Kidney examination

The investigation (diagnosis) of the kidneys is quite a difficult task, since most of the so-called nephrological diseases have a latent flow for a long time, it does not manifest itself with subjective symptoms (unpleasant sensations, and most importantly, pains) that make it necessary to consult a doctor and, therefore, medical examination for another reason: for example, during pregnancy or during the primary detection of high blood pressure, a simple urinalysis is very important To identify a secretively developing kidney disease. Many well-known clinicians paid attention to the examination of the patient with kidney disease. In the first place should be called R. Bright (1789-1858), whose name is particularly closely linked with the development of nephrology.

More than 150 years ago, the clinical descriptions of various manifestations of kidney diseases were made by R. Bright more than once: "With the passage of time, a healthy complexion fades, weakness or pain in the lower back is added, headaches often accompanied by vomiting are added to the general discomfort: fatigue, lethargy and depression gradually take possession of his spirit and body ... If the nature of the disease is suspected, a thorough urine test is performed, and albumin is detected almost at each examination. "

[1], [2], [3], [4]

Questioning the patient about kidney disease

Knowing the basics of clinical kidney research is important not only for the future nephrologist, but also for a doctor of any other profile, let alone a general practitioner. It begins with the questioning of the patient, primarily the study of his complaints.

Complaints

The state of health of the renal patient, despite the existing disease, often remains satisfactory for a long time. Often an active, purposeful questioning with clarification of complaints and anamnesis of the disease is necessary.

Considering that renal damage is often leading in a number of general and systemic diseases ( gout, diabetes, systemic lupus erythematosus, etc.), the signs of the latter can be the main ones in the picture of the disease.

Very often, the patient is disturbed by general weakness, fatigue, reduced ability to work, which patients of any age, most often during an exacerbation of kidney disease : usually in the period of increased renal edema or arterial hypertension, ie, during the intensification of activity of the pathological process. Such complaints as nausea, vomiting, diarrhea, and also pruritus may be signs of a far-gone renal failure (uremia), a terminal stage of kidney disease (long and latent), which the patient did not know about.

A number of complaints can be associated with violations of homeostasis, the maintenance of which, as is well known, largely depends on the activity of the kidneys, this most important "arbitrator" of homeostasis. Thus, some symptoms are associated with a large loss of urine albumin, and with it other substances - trace elements, enzymes, etc. For example, excretion of iron leads to the development of anemia and related complaints, the loss of zinc causes a decrease in taste and t etc. A symptom is a common fever for many diseases-fever-in a number of cases, it develops as a result of a urinary tract infection (fever with chills and profuse sweat after pyelonephritis ), but often due to a common infection, sepsis (eg, subacute infection onocardial endocarditis ), in which there is often a kidney damage. Sometimes the fever is non-infectious (immune), which occurs in a number of systemic diseases (systemic lupus erythematosus, rheumatoid arthritis, etc.) that occur with nephropathies. These systemic diseases are characterized by the involvement of joints, skin, and muscles in the process, which makes the kymptomatics of the renal process caused by them more diverse. With such common common diseases as gout, diabetes mellitus, the clinical symptoms of the kidney process can be obscured by signs of a common disease: articular syndrome with gout expressed by thirst for diabetes mellitus, etc.

In some cases, the patient may have symptoms directly related to kidney disease, but manifesting atypically: for example, sudden blindness due to severe renal hypertension causes the patient to seek help from an oculist or bone fractures due to the nephrogenic nature of osteopathy leading him to a surgical hospital . Headache, dizziness, palpitations with pain in the heart, dyspnea often occur with a nephrogenic hypertonic syndrome, mistakenly interpreted as a sign of hypertensive disease, and not kidney disease.

There are a number of complaints that are traditionally linked directly to kidney damage. First of all, it is edemas, they are often a sign of diseases of other organs and systems: cardiovascular (decompensated defects of the redtus, but more often congestive heart failure in patients with ischemic and hypertensive diseases, cardiomyopathies), as well as endocrine ( myxedema ), etc.

For the first time R. Bright connected the main manifestation of kidney diseases - edema (dropsy) - with the obligatory pronounced albuminuria and with the anatomical changes in the kidneys revealed at autopsy. He wrote: "I have never before discovered the corpse of a large, edematous and coagulating urine, in which there was no obvious pathology of the kidneys."

In diseases of the kidneys, edema is diverse in terms of severity, localization, and persistence. Most often they appear on the face, usually in the morning. Expressed edemas deliver a number of unpleasant subjective sensations and inconveniences to the renal patient - a cosmetic defect, the inability to wear shoes, difficulties in walking due to edema of the scrotum, etc., and with an anasarca (total swelling), when the puffiness of subcutaneous fat is noted, dropsy cavities (hydrothorax, ascites, hydropericardium ) there are additional more serious complaints, for example, dyspnea. Often, edema develops gradually, but sometimes it can be acute, within a few hours (acute nephritis). Usually, edema is combined with a decrease in the formation and excretion of urine (a decrease in diuresis) - oliguria (diuresis less than 500 ml / day), anuria (diuresis less than 200 ml / day). Of particular clinical importance is the true anuria - the cessation of urine in the bladder, usually due to the cessation of its formation, which leads to acute kidney damage by nephrotoxic factors (various poisoning, severe intoxication) or a violation of their blood supply (shock of various etiologies, including cardiogenic in acute myocardial infarction), as well as acute inflammation of the kidney parenchyma (acute nephritis). Most often, true anuria is a sign of acute renal failure. It should be borne in mind that a sharp decrease in diuresis can be a consequence not only of true anuria, but also due to acute retention in the urinary bladder of normally formed urine (acute urination retention ), which is most common in adenoma or prostate cancer, paraproctitis, diseases of the central nervous system, the use of drugs, atropine, ganglion blockers and other medications.

Increased diuresis - polyuria (diuresis more than 2000 ml / day) may be associated with some features of nutrition, drinking regimen, use of diuretics. However, the combination of polyuria with nicturia (predominance of nocturnal diuresis over daytime) is often found in a patient with chronic kidney disease as a sign of chronic kidney failure and can remain its only manifestation for a long time.

The pain that often occurs with a large number of internal diseases, as a rule, is absent with the most common kidney diseases (primarily chronic nephritis).

Bilateral pain in the lumbar region, usually obtuse, but sometimes more severe, disturb patients with acute nephritis. Sharp lumbar pains, often one-sided, are caused by a heart attack of the kidney and acute pyelonephritis. Special attention is required by the so-called renal colic - paroxysmal, severe pain localized in one of the half of the waist, radiating into the inguinal area, along the ureter, into the urethra, perineum, thigh. Pain is often accompanied by nausea and vomiting, the appearance of blood in the urine (macrogematuria, often microhematuria), the anxiety of a patient who does not find room for pain.

At the heart of these pains, apparently, lie the spastic contractions of the renal pelvis due to its stretching due to a blockage of the ureter with a stone, purulent or blood clots, less often tissue detritus (tumor decay). Licking the waist (like sharp movements), riding in a car, on a bicycle causes an increase in pain. Pain in the lumbar region can be caused by a moving shifting, especially with abrupt movements, the so-called wandering kidney. Severe pain in the lumbar region of a permanent nature occurs with acute inflammation of the pericardial cellular tissue - acute paranephritis, these pains intensify with an elongated leg.

There are other localizations of painful sensations - in the lower abdomen (with acute inflammation of the bladder - acute cystitis), in the area of the urethra with its inflammation (acute urethritis); in these cases the pain is often combined with unpleasant sensations when urinating.

In general, disorders of urination - dysuria - usually a sign of urological diseases. Frequent urination - pollakiuria - is a result of increased sensitivity of nerve endings in the mucosa of the bladder, the irritation of which leads to frequent urination on urination, which occurs even with a small amount of urine in the bladder.

Frequently frequent urination is accompanied by soreness, sensation of rezi, burning sensation. Usually these dysuric phenomena are caused by cystitis, urethritis, pyelonephritis, urolithiasis.

Patients may complain of a change in the type of urine, which is primarily due to macrogematuria - an admixture of a large number of red blood cells. Red urine usually occurs after the kidney colic (stones). Especially speak about the urine of the kind of "meat slop", when, in addition to red blood cells, it has a lot of leukocytes, mucus, epithelium, which is usually characteristic of acute jade.

[5], [6], [7]

Anamnesis of the disease

Carefully collected history has | for understanding the nature of nephropathy is not less important than in the diagnosis of heart disease, lungs, etc.

Kidney damage often develops after cooling, catarrhal disease, streptococcal infection (angina, scarlet fever), allergic reactions (drug, postvaccinal, (less often food allergy), toxicosis of pregnant women, treatment with gold preparations, penicillamine, antiepileptic drugs, especially abuse of analgesics, alcohol , drugs (heroin).

Undoubtedly, when studying an anamnesis, one should take into account the fact that kidney damage can develop in systemic diseases (systemic lupus erythematosus, rheumatoid arthritis), liver cirrhosis, can complicate diabetes mellitus, gout, hypertension and atherosclerosis, chronic purulent (osteomyelitis, bronchiectasis) and oncological diseases.

When studying a professional anamnesis, attention should be paid to contact with ionizing radiation, hydrocarbons and organic solvents, heavy and rare metals (mercury, lead, chromium, cadmium, copper, uranium), aminoazo compounds (benzene, hemolytic poisons (arsenious hydrogen, phenylhydrazine, nitrobenzene) .

It is important to point out the development of anuria (oliguria) after shock or collapse, blood transfusion, septic abortion, the use of nephrotoxic medicines (antibiotics from the aminoglycoside group).

It should be clarified whether the patient had a history of tuberculosis, viral hepatitis, syphilis, whether he was in the endemic foci of leptospirosis, hemorrhagic fever, schistosomiasis, malaria, in which kidney damage is possible.

Knowledge of the family history of the patient is necessary for the exclusion of hereditary nephritis, genetic (primarily for periodic disease) amyloidosis, tubulopathy and enzymopathy. All these data should be reflected on the chart of the history of the disease, for example, a young sailor who fell ill with acute nephritis with a fast-progressive course and died from acute heart failure, which R. Bright observed.

[8], [9], [10], [11], [12], [13], [14]