URIN Hx & Exam

Urinary

Chronic Renal Failure

History

1. Duration of Symptoms:

   • Ask about the onset and duration of symptoms such as fatigue, swelling, and changes in urination.
   • Chronic renal failure typically develops over months to years.

2. Urinary Symptoms:

   • Polyuria (increased urine output) or Oliguria (reduced urine output).
   • Nocturia (frequent urination at night).
   • Hematuria (blood in urine).
   • Foamy urine (suggestive of proteinuria).
   • Dysuria (painful urination) may indicate a concurrent urinary tract infection.

3. Past Medical History:

   • Hypertension: A common cause and consequence of CRF.
   • Diabetes Mellitus: A leading cause of CRF due to diabetic nephropathy.
   • Glomerulonephritis: History of autoimmune diseases or infections.
   • Polycystic Kidney Disease: Family history of kidney disease.
   • Recurrent Urinary Tract Infections or Obstructive Uropathy (e.g., kidney stones, enlarged prostate).
   • Nephrotoxic Drug Use: Long-term use of NSAIDs, certain antibiotics, or chemotherapy agents.

4. Systemic Symptoms:

   • Fatigue and weakness due to anemia (common in CRF).
   • Nausea, vomiting, and loss of appetite due to uremia.
   • Pruritus (itching) due to accumulation of uremic toxins.
   • Bone pain or fractures due to renal osteodystrophy (secondary hyperparathyroidism).
   • Peripheral edema (swelling in legs and feet) due to fluid retention.
   • Shortness of breath due to fluid overload or anemia.

5. Family History:

   • Family history of kidney disease, hypertension, or diabetes.

6. Social History:

   • Alcohol and tobacco use.
   • Occupational exposure to nephrotoxins.
   • Dietary habits (high salt or protein intake).

7. Medications:

   • Review all medications, especially NSAIDs, ACE inhibitors, ARBs, diuretics, and nephrotoxic drugs.

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General Examination

A general examination in CRF is aimed at identifying signs of systemic involvement and complications of kidney failure.

1. General Appearance:

   • Pallor: Due to anemia.
   • Cachexia: Wasting in advanced disease.
   • Uremic Frost: Rare, but a sign of severe uremia where urea crystals deposit on the skin.
   • Skin Changes: Dry, itchy skin, hyperpigmentation, or excoriations from scratching.

2. Vital Signs:

   • Blood Pressure: Hypertension is common in CRF.
   • Pulse: Tachycardia may indicate anemia or fluid overload.
   • Respiratory Rate: Tachypnea may indicate metabolic acidosis or pulmonary edema.
   • Temperature: Low-grade fever may indicate infection.

3. Edema:

   • Peripheral Edema: Swelling in the legs, ankles, and feet due to fluid retention.
   • Periorbital Edema: Swelling around the eyes, especially in the morning.
   • Ascites: Fluid accumulation in the abdomen in severe cases.

4. Cardiovascular Examination:

   • Jugular Venous Distension (JVD): Suggestive of fluid overload.
   • S3 Gallop: May indicate heart failure due to volume overload.
   • Pericardial Rub: Suggestive of uremic pericarditis.

5. Respiratory Examination:

   • Crackles or rales: May indicate pulmonary edema due to fluid overload.
   • Pleural Effusion: Dullness to percussion and decreased breath sounds.

6. Abdominal Examination:

   • Hepatomegaly: May indicate congestive heart failure.
   • Palpable Kidneys: In cases of polycystic kidney disease.

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Examination

Inspection:

1. Skin:

   • Look for pallor (anemia), hyperpigmentation, or uremic frost.
   • Excoriations from scratching due to pruritus.
   • Bruising or petechiae due to platelet dysfunction in uremia.

2. Face:

   • Periorbital edema (swelling around the eyes).
   • Pallor of the conjunctiva (anemia).

3. Hands:

   • Pallor of the nails (anemia).
   • Clubbing or koilonychia (spoon-shaped nails) in severe anemia.

4. Legs:

   • Pitting edema in the lower extremities due to fluid retention.

Palpation:

1. Abdomen:

   • Palpable kidneys: Enlarged kidneys may be felt in polycystic kidney disease.
   • Tenderness: May indicate infection or obstruction.

2. Peripheral Pulses:

   • Check for diminished pulses in the lower extremities, which may indicate peripheral vascular disease, common in CRF patients.

Percussion:

1. Abdomen:

   • Shifting dullness: May indicate ascites in severe fluid overload.
   • Dullness over the flanks: Suggestive of fluid accumulation.

2. Costovertebral Angle (CVA) Tenderness:

   • Tenderness over the kidneys may indicate pyelonephritis or obstruction.

Auscultation:

1. Heart:

   • S3 gallop: Suggestive of heart failure due to fluid overload.
   • Pericardial friction rub: Suggestive of uremic pericarditis.

2. Lungs:

   • Crackles or rales: Suggestive of pulmonary edema.
   • Decreased breath sounds: May indicate pleural effusion.

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Other Notes

• Laboratory Investigations:

  • Serum Creatinine and Blood Urea Nitrogen (BUN): Elevated in CRF.
  • Electrolytes: Hyperkalemia, hyperphosphatemia, hypocalcemia.
  • Complete Blood Count (CBC): Anemia due to decreased erythropoietin production.
  • Urinalysis: Proteinuria, hematuria, or casts.
  • Glomerular Filtration Rate (GFR): Decreased in CRF.
  • Imaging: Renal ultrasound to assess kidney size and structure.

• Complications to Monitor:

  • Cardiovascular Disease: Leading cause of death in CRF patients.
  • Anemia: Due to decreased erythropoietin production.
  • Bone Disease: Due to secondary hyperparathyroidism.
  • Electrolyte Imbalances: Hyperkalemia, metabolic acidosis.
  • Infections: Due to immune dysfunction in uremia.

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Example Case

C1

55 years old male driver from bangaladish known case of DM, HTN, and high cholesterol. presented to hospital with 10D dysuria, oliguria with increased fluid intake subsided later in with treatment, 7D hx of abdominal pain, associated with back pain, headache

On inspection he is alert and conscious on foley catheter

C2

58-year-old male with a history of hypertension and type 2 diabetes mellitus presents with fatigue, swelling in the legs, and decreased urine output over the past 6 months.

History:

• Chief Complaint: Fatigue, leg swelling, and decreased urine output.
• Duration: Symptoms have been progressively worsening over the past 6 months.
• Urinary Symptoms: Nocturia, oliguria, and occasional foamy urine.
• Past Medical History: Hypertension for 10 years, type 2 diabetes for 15 years.
• Medications: Metformin, lisinopril, and aspirin.
• Family History: Father had hypertension and died of a heart attack at age 65.
• Social History: Smokes 1 pack of cigarettes per day for 30 years, occasional alcohol use.

General Examination:

• Vital Signs: BP 160/95 mmHg, HR 88 bpm, RR 18/min, Temp 98.6°F.
• General Appearance: Pale, tired-looking, with periorbital edema.
• Edema: 2+ pitting edema in both lower extremities.
• Cardiovascular: Jugular vein distention present, S3 gallop heard.
• Respiratory: Crackles heard at the lung bases bilaterally.
• Abdomen: Non-tender, no palpable masses, no hepatomegaly.

Investigations:

• Serum Creatinine: 4.5 mg/dL (elevated).
• BUN: 60 mg/dL (elevated).
• GFR: 20 mL/min (Stage 4 CKD).
• Electrolytes: Hyperkalemia (K+ 5.8 mEq/L), hypocalcemia.
• CBC: Hemoglobin 9.5 g/dL (anemia).
• Urinalysis: Proteinuria, no hematuria.
• Renal Ultrasound: Bilateral small kidneys with increased echogenicity.

Diagnosis:

• Chronic Renal Failure (Stage 4 CKD) secondary to hypertensive nephropathy and diabetic nephropathy.

Plan:

• Management:
  • Control blood pressure with ACE inhibitors.
  • Manage diabetes with insulin.
  • Dietary restrictions (low potassium, low phosphate).
  • Erythropoietin therapy for anemia.
  • Referral to nephrology for possible dialysis planning.

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HOW WILL YOU TREAT A PATIENT WITH CRF?

• Control DM and HTN
• Treat the underlying cause
• Avoid renal damaging agents: NSAIDs, aminoglycosides, i.v. contrast
• Low protein diet
• Anemia: Fe and erythropoietin
• Fluid overload: Diuretics, low salt and water
• Proteinuria: ACE

• Pericarditis only dialysis
• Neuro symps only dialysis
• Acidosis : Na bicarb tabs
• Bone problems: Vit D, Calcium, sometimes cinacalcet ( to suppress PTH)
• Finally, may be dialysis or transplant, if there is indication