Pulse: rate and volume (tachycardia and low volume may be due to blood loss)
Arms: arteriovenous fistula (look for active needle marks to see if it’s being used), bruising (Cushing’s syndrome), blood pressure (may be high due to hypertension, in renal graft rejection, or due a to calcineurin inhibitor),skin lesions (immunosuppression)
Heda and neck
Face: yellow tinge (uraemia), butterfly rash (SLE), hearing aid (Alport syndrome), collapsed nasal bridge (granulomatosis with polyangiitis)
Inspection: distension (5Fs: Fluid, Flatus, Fat, Fetus, Faeces), scars (loin scar, may appear on back; Rutherford Morrison scar in L/RIF from transplanted kidney – see scars), fat hypertrophy/lipodystrophy (insulin injections), peritoneal dialysis scars
Palpation: check for pain and begin palpation away from painful areas
Superficial palpation (for tenderness): you crouch to their level and roll fingers over nine regions while watching the patient’s face. Check for: tenderness, guarding or rebound tenderness (peritonitis).
Deep palpation (for masses): feel particularly for smooth renal graft in iliac fossae if scar present(tenderness = rejection)
Kidney palpation: one hand anterior, one posterior. Ask patient to expire as you press up into renal angle with your posterior hand and press down with your anterior hand. As patient breathes in, you may feel it between your hands. Ballot the kidney by flexing the metacarpophalangeal joints of your posterior hand. Do flick, flick, stop and repeat as necessary (palpable = polycystic kidney disease).
Percussionof flank: should be resonant (tap all the way across abdomen horizontally). If dull, demonstrate shifting dullness (have patient roll to side and percuss all the way across again), or demonstrate fluid thrill (have patient press hand firmly on abdominal midline while you tap one side and feel the other; ascites in co-existent liver disease)
Auscultation for renal bruits (5cm superior and lateral to umbilicus bilaterally; renal artery stenosis)
Pedal oedema (nephrotic syndrome or fluid overload)
Thank patient and restore clothing
Summarise and suggest further investigations you would consider after a full history
What are the most common causes of end-stage kidney disease
What symptoms may you expect in end-stage kidney disease?
What are the main indications for renal replacement therapy in kidney disease?
List some complications of chronic kidney disease
What options are available to patients with end-stage chronic kidney disease?