCOSTAL: anterior extremity of X rib PARAOMBILICAL: intersection of the horizontal line passing through umbilicus with the vertical line passing through MacBurney’s point MIDDLE URETERAL: inferior part of the hypogastrium, close to midline using rectal palpation

62. LOMBAR REGION, ABDOMEN and GENITALIA EXAMINATION III. KIDNEY PERCUSSION RESONANCE when anterior percussion of the flanks dullness in : CYSTS and LARGE TUMORS DULLNESS in HYPOGASTRIUM: DISTENDED BLADDER GIORDANO maneuver Sit the patient forward and palpate firmly but gently with your fingers. If this does not cause the patient discomfort, warn the patient what to expect firmly strike the renal angle once with the ulnar aspect of your closed fist It is POSITIVE (elicits/aggravates pain in the lombar region) in: KIDNEY DISTENSSIONS, STONES (!), ACUTE PYELONEPHRITIS IV. AUSCULTATION FLANKS, LOMABR REGION in UNI/BILATERAL RENAL ARTERY STENOSIS: ARTERIAL BRUIT