This document covers a detailed clinical assessment approach in nephrology, emphasizing the importance of patient history, symptomatology, and various urinary dysfunctions. It highlights key symptoms such as dysuria, polyuria, hematuria, and their potential causes, alongside considerations for past medical history, risk factors, and treatment approaches. Moreover, it discusses the management of patients on renal replacement therapy, outlining specific questions to facilitate effective patient care.

1. Email: usamaragab@medicine.zu.edu.eg, usama.ragab.zu@gmail.com
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2. Concept
• In nephrology, as in all
branches of medicine, a
competent clinical
assessment is crucial.

3. Personal History =
NAS OMRHH
• Name
• Age
• Sex
• Occupation
• Marital status
• Residence
• Habits (special)
• Handedness

4. Chief Complaint= ‫بالبلدي‬ ‫العيان‬ ‫كالم‬
Recent Short Non-medical terms

5. History of present illness= ‫منمق‬ ‫طبي‬ ‫كالم‬
Chronologically arranged
Long
Medical terms
= symptomatology of urology system

6. The history should incorporate symptoms and signs
Arising locally from the kidneys and urinary tract.
Resulting from impaired salt and water handling.
Caused by failing renal excretory and metabolic function.
Relating to a systemic disease, causing or contributing to renal dysfunction.

7. Sometimes, kidney is silent…
Abnormal BP, urinalysis, or eGFR.
Clinically useful syndromes.
Biochemistry, radiology, and/or histopathology are completing the puzzle
Diagnostic treatment e.g., cessation of a nephrotoxic drug or volume restoration

8. Local Symptoms in any system
Pain Swelling
Disturbance
of function
Loss of
function

9. Local symptoms of urinary tract disease
• Pain: Loin pain, ureteric colic, suprapubic pain.
Onset, course, duration.
Character.
Site, radiation.
What increase and what decrease
Association.
• Swelling
Edema
Local swelling = surgical consultation
• Disturbance of function (next slide)
• Loss of function= renal failure, ED
• Patient with new kidney

10. Disturbances of function
• Obstructive symptoms.
• Irritative symptoms.
• Volume abnormalities:
polyuria, oligurea and anuria.
• Change in urine appearance;
color abnormalities: e.g.
hematuria,
hemoglobinuria...etc...
Obstructive symptoms Irritative symptoms
•
Hesitancy; or abdominal
strain.
•
Poor stream
•
Intermittent stream
•
Terminal dribbling
•
Acute retention of urine
•
Sense of incomplete
emptying
•
Burning on micturition;
dysuria.
•
Urgency
•
Daytime frequency
•
Nocturia
•
Urge incontinence

11. Analysis of
Symptoms

12. 1- Dysuria, frequency & urgency
Dysuria means pain on passing urine rather than difficulty in doing
so
Frequency means that the urine is passed more often than normal
without an increase in the total volume.
Urgency is a strong desire to pass urine, which may be followed by
incontinence if the circumstances are not suitable (very common)
•Dysuria, frequency and urgency are associated with irritation
of the bladder and urethra by infections, tumor or stone.
•Dysuria alone may be due to urethritis.
•Urgency alone may be due to anatomical change as in
gynecological disorder or neurological diseases e.g. prolapse.
•Frequency alone may be due to anxiety or abnormal bladder
muscle tone (Detrusor instability) e.g. during examinations.

13. 2- Polyuria
This means an increase in urinary output> 3L/d regardless the
frequency of micturition.
Severe polyuria will cause thirst, which may be the presenting
symptom. Normal urine volume = 600 mL- 1800 mL.

14. Different cause of polyuria (Major
Polyuria syndrome)
1- Renal
- Chronic interstitial nephritis.
-Polyuric phase of acute tubular
necrosis
- Diuretic therapy.
- DI.
- RTA, Fanconi syndrome
2- Endocrinal
- D.M.; osmotic diuresis
- Cushing → K dieresis, HTN,
hyperglycemia
- Conn's → K diuresis (↓ K→
nephrogenic DI)
- Hypothalamic & pituitary D.I.
- Hyperparathyroidism (Ca diabetes)
3- Sickle cell disease 4- Functional

15. Patient with polyurea, polydipsia
Low specific gravity
Water deprifation test for 12 h.
No response
DI
Give ADH
Good response
Pituitary DI
No reponse
Nephrogenic DI
Good response
Psychogenic polydipsia
High specific gravity
If there is +ve sugar
in urine
DM

16. 3- Oliguria & Anuria
Oliguria: Urine output <400 mL/d (which is the minimal volume of
urine which is necessary to excrete the waste products); this varies
with diet, physical activity and metabolic rate as well as renal
function.
Anuria: means that urine volume is <100 ml /24hrs; it raises the
possibility of urinary tract obstruction (if obstruction is excluded,
consider bilateral renal infarction due to thrombosis of the renal
arteries or a descending aorta).

17. 4- Hematuria
• Presence of blood in urine
attributed to bleeding
from the urinary tract
You must ask whether it is painless or painful

18. Notes on
hematuria
When there is also frequency or dysuria
the bleeding mostly from bladder.
Hematuria that clears during micturition
arises from urethra
Hematuria all through usually arises
from the kidney.
Terminal hematuria is also of bladder
origin as in cases of bilharziasis.

20. Interpretation of Dipstick Positive Haematuria

21. 5- Pneumaturia
• It means sensation of passing
bubbles in the urine; this is
usually caused by vesicocolic
fistula (malignancy).

22. 6- Alteration of the force of micturition
A poor urinary
stream is common
in old males due
to senile prostate.
Demonstrate how
near he has to
stand to an
imaginary toilet.
This also can occur
with a urethral
stricture (less
common).

23. 7- Nocturia
• The need to pass urine at night or during
the sleeping hours may be a lifelong habit,
but a newly developing habit it may be due
to:
Prostatic obstruction → residual urine
→ irritation → desire
Heart failure

24. 8- Incontinence
(Types and causes)
• It is defined as inability of the urinary
bladder to retain urine.
Many females suffer from urinary
incontinence provoked by the stress
of laughing, sneezing or coughing,
this is due to gynecological disorders
e.g. prolapse
Retention with overflow leads to
incontinence (see neurogenic
bladder).
Urgency may also lead to
incontinence (urge incontinence).

25. 9- Urogenital pain
Renal Pain
• Patient could withstand it
• It is described as dull aching pain in
the loin.
• As in hydronephrosis and staghorn
stone, it is intermittent in polycystic
kidney due to spontaneous bleeding
into a cyst.
• Also renal pain occurs with acute
pyelonephritis.
Ureteric pain (colic)
• Patient in agony
• It is a more severe pain due to
obstruction of the ureter by stone or
blood clot. The pain radiates
downward to the groin and genitalia
(loin to groin).
• Once a stone reaches the bladder, it
becomes usually asymptomatic unless
it enters the urethra to cause dysuria.
• The ureteric colic is usually severe and
sustained associated with nausea and
vomiting; parasympathetic effect.

26. 10- Other
urinary
symptoms
Strangury: It is severe suprapubic pain
associated with inability to pass urine
(or dribbling), dysuria and urgency. It is
usually due to acute bladder neck
obstruction by a stone or blood clot.
Urgency: It is a sudden need to pass
urine.

27. 10- Other
urinary
symptoms
(cont.)
Hesitancy: It is a delay in initiating urine
flow; more in females, more prone to
postural syncope
Double micturition is when a patient,
soon after emptying the bladder wants to
do so again. This occurs in patients with
vesicoureteral reflux as they have a large
residual urine volume in the bladder.

28. 11- ED
Ask about the desire
With reduced libido With preserved libido
1. Hypogonadism
2. Depression
1. Psychological problems, including
anxiety, first experience
2. Vascular insufficiency (atheroma)
3. Neuropathic causes (e.g. diabetes
mellitus, alcohol excess, multiple
sclerosis)
4. Drugs (e.g. β-blockers, thiazide
diuretics)

29. 12- Edema
Usually involves the face (at first), the
ankles and legs.
There can be associated with ascites as
in the case of the nephrotic syndrome.
Anasarca= generalized edema.

30. 13- Renal failure
• The patient may complain of
nonspecific symptoms and
consult diverse of physicians
before being diagnosed.

31. Past History
Urinary tract problems as a child (e.g.,
infections, nocturnal enuresis).
Previously documented renal or urinary tract
disease of any kind. Ask specifically about
infections, stone disease, and, in ♂, prostatic
disease.
Hypertension. When diagnosed? Who is
responsible for follow-up? Current and
historical treatment? Level of control? Self-
monitoring with home BP monitor?

32. Past History
(cont.)
Cardiovascular risk factors or disease (e.g. IHD, CVA,
PAD, dyslipidaemia).
Other relevant systemic disease (e.g. diabetes
mellitus, connective tissue disorder, gout,
inflammatory bowel disease, sarcoidosis).
Insurance or employment medicals can provide
invaluable historical benchmarks. Can they recall a
past BP check or providing a urine specimen? Have
they had blood tests in the past?

33. Social History
Smoking: general CV risk in (and progression of) CKD, renovascular disease, urothelial
malignancy (74-fold risk), pulmonary haemorrhage in Goodpasture ’ s disease.
Physical activity.
Occupational history: risk factors for urothelial malignancy. Hydrocarbon exposure has
been implicated in glomerular disease, particularly anti-GBM disease.
Hepatitis and HIV risk factors.
A patient’s understanding of their kidney disease should be evaluated, and they should
be encouraged to be involved in decisions about their care.

34. Review of systems

35. May provide clues to an underlying systemic
condition
Skin rashes, photosensitivity, mouth ulcers e.g., SLE
Painful, stiff, or swollen joints e.g., RA, SLE
Myalgia.
Raynaud’s phenomenon e.g., vasculitis
Constitutional manifestation e.g., CTD
Thromboembolic episodes e.g., APS
Red or painful eyes e.g., RA, vasculitis

36. May provide clues to an underlying systemic condition (cont.)
ENT: Sinusitis,
rhinitis,
epistaxis e.g.,
GPA
Sicca
symptoms
(dry eyes, dry
mouth).
Haemoptysis
e.g., GPS
Hair loss e.g.,
SLE, vasculitis

37. Drug and treatment history
Antihypertensive therapy — past and present. Any important tablet
intolerances or side effects.
Analgesics — ask specifically about common NSAIDs (by their over-
the-counter names, if necessary). Then ask again.
Any ‘one-off ’ courses of therapy that may not be mentioned as part
of regular treatment, e.g. recent antibiotics (interstitial nephritis).

38. Drug and
treatment
history (cont.)
Oral contraceptive (increase BP).
Steroids, immunosuppressive agents —
type and duration.
Non-prescription, recreational
(cocaine, IVDU), and herbal medicines.
Current or historical exposure to
important nephrotoxic drugs.

39. Important
nephrotoxins

40. Family History
• Consanguinity
• Similar conditions
• Essential HTN: more
common if one or both
parents affected.
• DM (types 1 and 2): more
common if close relative
affected.

41. Sexual,
gynecological
& obstetric
history
Decreased libido and impotence are extremely
common in CKD.
Irregular menses and subfertility are frequently
encountered in ♀. Amenorrhea is common in
ESRD.
Previous pregnancies and any complications (UTI,
proteinuria, i BP, pre-eclampsia). Miscarriages,
terminations? Were infants healthy and born at
term?

42. Sexual,
gynecological
& obstetric
history (cont.)
In CKD, maternal and fetal outcomes are
importantly related to GFR, degree of
proteinuria, and BP.
Cytotoxic drugs used in the treatment of
glomerular disease can induce premature
menopause in ♀ or infertility in ♂. This may
influence treatment in a ♀ of childbearing age.
Risk factors for sexually transmitted disease
when appropriate (HIV, hepatitis B and C can
all cause glomerular disease).

43. Dietary
History
Changes in appetite and weight.
Dietary habits (alcohol, vegan, ethnic diet,
protein or creatine supplements).
Dietary advice is an important part of the
management of many renal disorders (i BP,
AKI, CKD, the nephrotic syndrome, stone
disease, dialysis).

44. Ethnicity & Renal Diseases
• IgA nephropathy: Caucasians and certain Asian populations
(China, Japan, and Singapore).
• Diabetic nephropathy: black, Mexican American, Pima Indian
(a native American tribe in Southern Arizona, beloved of
epidemiologists and geneticists). An increasing problem in
the immigrant Asian population in the UK.
• SLE: Asian and black patients (and more aggressive disease).
• Hypertension and hypertensive renal failure: black patients.
• In the UK, the incidence of end-stage renal disease (ESRD) is
73x higher in South Asian and black patients than in
Caucasians.

45. Approach to the patient on
renal replacement therapy
When managing a dialysis or transplant patient, there are a few direct questions that
will help you to get to grips with (and reassure the patient that you are familiar with)
their treatment. It will also facilitate discussion with the patient ’ s renal unit.

46. All dialysis patients
How long have they been on
dialysis?
How much urine do they pass,
if any?
What is their dry (aka flesh,
target, post-dialysis) weight?
What is their daily fluid
allowance?
Do they adhere to a renal
diet?
Do they know the cause of
their ESRD?
Do they receive EPO
injections?
Have they always been on the
same modality of dialysis?
Are they ‘listed ’ for deceased
donor transplantation?
Have they previously received
a transplant?
How are they coping with
dialysis?

47. The patient on haemodialysis
Where does the haemodialysis treatment take place?
How many times per week and how many hours
What is the patient’s current access for dialysis (e.g. an arteriovenous fistula)
What is their usual fluid gain between treatments?
Do they know their blood pressure at the end of session

48. The patient on peritoneal dialysis
(CAPD) or
automated
overnight (APD)?
How many
exchanges do they
perform?
How many litres is
each exchange?
Do they have fluid in
at the moment?
Do they need
assistance to
perform
Do they measure
their own blood
pressure at home?
Exit site of their
dialysis catheter
clean and dry?
Are the dialysis bags
clear or cloudy
When was their last
episode of
peritonitis?

49. The transplant patients
When and where was
the transplant
performed?
What
immunosuppression is
the patient taking?
Who is responsible for
their follow-up?
Do they know their
baseline SCr?
Was the transplant
from a living or
deceased donor?
Do they use sunblock
and attend a skin
clinic?
Do they know if they
had any rejection
episodes?
Do they know the
cause of their end-
stage renal disease?
What mode of dialysis
were they on prior to
transplantation?

51. Thanks
Email: usamaragab@medicine.zu.edu.eg, usama.ragab.zu@gmail.com
SlideShare: https://www.slideshare.net/dr4spring/
Facebook: https://www.facebook.com/doc.usama
Facebook Clinic: https://www.facebook.com/usamaclinic
Mobile: 00201000035863