[Music] so what did the doctor tell his patient who had kidney stones he said sir you're in trouble you're in my thoughts um hi everybody it's Dr Ryan here and we're going to be talking about history and examination of the renal system hope you and your family are well here's the outline of today's talk we're going to be tackling a handy clinical case and then looking to genetically get into history taking and attacking an approach the examination of the genital urinary system talking about the technique behind examination looking at renal masses and the Chuck load of differentials behind those interpreting changes in the urine dipstick talking a bit about proteinuria hematuria touching on chronic kidney disease and we're going to be closing with investigations immunal disease and encouragement from scripture all right here's our clinical case an evaluation of acute kidney injury patient who has recently undergone cardiopulmonary bypass trading matter of replacement which of the following findings on neuromicroscopy is most suggestive of cholesterol imply as being the source of the Nino failure is it a calcium oxalate crystals D normal sediment or e y blood cell cast I wonder so this is my time on the sequence for history taking I'm sure if you're familiar with my videos you're familiar with this template the mnemonic here is perhaps salt makes good food so tantalizing but of course we're honing into the systemic inquiry as it pertains to the renal system also note medication history is very important uh noting conditions like diabetes hypertension HIV which has the potential to damage the kidneys as well as a variety of therapeutic options especially medication like amphotitis and B like Amino glycoside antibiotics like nostril anti-inflammatory drugs right so you want to take a good medication history now when teasing out the systemic and quietly as it pertains to the renal system you want to ask first about change in the appearance of urine sometimes it's maybe obvious because it's just hematuria which is macroscopic then you want to inquire about changes in the urine volume or Stream So if you have to typically quantify this in the hospital setting probably urea is defined as a passage of more than three liters of urine per 24 hours oliguria is a passage of less than 400 moles of eating per 24 hours and Udi is even worse less than 100 miles per 24 hours you want to inquire from the patient about not Julia which pertains to maybe diabetes meniscus a decrease in the Stream size hesitancy on starting to pass urine terminal dribbling after passing urine and urinary retention all of which could suggest maybe BPH in and out in the male and these are what we call lower urinary exact symptoms then there's this entity called strain Guri strain Yuri which speaks to a blockage or irritation at the bladder base and sky have a severe pain with an intense urge to urinate another symptom is called it speaks to double voiding which implies incomplete bladder emptying as well as incontinence of urine is something we must always ask about right what about renal colic now renal colic is typically described as loin to grind pain and it speaks to some kind of obstruction calling causing chronically pain in those units most commonly um you know a renal Stone then you want to inquire about this urea which speaks to painful micturition and of course that's coupled with frequency urgency and incontinence uh fever and loinc pain any erythritical discharge and you also want to inquire about symptoms suggestive of chronic kidney disease and then we have like you mentioned oliguria nocturia polyurea anorexia a metallic taste in the mouth vomiting fatigue hiccups insomnia as well as proritis intense prolitis is itchy man bruising and edema as well then in terms of the uh genital portion of the Genesis urinary history it's good to inquire about men seeds and females and talk about the age of onset which is the regularity of the periods the last period dates as well as inquiring about dysmenorrhea and menorrhagia in men you know it's a bit of a touchy issue but it's good to find 15 diabetics about impotence and loss of libido and infertility and the females how many times have they been pregnant before so establish the parity and gravity and any complications in those pregnancies it's good to inquire about udit and vaginal discharge as well as any genital rash or righty clouds and shows us the location of the kidneys they sit as we know retro peritoneally just behind the 11th rib you got a right and a left kidney all right and this is just demonstrating the functional units of the kidney which is the nephron okay so we start off with the vasculature right so we have afferent arterial which gives rise to the glomerulus and the Earth and arterial and thereafter that forms the renal artery in the renal vein what happens here is that blood is filtered through the glominious and passes through a system of shovels already so we have the proximal convoluted tubule then we have the loop of Hennel which consists of a thin wall segment and a thick wall segment descending and ascending right then that gives Ash the distal convolution tubule and then circulating tubule which goes to collecting duct and out via the ureter all righty so this just demonstrating once again the male unit attack so we start off with um the calluses so you have the renal pelvis and the calyx which drains adrenal pyramids coming down into the urethra and that comes on with the bladder and from the bladder out by the urethra right so we have the internal sphincter and the external sphincter here right and we have different portions of the urethra we have the prostatic urethra we have the members urethra the spongiosurita and the external urethra okay so this is giving us a bird's eye view of what we're gonna encounter when we examine that you know system so we're going to observe generally for power and fatigue and tightness breathlessness and assist the hydration in terms of reduction in Skin Surgery or fluid depletion uh bruising itching and scratch marks right in the hands you look for acid axis remember the differential of acidics this is Broad it can be renal failure or a spiritual failure hepatic failure the disc goes on in the nails you want to pay attention to both lines splinter hemorrhages pigmentation and mux lines as well as titties Nails right and the arms don't miss the opportunity to take the past and the blood pressure look for AV fistula and carpal tunnel syndrome and the face and neck you're looking for the salar complexion Pala check the GDP address this whether the patient is full volume overloaded so smell Fury make feature but this of course is fallen out of favor because of the risk of transmission of covid so I mean that's not a very prudent sign but also be able to look after gingival hypoplasia and is looking for the typical changes of hypertensive and diabetic retinopathy as well as bandicootopathy you want to ask our state in the posterior basis for crackles and also note if there's hyperventilation that we have customized respiration and the heart you want to listen for your extra heart sounds which may speak to full volume overload or the pericardial friction drop which happens with uremia in the abdomen we're going to talk about that right later on the legs check for edema which speaks to hypoproteinemia and fluid overload and of course example four peripheral neuropathy okay let's get started guys when you're examining the renal system you want to lay the patient flat in bed while performing the usual gentle inspection you want to particularly note the mental status of the patient the presence of the salmon complexion the state of hydration in any hyperventilation or hiccuping then detail examination begins with the hands examination of the nails which may reveal eukanokia because of hypoallinemia in the setting of nephrotic syndrome all right you may have white transverse lines something we call mux lines a single White Band which is mise lines and a distal ground Arc which is what they tell half and half nails or Terry's Nails we're going to see a picture of that later on you want to examine the wrists and arms for vascular access sites get the patient to hold out the hands and up the wrist to separate the fingers and look for the flapping trimmer of asterixis you want to inspect the arms for bruising living with that in renal impairments we have a qualitative plated dysfunction which will lead to problems with clotting and inevitably you end up with bruising no deer subcutaneous nodules and also calcium phosphate deposits pigmentation scratch marks and Gautier so here is a beautiful picture showing us uh prioritis exclamation in the lower limbs associated with chronic kidney disease here's a beautiful picture of Cherry's Nails otherwise known as half and half nails with the distal half being hyperpigmented and the proximal half being hypo pigmented right this is an example of an arterial venous fistula showing sites of needle cannulation for hemodialysis already okay then you want to proceed to the face and examine the eyes looking for parallel for jaundice and band keratopathy examine the mouth for dryness ulcers and for fetal and note the presence of a vasculitic rash on the face always be on the lookout especially in young females with a butterfly of Ash of systemic lupus erythematosis the wolf oh the patient should be lying flat while the abdomen is examined you want to note any scars indicative of peritoneal dialysis or any operations including a prior renal transplant palpate those kidneys and recovered how to ballot and feel for kidneys when we looked at the examination of the abdomen in a previous video I encourage you to go and have a look at that so you have a puppete for kidneys including transplanted kidneys then examine for the liver and the spleen fuel for an abdominal aortic aneurysm percuss over that bladder and determine whether they are societies material signs of ascites or 15 dollars food though and you may have a puddle sign listen for those renal Breeze uh you know listen uh just two centimeters above the umbilicals to the left or to the right listen for those zenal praise and rectal examination is indicated to detect the prostatomegaly or bleeding as indicated so here is showing us the proper technique for blotting the kidneys so you go one posterior one anterior and you try and block the kidneys between the two alrighty um so this is once again just a different picture showing the same technique of blotching of the kidneys this is what we efficiently called Murphy's kidney punch right so this is trying to ascertain whether the patient has any loin pain associated with pyelonephritis okay um so that being said we just gonna set the patient up and I'll pay the back for tinnitus of any cycle edema look at the jugular Venus pressure with the patient at 45 degrees if it's elevated it may speak to a fluid volume overload you want to examine the heart for signs of pericarditis which happens in the setting of uremia cardiac failure and auscultate those uh posterior lung bases for pulmonary edema okay so this is how we assess renal angle tinnitus as shown all right so a differential if you find a big old renal Mass it could be a unilateral kidney or bilateral for the kidneys now the common coupler for unilateral kidney include renal cell carcinoma it could be any natural hydronephrosis or pyonephrosis could be polycystic kidneys with asymmetrical enlargement that could be acute renal vein thrombosis occupied and Fighters regular abscess or compensation hypertrophy of a single functional kidney if you get bilateral big old palpable kidneys it could indicate adult onset polycystic kidney disease by natural hydronephrosis renal cell carcinoma diabetic nephropathy early on nephronic syndrome infiltrative disease like amyloidosis and former the list goes on acromegaly and very rarely bilateral adrenal vein thrombus all right then you want to lay the patient down and look at the legs look at them legs for edema which could signify nephrotic syndrome or cardiac failure check for bruising pigmentation scratch marks and note for the presence of any gouty topi lastly example for peripheral neuropathy in which case that will manifest as diminished sensation and loss of the more distal reflexes don't miss the opportunity to measure the blood pressure both lying and standing or else you're going to miss postural or orthostatic hypotension dual fundoscopy and look for those beautiful changes of diabetic and hypertensive retinopathy and guys I know we said if the last thing was in the previous tab actually there's more to look for I'm sorry I was wrong you want to do your urine dipstick and what you're looking for is specific parameters like the specific gravity the pH the glucose the presence of blood protein leukocytes and ketones okay so here we're looking at some causes of unity color changes right so if the urine is very pale or colorless that indicates diluted and you couldn't beat your bottom dollar that patient is over hydrated or had maybe diabetes insipidus or has post obstructive biosis if the urine is you know orange that speaks to a very concentrated urine so the patient is probably dehydrated but it could be caused by bilirubin or certain substances as mentioned if it's a brownish urine it's probably bilirubin in there on of course some antibodies can cause it as well pink urine usually speaks to beetroot consumption or uh for an afternoon or uric acid crystalluria which is massive red urine is always concerning for hematuria we can also be due to hemoglobin urea or myeloma which may also be pink brown or black watch out for other causes like porphyria or porphyrins and if you not sure whether a patient is compliant on a TBC but just look at the urine if the urine is nice and orange that probably speaks too and if Ampersand causing it okay so that patient is probably compliant on the TV treatment and the causes of green and black urine are mentioned here as well as white or milky urine speaking to kyaluria if your name is Kyle I'm not talking about you I'm talking about kinderia so here I'm looking at causes of proteinuria so proteinuria can be due to renal disease or non-renal disease from the causes of renal causes of proteinuria we speak together Fighters diabetes menises amyloidosis SLE drugs like gold and penicillin amine malignancy as in myeloma or infection but non-renal causes include fever severe exertion Burns heart failure orthostatic protonator which occurs when the patient is upright but not lying down and that will manifest usually in the first morning sample which will not show protein media and of course severe hypertension right fund diagram for midcomate.com showing us a differential or the different kinds of unity costs that we get right so a broad or a waxy cast happens in the setting of chronic little failure a higher Line cast can happen with exercise diuretics concentrated urine fatty casts and the way of overall fat body is usually are pathognomic for nephrotic syndrome okay a white blood cell cast happens in the setting of a decision the virus or finally nephritis a red blood virus renal tubular epithelial cell cast happens in the setting of acute human necrosis yes if prenatal failure goes on without being properly Managed IT can give rise to ATN which is probably the most common cause of Aki in the hospital setting granular casts in the setting of chronic renal failure but if it's money broadcasts that usually happens in the setting of acute tubular necrosis talking about about nephratic syndrome okay the definition of nephronics and investor proteinuria which is above 3.5 grams for 24 hours and all the other features can be simply explained by that loss of protein do you also get hypo album anemia with acetamine being below 30 gram per liter you get edema on account of the hypoaminemia and you get hypolipidemia why pre-tel do you get hyperlipidemia due to the increased LDL of cholesterol probably from loss of the plasma factors that regulate lipoprotein synthesis and the common complex for nephratic syndrome if it's secondary are drugs as mentioned systemic disease in a way of essence or diabetes amyloidosis it could be a malignancy Associated the lacks of mass of myeloma lymphoma and infections Hepatitis B hepatitis C Infinity malaria HIV but we also have the primary flavor of nephrotic syndrome and the usual couples there are minus grain interference minimal change domain and refinance and focal and sigmatical among sclerosis one of the common causes of glycosidia and ketoneuria well of course the poster child for glycosidia is diabetes mellitus however other reducing substances can also cause it as well as the impaired renal tubular ability to absorb glucose especially affecting the proximal tubules and if that be the case you'll also have leakage of protein and other substances and that's what we call fanconi syndrome kitchen area often happens in the setting of diabetic ketoacidosis starvation also an alcoholic induced ketocerosis as well this is a nice diagram showing us the different sources of hematuria so it could be coming from the kidney in the way of renal cancerous polycystic kidney disease you know vascular disease it could be TB affecting the urinary tract being in the kidney oil the ureters hypertension induced nephroserosis it could be a transitional cancer now coming lower down can be due to renal stones schistosomiasis in the bladder a urinary tract infection prostate cancer iriditis or contamination right so there's a whole truckload of causes of hematuria right and then we can further certify that into whether the hematuria is painless painful or either the common cause of pain less the materials TB right schistosomiasis hypertensive leftover sclerosis acute tubular necrosis renal ischemia as well as coagulation disorders if that hematuria is associated with pain you're thinking about a urinary attack infection or the 90 grain paint of renal stones without obstruction uh and these causes mentioned at the bottom can either manifest with painless or painful hematuria okay looking at the features of chronic kidney disease in this beautiful diagram from the clouds so you want to look if the patient has any dialysis catheter right whether it's a tank cough or whether it's a temporary vascular catheter or a dual Lumen permanent catheter you're looking for a yellow complexion palette the jvp is usually erased in a setting of flow volume or with tamponade coming from uremia right there could be an increase respiration rate and depth in metabolic acid also speaking to Cosmos respiration watch out for that pericardial friction rub feel for the transplanted kidney with overlying scar look for your titties nails look for the excoriation look for easy bruising and examine four peripheral neuropathy in the way of absent reflexes diminished sensation and paresthesia this is a fun way to represent the different stages of chronic kidney disease so we know the stage one through stage five and stage three split into three a and three B so in stage one there's kidney damage with a normal or increased granular filtration rate and the GFI here is usually above 90 and our aim here is to diagnose and treat the underlying conditional probabilities stage 2 kdgo is where your GFR drops to between 1689 and here we want to estimate the rate of progression ch3 is what we call Modric right which is a GFR between 30 and 59 right so if it's between um basically 45 and 59 that's what we call ckdc3a and 3B is between 30 and 45 and here we aim to evaluate and see complications if your GFR drops between 15 and 29 that's what we call stage 4 or severe CKD and here we want to make preparations for real replacement therapy because our patient is going to require dialysis soon th5 is end-stage renal disease which is basically what the patient requires dialysis this is just showing us a nice viewed dipstick and here the different parameters we're going to look at when you analyzing the urine dipstick right so the specific gravity reflects the urine solid concentration and varies between 1.02 and 1.035 this the specific gravity is increased when the kidneys actively reabsorb water as in the setting of fluid depletion or renal failure due to diminished profusion low specific gravity speaks to failure of the kidneys to concentrate urine the normal urine Pierce is between 4.5 and 8 internal tubular acidosis the pH never Falls below 5.3 despite acidemia of cosmic for glucose small amounts excluded in the urine are usually normal but anything above two plus is pathological check for your ketones check for protein for blood for bilirubin and neurobion when leukocyan esterase which would probably speak to urinary attack infection or inflammation stones or urothelial cancers check for your nitrites as well which also speaks to infection all right the common causes of chronic kidney disease the most common cause of chronic kidney disease worldwide is diabetes and hypertension closely there but in the developing World Romanian arthritis is also an emerging cause and of course the other causes as mentioned here one of the clinical features that suggests that renal failure is chronic rather than acute is your small kidney size and ultrasound except when you're dealing with polycystic kidneys diabetes Amino Doses and myanoma those are the four exceptions otherwise CKD usually manifests with bil natural small kidneys renal bone disease which is terminal osteodes but you also get a dynamic bone disease and Brown's tumor anemia with normal red blood cell in this it's a normal static number chromic anemia why do you get that because the diminishes Metropolitan coming from the kidney and peripheral neuropathy so these four features speak to chronicity of kidney disease already okay guys we're just approaching the end shortly this is a list of the different biochemical and serological investigations we do in the setting of kidney disease so we can estimate your creatinine clearance we can compare to your estimated level of filtration date and we spoke about that into the urea and electrolytes we look at the different individual electrolytes looking at potassium which is usually a high in advanced CKD bicarbonate which is going to be low because of the acidosis you have diminished calcium on the back of impaired renal vitamin D3 activation and hyperphosphatemia and diminish excretion in CKD increased urate is common in CKD but Sodom associated with God you can also do the urine osmolality the alkaline phosphatase and plants that are hormone which tends to be increased in the setting of secondary hyper parathyroidism related to diminished calcium and increased phosphate and if you're looking for a prospective cost you can also look at your antinuclear factor and your anchor as we know that SLE and vasculitis may affect the kidneys all right other investigations as mentioned the plane abdominal x-ray as we note that more than 90 percent of stones are radio opaque and ultrasound scan it can be done for a number of reasons to assess the kidney science and shape and position to look for evidence of obstruction and hydronephrosis or hydrogenita Justice for renal assists or solid lesions with stones to establish the post maturation residual volume and any gross abnormality of the planet and it's also used to guide kidney biopsy Dr autosynthedral vessels if you're thinking about renal artery stenosis the intervent thrombosis or Universal disease you can also go for IV urography or CT urography suspecting a Urological issue and the way of stone disease a renal Mass tumor staging and so forth other investigations include CT angio or Mr angio isotope scan adenobiopsy which is used to diagnose parenchymore renal disease it's coming back to our case guys we've been sitting off or in the evaluation of Aki in a patient who's recently undergone cardiopulmonary biopath during matchup after basement which the following findings are suggestive of cholesterol emboli as a source of the renal failure drum roll please [Music] urea so as we know that cholesterol employee are an important source of Aki in patients who have undergone chronic procedures that may disadopt iotic atherosclerotic disease Now The Telltale sign guys on physical examination of this is what we call liver reticularis which is the net-like formation that we see in the skin peripheral blood is in the philia may be present as well so everybody I just want to encourage you from the scripture today I want to talk about growing old in the book of Isaiah chapter 46 4 it tells us even to your old age I am he and the gray hairs I will carry you book of Psalm Chapter 19 Verse 12 says Lord teach us the number of days to be making a heart of wisdom listen none of us are getting any younger but the promise is that the Lord is with us he is always with us and he will never leave nor forsake us I pray that you will actively pursue him and actively pursue Jesus even as we grow old these are my references thank you for joining me I'll see you soon with another video on my YouTube channel I just want to thank everybody for your support in watching my videos and subscribing and liking and sharing God bless you in advance I'll see you soon foreign