The Renal Examination

The renal examination may provide clues as to the cause and complications of a patient's renal dysfunction. Fluid balance is often difficult in renal failure patients and the examination can be used to assess current fluid status. The renal exam may also suggest the type of treatment the patient is receiving, whether it be via a fistula, vascath or peritoneal dialysis catheter.

Signs of chronic kidney disease

The Patient

The Hands

The Arms

The Face

The Neck

The Chest

Auscultate Each Area

Aortic, pulmonary, tricuspid and mitral areas, axilla
Listen for Heart Sounds

S1 + S2, S3 / S4
Listen for Murmurs

Listen while palpating radial pulse, maneuvres
Listen for Pericardial Rub

Superficial, scratching sound

The Back

The Abdomen

The Legs

Aydin M, Harvey-Woodworth CN. Halitosis: a new definition and classification. British dental journal. 2014;217:E1-E1. Pubmed

Azad K, Hajirnis K, Sawant S, Sabnis V. Kyrle's disease. Indian dermatology online journal. 2013;4:378. Pubmed

Ballas M. Bleeding and bruising: a diagnostic work-up. Am Fam Physician. 2008;77:1117. Pubmed

Barkun AN, Camus M, Green L, Meagher T, Coupal L, De Stempel J, Grover SA. The Bedside Assessment of Splenic Enlargement. The American Journal of Medicine. 1991 Nov; 91: 512-518. Link

Barron M. Importance of Hepatomegaly and Splenomegaly in Differential Diagnosis. Arch Intern Med (Chic). 1932; 50(2): 240-256. Link

Beathard GA. Physical examination of the dialysis vascular access. Semin Dial. 1998; 11:231. Link

Bernhard JD, Yosipovitch G. Chronic pruritis. The New England Journal of Medicine. 2013;368:1625. Pubmed

Blackard EH. Pulse Characteristics of Abdominal Aortic Aneurysm and of the Femoral Artery Distal to It. Circulation. 1958 Dec; 18: 1135-1138. Link

Bohadana A. Fundamentals of Lung Auscultation. The New England Journal of Medicine. 2014 May; 370(21): 2053. Link

Cabot RC. The Causes of Ascites: A Study of Five Thousand Cases. The American Journal of the Medical Sciences. 1912 Jan; 143(1): 1-14. Link

Callender VD, St Surin-Lord S, Davis EC, Maclin M. Postinflammatory hyperpigmentation. American Journal of Clinical Dermatology. 2011;12:87. Pubmed

Carmant L. Assessing ketosis: Approaches and pitfalls. Epilepsia. 2008;49:20-22. Pubmed

Cartwright MM, Hajja W, Al-Khatib S, et al. Toxigenic and metabolic causes of ketosis and ketoacidotic syndromes. Critical care clinics. 2012;28:601-631. Pubmed

Cestari TF, Dantas LP, Boza JC. Acquired hyperpigmentations. Anais Brasileiros de Dermatologia. 2014;89:11-25. Pubmed

Challenger F, Walshe JM. Foetor hepaticus. Lancet. 1955;268:1239.2007;13:71-76. Pubmed

Choi P, Nemati E, Banerjee A, Preston E, Levy J, Brown E. Peritoneal dialysis catheter removal for acute peritonitis: a retrospective analysis of factors associated with catheter removal and prolonged postoperative hospitalization. American journal of kidney diseases : the official journal of the National Kidney Foundation. 2004;43:103. Pubmed

Choong S, Emberton M. Acute urinary retention. BJU International. 2000;85:186-201. Pubmed

Chua Chiaco JM, Parikh NI, Fergusson DJ. The Jugular Venous Pressure Revisited. Cleveland Clinic Journal of Medicine. 2013 Oct; 80(10): 638-644. Link

Crighton Bramwell, The Arterial Pulse in Heath and Disease, The Lancet, Volume 230, Issue 5944, 31 July 1937 Link

Davies S, Spanel P, Smith D. Quantitative analysis of ammonia on the breath of patients in end-stage renal failure. Kidney International. 1997;52:223-228. Pubmed

Dorrington KL. Skin Turgor: Do We Understand the Clinical Sign? Lancet. 1981 Jan; 317(8214): 264-266. Link

Douglas VC, Josephson SA. Delirium. Continuum: Lifelong Learning in Neurology. 2010 April; 16(2): 120-134. Link

Eipper DF, Gifford RW, Stewart BH, Alfidi RJ, McCormack LJ, Vidt DG. Abdominal Bruits in Renovascular Hypertension. The American Journal of Cardiology. 1976 Jan; 37: 48-52. Link

Fokou M, Teyang A, Ashuntantang G, et al. Complications of arteriovenous fistula for hemodialysis: an 8-year study. Annals of vascular surgery. 2012;26:680. Pubmed

Fostini AC, Girolomoni G, Tessari G. Prurigo nodularis: an update on etiopathogenesis and therapy. Journal of Dermatological Treatment. 2013;24:458-462. Pubmed

Franks AG. Skin Manifestations of Internal Disease. Medical Clinics of North America. 2009;93:1265-1282. Pubmed

Gokdogan O, Catli T, Ileri F. Halitosis in otorhinolaryngology practice. Iranian journal of otorhinolaryngology. 2015;27:145-153. Pubmed

Guevara M, Sanchez-Fueyo A, Rodes J. Ascites. Medicine. 2002; 30(12): 73-74. Link

Gupta K, Dhawan A, Abel C, Talley N, Attia J. A Re-evaluation of the scratch test for locating the liver edge. BMC Gastroenterology. 2013; 13: 35. Link

Hall GW, Hann IM. Investigating Splenomegaly. Current Paediatrics. 1998; 8: 220-224. Link

Henker R, Kramer D, Rogers S. Fever. AACN Clin Issues. 1997;8:351-367. Pubmed

Hillman K. Respiratory rate: the neglected vital sign. Medical journal of Australia. 2008; 188(11): 657. Link

Hillman, K (2008). Respiratory rate: the neglected vital sign. Medical journal of Australia (0025-729X), 188 (11), p. 657. Link

Howard RS. Coma and Stupor. Handbook of Clinical Neurology. 2008; 90: 57-78. Link

Howard SR, Siegfried EC. A case of leukonychia. The Journal of pediatrics. 2013;163:914-915. Pubmed

Huang C. ED presentations of acute renal infarction. Am J Emerg Med. 2007;25:164-169. Pubmed

Jacoby E, Barzilai A, Laufer J, et al. Neonatal Hyperpigmentation: Diagnosis of Familial Glucocorticoid Deficiency with a Novel Mutation in the Melanocortin‐2 Receptor Gene. Pediatric Dermatology. 2014;31:e13-e17. Pubmed

Kavouras SA. Assessing Hydration Status. Current Opinion in Clinical Nutrition & Metabolic Care. 2002 Sept; 5(5): 519-524. Link

Kennedy C, McCarthy C, Alken S, et al. Pleuroperitoneal leak complicating peritoneal dialysis: a case series. International journal of nephrology. 2011;2011:526753-4. Pubmed

Kingery FA. Xanthelasma: Curbstone Recognition of Dyslipidosis. JAMA. 1965; 193(6): 439. Link

Kumar V, Aggarwal S, Sharma A, Sharma V. Nailing the diagnosis: koilonychia. The Permanente journal. 2012;16:65-65. Pubmed

Kuypers DR. Skin problems in chronic kidney disease. Nature Clinical Practice Nephrology. 2009;5:157-170. Pubmed

Leung AK, Chan KW. Evaluating the child with purpura. American family physician. 2001;64:419. Pubmed

Lewin J, Maconochie I. Capillary Refill Time in Adults. Emerg Med J. 2008; 25: 325-326. Link

Ludbrook J, Clarke AM, McKenzie JK. Significance of Absent Ankle Pulse. British Medical Journal. 1962; 1(5294): 1724-1725. Link

Mak V, Melchor R, Spiro S. Easy bruising as a side-effect of inhaled corticosteroids. European Respiratory Journal. 1992;5:1068. Pubmed

MArx HT, Yu PN. Clinical examination of the arterial pulse. Progress in Cardiovascular Diseases. 1967 Nov; 10(3): 207-235. Link

McKnight JT, Adcock BB. Paresthesias: a practical diagnostic approach. Am Fam Physician. 1997;56:2253. Pubmed

Meidl EJ, Ende J. Evaluation of liver size by physical examination. Journal of General Internal Medicine. 1993 Nov; 8(11): 635-637. Link

Minford AMB, Richards EM. Excluding medical and haematological conditions as a cause of bruising in suspected non-accidental injury. Archives of disease in childhood. Education and practice edition. 2010;95:2-8. Link

Mittal T, Kumar V, Khullar R, et al. Diagnosis and management of Spigelian hernia: A review of literature and our experience. Journal of Minimal Access Surgery. 2009;4. Pubmed

Mortimer PS. Levick JR. Chronic Peripheral Oedema: the Critical Role of the Lymphatic System. Clinical Medicine. 2004; 4(5): 448-453. Link

Moses WR. Shifting Dullness in the Abdomen. Southern Medical Journal. 1946; 39(12): 985. Link

Murphy RL. Auscultation of the Lung: Past Lessons, Future Possibilities. Thorax. 1981; 36: 99-107. Link

Musa-Veloso K, Likhodii SS, Cunnane SC. Breath acetone is a reliable indicator of ketosis in adults consuming ketogenic meals. The American journal of clinical nutrition. 2002;76:65. Pubmed

Naylor C. Physical Examination of the Liver. JAMA. 1994; 271(23): 1859-1865. Link

Országh J, Kódlová E. Cesk. Asterixis as a nonspecific sign of respiratory encephalopathy. Neurol Neurochir. 1977 Sep;40(5):354-5. Link

Pal G, Lin MM, Laureno R. Asterixis: a study of 103 patients. Metabolic Brain Disease. 2014;29:813-824. Pubmed

Patel LM, Lambert WC, Lambert PJ, Gagna CE, Maghari A. Cutaneous signs of systemic disease. Clinics in Dermatology. 2011;29:511-522. Pubmed

Poncelet AN. An algorithm for the evaluation of peripheral neuropathy. Am Fam Physician. 1998; 57: 755. Link

Rodríguez-García PL, Rodríguez-Pupo L, Rodríguez-García D. Clinical techniques for use in neurological physical examinations. I. General organisation, cranial and peripheral spinal nerves. Rev Neurol. 2004 Oct; 39(8): 757-66. Link

Sahoo AK, Rauta S. Kyrle's Disease: A Rare Skin Manifestation of Systemic Diseases. Journal of Medicine. 2014;15:144. Pubmed

Söder B, Johansson B, Söder PO. The relation between foetor ex ore, oral hygiene and periodontal disease. Swedish dental journal. 2000;24:73. Pubmed

Schroth BE. Evaluation and Management of Peripheral Oedema. JAAPA. 2005 Nov; 18(11): 29-34. Link

Schumaker HB. The Diagnosis of Coarctation of the Aorta with Particular Reference to the Importance of Absent or Diminished Abdominal Aortic Pulsation. Annals of Surgery. 1952 Jan; 135(1): 111-113. Link

Seo AY, Kim N, Oh DH. Abdominal Bloating: Pathophysiology and Treatment. J Neurogastroenterol Motil. 2013 Oct; 19(4): 433-453, Link

Singh G. Nails in systemic disease. Indian journal of dermatology, venereology and leprology. 2011;77:646-651. Pubmed

Smith MD, Seth JH, Fowler CJ, Miller RF, Panicker JN. Urinary retention for the neurologist. Practical neurology. 2013;13:288. Pubmed

Sousa CN, Apóstolo JL, Figueiredo MH, Martins MM, Dias VF. Physical examination: How to examine the arm with arteriovenous fistula. Hemodialysis International. 2013;17:300-306. Pubmed

Specchio F, Carboni I, Chimenti S, Tamburi F, Nistico' S. Cutaneous manifestations in patients with chronic renal failure on hemodialysis. International journal of immunopathology and pharmacology. 2014;27:1. Pubmed

Speeckaert R, Van Gele M, Speeckaert MM, Lambert J, Geel N. The biology of hyperpigmentation syndromes. Pigment Cell & Melanoma Research. 2014;27:512-524. Pubmed

Taguchi Y, Takashima S, Tanaka K. Koilonychia in a patient with subacute iron-deficiency anemia. Internal medicine (Tokyo, Japan). 2013;52:2379. Pubmed

Tangerman A, Meuwese-Arends M, Jansen JMJ. Foetor hepaticus. The Lancet. 1994;343:1569-1569. Pubmed