Tooltip
.tooltip {
position: relative;
cursor: pointer;
text-decoration: none;
border-bottom: 1px dashed rgba(0, 0, 0, 0.6);
}
.tooltip::before {
content: attr(data-tooltip);
position: absolute;
top: -40px; /* Trochę niżej nad słowem */
left: 50%; /* Wyśrodkowanie */
transform: translateX(-50%);
background-color: rgba(255, 255, 255, 0.9);
color: #333;
padding: 6px 12px;
border-radius: 8px;
white-space: nowrap;
opacity: 0;
visibility: hidden;
transition: opacity 0.3s ease, visibility 0.3s ease;
font-family: ‘Arial’, sans-serif;
font-size: 14px;
box-shadow: 0px 4px 8px rgba(0, 0, 0, 0.1);
z-index: 10;
}
.tooltip:hover::before {
opacity: 1;
visibility: visible;
}
document.addEventListener(‘DOMContentLoaded’, function () {
const wordsToTooltip = {
“General inspection”: “Ogólna ocena”,
“Clinical signs”: “Objawy kliniczne”,
“Underlying pathology”: “Podstawowa patologia”,
“Pallor”: “Bladość”,
“Paleness of the skin”: “Bladość skóry”,
“Mucous membranes”: “Błony śluzowe”,
“Anemia”: “Niedokrwistość”,
“Chronic kidney disease”: “Przewlekła choroba nerek”,
“Erythropoietin deficiency”: “Niedobór erytropoetyny”,
“Severity of anemia”: “Nasilenie niedokrwistości”,
“Renal insufficiency”: “Niewydolność nerek”,
“Decreased level of consciousness”: “Obniżony poziom świadomości”,
“Renal dysfunction”: “Dysfunkcja nerek”,
“Electrolyte imbalances”: “Zaburzenia elektrolitowe”,
“Hyperkalemia”: “Hiperkaliemia”,
“Severe acidosis”: “Ciężka kwasica”,
“Lethargic”: “Letargiczny”,
“Confusion”: “Dezorientacja”,
“Stuporous”: “Osłupienie”,
“Comatose”: “W stanie śpiączki”,
“Metabolic derangements”: “Zaburzenia metaboliczne”,
“Clinical stability”: “Stabilność kliniczna”,
“Edema”: “Obrzęk”,
“Swelling in limbs”: “Obrzęk kończyn”,
“Pedal edema”: “Obrzęk stóp”,
“Abdominal edema (ascites)”: “Obrzęk brzucha (wodobrzusze)”,
“Nephrotic syndrome”: “Zespół nerczycowy”,
“End-stage renal disease”: “Schyłkowa niewydolność nerek”,
“Fluid retention”: “Zatrzymanie płynów”,
“Renal failure”: “Niewydolność nerek”,
“Volume status”: “Stan objętościowy”,
“Hypoalbuminemia”: “Hipoalbuminemia”,
“Fluid management”: “Zarządzanie płynami”,
“Shortness of breath”: “Duszność”,
“Pulmonary edema”: “Obrzęk płuc”,
“Metabolic acidosis”: “Kwasica metaboliczna”,
“Tachypnea”: “Przyspieszenie oddechu (tachypnoe)”,
“Compensatory mechanism”: “Mechanizm kompensacyjny”,
“Breathing patterns”: “Wzorce oddychania”,
“Lung auscultation”: “Osłuchiwanie płuc”,
“Pulmonary complications”: “Powikłania płucne”,
“Renal pathology”: “Patologia nerek”,
“Skin changes”: “Zmiany skórne”,
“Uraemic complexion”: “Cera mocznicowa”,
“Yellowish discoloration”: “Żółtawe przebarwienia”,
“Dehydration”: “Odwodnienie”,
“Decreased skin turgor”: “Zmniejszone napięcie skóry”,
“Fluid losses”: “Utrata płynów”,
“Reduced intake”: “Zmniejszone spożycie”,
“Excoriations”: “Drapanie”,
“Pruritus”: “Świąd”,
“Uraemia”: “Mocznica”,
“Nitrogenous waste products”: “Produkty przemiany azotu”,
“Irritation to the skin”: “Podrażnienie skóry”,
“Cachexia”: “Kacheksja”,
“Muscle wasting”: “Zanik mięśni”,
“Protein-energy wasting”: “Utrata białek i energii”,
“End-stage renal disease”: “Schyłkowa niewydolność nerek”,
“Poor nutritional status”: “Słaby stan odżywienia”,
“Catabolism”: “Katabolizm”,
“Prognosis”: “Rokowanie”,
“Nutritional needs”: “Potrzeby żywieniowe”,
“Costovertebral angle tenderness”: “Tkliwość kąta żebrowo-kręgowego”,
“Goldflam’s sign”: “Objaw Goldflama”,
“Renal pathology”: “Patologia nerek”,
“Costovertebral angle”: “Kąt żebrowo-kręgowy”,
“Pyelonephritis”: “Odmiedniczkowe zapalenie nerek”,
“Renal calculi”: “Kamica nerkowa”,
“Urinary tract obstruction”: “Zatkanie dróg moczowych”,
“Upper urinary tract”: “Górne drogi moczowe”,
“Inflammation or infection of the kidney”: “Zapalenie lub infekcja nerek”,
“Diagnostic evaluation”: “Ocena diagnostyczna”,
“Imaging”: “Badania obrazowe”,
“Laboratory testing”: “Badania laboratoryjne”,
“Upper urinary tract involvement”: “Zajęcie górnych dróg moczowych”,
“Renal conditions”: “Choroby nerek”,
“Abdominal examination”: “Badanie jamy brzusznej”,
“Inspection of the abdomen”: “Oględziny brzucha”,
“Abdominal distension”: “Wzdęcie brzucha”,
“Surgical scars”: “Blizny pooperacyjne”,
“Visible masses”: “Widoczne masy”,
“Bladder enlargement”: “Powiększenie pęcherza moczowego”,
“Intra-abdominal masses”: “Masy wewnątrzbrzuszne”,
“Surgical interventions”: “Interwencje chirurgiczne”,
“Nephrectomy”: “Nefrektomia”,
“Renal transplantation”: “Przeszczepienie nerki”,
“Bladder surgery”: “Operacja pęcherza moczowego”,
“Abdominal abnormalities”: “Nieprawidłowości w jamie brzusznej”,
“Symmetry”: “Symetria”,
“Visible pulsations”: “Widoczne pulsacje”,
“Percussion”: “Opukiwanie”,
“Bladder percussion”: “Opukiwanie pęcherza”,
“Suprapubic region”: “Okolica nadłonowa”,
“Bladder distension”: “Rozdęcie pęcherza moczowego”,
“Dull sound upon percussion”: “Tępy dźwięk przy opukiwaniu”,
“Urinary retention”: “Zatrzymanie moczu”,
“Suprapubic dullness”: “Tępy odgłos w okolicy nadłonowej”,
“Kidney percussion”: “Opukiwanie nerek”,
“Underlying masses”: “Ukryte masy”,
“Hydronephrosis”: “Wodonercze”,
“Perinephric abscess”: “Ropień okołonerkowy”,
“Palpation”: “Palpacja”,
“Bladder palpation”: “Palpacja pęcherza moczowego”,
“Bladder tenderness”: “Tkliwość pęcherza moczowego”,
“Cystitis”: “Zapalenie pęcherza moczowego”,
“Bladder inflammation”: “Zapalenie pęcherza moczowego”,
“Kidney palpation”: “Palpacja nerek”,
“Kidney enlargement”: “Powiększenie nerki”,
“Bimanual palpation”: “Palpacja oburęczna”,
“Thin individuals”: “Osoby szczupłe”,
“Hydronephrosis”: “Wodonercze”,
“Polycystic kidney disease”: “Wielotorbielowatość nerek”,
“Renal masses”: “Guzki nerkowe”,
“Digital rectal examination (DRE)”: “Badanie przez odbytnicę”,
“Prostate gland”: “Gruczoł krokowy”,
“Lower urinary tract symptoms”: “Objawy dolnych dróg moczowych”,
“Urinary frequency”: “Częste oddawanie moczu”,
“Nocturia”: “Nykturia”,
“Dysuria”: “Bolesne oddawanie moczu”,
“Prostate palpation”: “Palpacja prostaty”,
“Prostate size, shape, and consistency”: “Wielkość, kształt i konsystencja prostaty”,
“Tender prostate”: “Tkliwość prostaty”,
“Boggy prostate”: “Rozpulchniona prostata”,
“Prostatitis”: “Zapalenie gruczołu krokowego”,
“Nodular prostate”: “Guzkowata prostata”,
“Prostate malignancy”: “Nowotwór prostaty”,
“Benign prostatic hyperplasia (BPH)”: “Łagodny przerost gruczołu krokowego (BPH)”,
“Prostate mobility”: “Ruchomość prostaty”,
“Prostate surface texture”: “Tekstura powierzchni prostaty”,
“Male patients with obstructive urinary symptoms”: “Mężczyźni z objawami obturacji dróg moczowych”,
“Groin and genital examination”: “Badanie pachwiny i narządów płciowych”,
“Male patients examination”: “Badanie pacjentów płci męskiej”,
“Penis inspection”: “Oględziny prącia”,
“Urethral meatus”: “Ujście cewki moczowej”,
“Discharge”: “Wydzielina”,
“Erythema”: “Rumień”,
“Ulcers”: “Owrzodzenia”,
“Lesions”: “Zmiany”,
“Urethritis”: “Zapalenie cewki moczowej”,
“Hypospadias”: “Spodziectwo”,
“Epispadias”: “Wierzchniactwo”,
“Testes examination”: “Badanie jąder”,
“Epididymis examination”: “Badanie najądrzy”,
“Testicular tenderness”: “Tkliwość jąder”,
“Testicular swelling”: “Obrzęk jąder”,
“Epididymitis”: “Zapalenie najądrza”,
“Orchitis”: “Zapalenie jąder”,
“Testicular torsion”: “Skręt jądra”,
“Cremasteric reflex”: “Odruch mięśnia dźwigacza jądra”,
“Inner thigh stroke”: “Pocieranie wewnętrznej strony uda”,
“Testicular atrophy”: “Zanik jąder”,
“Inguinal examination”: “Badanie pachwinowe”,
“Lymphadenopathy”: “Powiększenie węzłów chłonnych”,
“Inguinal hernias”: “Przepukliny pachwinowe”,
“Scrotal pain”: “Ból moszny”,
“Direct and indirect hernias”: “Przepukliny bezpośrednie i pośrednie”,
“Lymphadenopathy”: “Limfadenopatia”,
“Infection or malignancy”: “Infekcja lub nowotwór”,
“Female patients examination”: “Badanie pacjentek”,
“Pelvic examination”: “Badanie miednicy”,
“External genitalia”: “Narządy płciowe zewnętrzne”,
“Pelvic organ prolapse”: “Wypadanie narządów miednicy”,
“Cystocele”: “Wypadanie pęcherza moczowego”,
“Rectocele”: “Wypadanie odbytnicy”,
“Urinary retention”: “Zatrzymanie moczu”,
“Bladder tenderness”: “Tkliwość pęcherza moczowego”,
“Interstitial cystitis”: “Śródmiąższowe zapalenie pęcherza”,
“Lower extremity examination”: “Badanie kończyn dolnych”,
“Fluid overload”: “Przeciążenie płynowe”,
“Renal dysfunction”: “Dysfunkcja nerek”,
“Pitting edema”: “Obrzęk ciastowaty”,
“Chronic kidney failure”: “Przewlekła niewydolność nerek”,
“Diuretic therapy”: “Terapia diuretyczna”,
“Ascites”: “Wodobrzusze”,
“Pleural effusion”: “Wysięk opłucnowy”,
“Systemic fluid accumulation”: “Układowa akumulacja płynów”,
“Auscultation”: “Osłuchiwanie”,
“Renal arteries”: “Tętnice nerkowe”,
“Renal artery stenosis”: “Zwężenie tętnicy nerkowej”,
“Secondary hypertension”: “Nadciśnienie wtórne”,
“Doppler ultrasound”: “Ultrasonografia Dopplerowska”,
“Vascular abnormalities”: “Nieprawidłowości naczyniowe”,
“Asterixis (flapping tremor)”: “Asteriksje (drżenie trzepoczące)”,
“Wrist dorsiflexion”: “Zgięcie grzbietowe nadgarstka”,
“Uraemia”: “Mocznica”,
“Metabolic disturbances”: “Zaburzenia metaboliczne”,
“Hypercapnia”: “Hiperkapnia”,
“Hyperammonemia”: “Hiperamonemia”,
“Severity of renal dysfunction”: “Nasilenie dysfunkcji nerek”,
“Skin and nail changes”: “Zmiany skórne i paznokciowe”,
“Leukonychia (white discoloration)”: “Leukonychia (białe przebarwienie)”,
“Splinter hemorrhages”: “Wylewy podpaznokciowe”,
“Calcinosis”: “Zwapnienia”,
“Gouty tophi”: “Guzki dnawne”,
“Muehrcke’s lines”: “Linie Muehrcke’go”,
“Lindsay’s nails”: “Paznokcie Lindsay’a”,
“Hypoalbuminemia”: “Hipoalbuminemia”,
“Chronic renal disease”: “Przewlekła choroba nerek”
};
// Normalize keys in the dictionary
const normalizedWordsToTooltip = {};
for (const [key, value] of Object.entries(wordsToTooltip)) {
const cleanedKey = key.replace(/(.*?)/g, ”).trim(); // Remove anything in parentheses
normalizedWordsToTooltip[cleanedKey.toLowerCase()] = value;
}
function processNode(node) {
if (node.nodeType === Node.TEXT_NODE && node.nodeValue.trim()) {
let content = node.nodeValue;
// Regex to match only the main words (ignores parentheses)
const regex = new RegExp(
`\b(${Object.keys(normalizedWordsToTooltip).join(‘|’)})\b`,
‘gi’
);
if (regex.test(content)) {
const wrapper = document.createElement(‘span’);
wrapper.innerHTML = content.replace(regex, (match) => {
const tooltip = normalizedWordsToTooltip[match.toLowerCase().trim()];
return `
${match}`;
});
node.replaceWith(wrapper);
}
} else if (node.nodeType === Node.ELEMENT_NODE) {
Array.from(node.childNodes).forEach(processNode);
}
}
document.querySelectorAll(‘body *:not(script):not(style)’).forEach((element) => {
Array.from(element.childNodes).forEach(processNode);
});
});
Podświetlanie tekstu z notatkami
body {
margin: 0;
padding: 0;
font-family: Arial, sans-serif;
}
.highlight {
background-color: #cce7ff; /* Highlight color without notes */
position: relative;
display: inline;
}
.highlight.with-note {
background-color: #ffeb3b; /* Highlight color with notes */
}
.note-box {
position: absolute;
background-color: #f9f9f9;
color: #333;
font-size: 14px;
line-height: 1.6;
padding: 10px 15px;
border: 1px solid #ddd;
border-radius: 5px;
box-shadow: 0 2px 5px rgba(0, 0, 0, 0.2);
max-width: 250px;
z-index: 1000;
white-space: normal;
text-align: left;
display: none; /* Hidden by default */
}
.note-controls {
position: absolute;
top: -30px;
right: -30px;
display: flex;
gap: 10px;
z-index: 10;
opacity: 0;
pointer-events: none;
transition: opacity 0.3s;
}
.note-controls.visible {
opacity: 1;
pointer-events: all;
}
.note-controls span {
cursor: pointer;
background-color: gray;
color: white;
padding: 5px 10px;
border-radius: 5px;
font-size: 16px;
font-weight: bold;
}
.note-controls span:hover {
background-color: darkgray;
}
document.addEventListener(“DOMContentLoaded”, () => {
/**
* Checks if an element is a header.
*/
const isHeaderElement = (node) => {
while (node) {
if (node.nodeType === 1 && node.tagName.match(/^H[1-5]$/)) {
return true;
}
node = node.parentNode;
}
return false;
};
/**
* Checks if an element is inside a table cell.
*/
const isInsideTable = (node) => {
while (node) {
if (node.tagName === “TD” || node.tagName === “TH”) {
return node;
}
node = node.parentNode;
}
return null;
};
/**
* Checks if an element belongs to the same list item.
*/
const isWithinSameListItem = (selection) => {
if (selection.rangeCount === 0) return false;
const range = selection.getRangeAt(0);
const startContainer = range.startContainer;
const endContainer = range.endContainer;
const getClosestListItem = (node) => {
while (node) {
if (node.nodeType === 1 && node.tagName === “LI”) {
return node;
}
node = node.parentNode;
}
return null;
};
const startListItem = getClosestListItem(startContainer);
const endListItem = getClosestListItem(endContainer);
// Ensure selection is within the same list item
return startListItem === endListItem;
};
/**
* Validates the selection.
* Ensures the selection is within a single header, table cell, or list item.
*/
const isSelectionValid = (selection) => {
if (selection.rangeCount === 0) return false;
const range = selection.getRangeAt(0);
const startContainer = range.startContainer;
const endContainer = range.endContainer;
const startInHeader = isHeaderElement(startContainer);
const endInHeader = isHeaderElement(endContainer);
// Block selection spanning headers
if (startInHeader !== endInHeader) {
return false;
}
const startCell = isInsideTable(startContainer);
const endCell = isInsideTable(endContainer);
// Block selection spanning table cells
if (startCell && endCell && startCell !== endCell) {
return false;
}
// Block selection spanning multiple list items
if (!isWithinSameListItem(selection)) {
return false;
}
return true;
};
/**
* Highlights the selected text.
*/
const wrapTextWithHighlight = (range) => {
const fragment = range.extractContents();
const highlight = document.createElement(“span”);
highlight.className = “highlight”;
highlight.appendChild(fragment);
range.insertNode(highlight);
const noteControls = document.createElement(“div”);
noteControls.className = “note-controls visible”;
const editNote = document.createElement(“span”);
editNote.textContent = “✎”;
editNote.title = “Edit note”;
noteControls.appendChild(editNote);
const removeHighlight = document.createElement(“span”);
removeHighlight.textContent = “x”;
removeHighlight.title = “Remove highlight”;
noteControls.appendChild(removeHighlight);
highlight.style.position = “relative”;
highlight.appendChild(noteControls);
let noteBox = null;
const updateNotePosition = () => {
const rect = highlight.getBoundingClientRect();
if (noteBox) {
noteBox.style.top = `${rect.height}px`;
noteBox.style.left = `${rect.width / 2}px`;
}
};
const hideControlsAndNoteAfterDelay = () => {
setTimeout(() => {
noteControls.classList.remove(“visible”);
if (noteBox) noteBox.style.display = “none”;
}, 3000);
};
// Show controls for 3 seconds after highlighting
hideControlsAndNoteAfterDelay();
highlight.addEventListener(“click”, () => {
noteControls.classList.add(“visible”);
if (noteBox) noteBox.style.display = “block”;
hideControlsAndNoteAfterDelay();
});
editNote.addEventListener(“click”, () => {
const noteText = prompt(“Add or edit a note:”, noteBox?.textContent || “”);
if (noteText) {
if (!noteBox) {
noteBox = document.createElement(“div”);
noteBox.className = “note-box”;
highlight.appendChild(noteBox);
}
noteBox.textContent = noteText;
noteBox.style.display = “block”;
highlight.classList.add(“with-note”);
updateNotePosition();
hideControlsAndNoteAfterDelay();
}
});
removeHighlight.addEventListener(“click”, () => {
const parent = highlight.parentNode;
while (highlight.firstChild) {
parent.insertBefore(highlight.firstChild, highlight);
}
parent.removeChild(highlight);
if (noteBox) noteBox.remove();
});
};
/**
* Handles the mouseup event to validate and apply highlighting.
*/
document.body.addEventListener(“mouseup”, () => {
const selection = window.getSelection();
if (selection.rangeCount > 0 && selection.toString().trim()) {
if (!isSelectionValid(selection)) {
alert(“Zaznaczenie musi być w obrębie jednego akapitu, komórki tabeli lub punktu listy!”);
selection.removeAllRanges();
return;
}
const range = selection.getRangeAt(0);
wrapTextWithHighlight(range);
selection.removeAllRanges();
}
});
});
Szacowany czas lekcji:
19 minut
.lesson-duration-container {
background-color: #f0f4f8; /* Szarawe tło dopasowane do reszty strony */
padding: 8px 15px; /* Wewnętrzny odstęp */
border-radius: 8px; /* Zaokrąglone rogi */
font-family: ‘Roboto’, Arial, sans-serif; /* Czcionka Roboto, jeśli dostępna */
font-size: 16px; /* Rozmiar tekstu */
color: #6c757d; /* Ciemny szary kolor tekstu */
display: inline-block; /* Wyświetlanie jako element blokowy */
margin-bottom: 20px; /* Odstęp na dole */
border: none; /* Bez obramowania */
}
.lesson-duration-label {
font-weight: 700; /* Pogrubienie dla etykiety */
color: #6c757d; /* Ciemny szary kolor dla etykiety */
margin-right: 5px; /* Odstęp od wartości */
}
.lesson-duration-value {
color: #6c757d; /* Ciemny szary kolor dla wartości */
font-weight: 700; /* Pogrubienie dla wartości */
}
Observation
The examination begins with a general inspection of the patient, focusing on clinical signs that may suggest underlying pathology:
- Pallor: Pallor, or paleness of the skin and mucous membranes, can indicate anemia, which may result from chronic kidney disease and associated erythropoietin deficiency. The degree of pallor can help gauge the severity of anemia and give an indication of underlying renal insufficiency.
- Decreased Level of Consciousness: A decreased level of consciousness could be indicative of severe renal dysfunction or electrolyte imbalances, such as hyperkalemia or severe acidosis. Patients may appear lethargic or confused, and in extreme cases, they may be stuporous or comatose. Observing the patient’s level of alertness is crucial as it provides insight into metabolic derangements and overall clinical stability.
- Edema: Swelling in the limbs, such as pedal edema, or in the abdomen (ascites), may indicate nephrotic syndrome, end-stage renal disease, or fluid retention due to renal failure. Noting the extent and distribution of edema can provide important insights into volume status and the presence of hypoalbuminemia. This assessment can also help in diagnosing chronic conditions and determining the patient’s need for fluid management.
- Shortness of Breath: Shortness of breath may be associated with pulmonary edema secondary to advanced renal disease or metabolic acidosis. Tachypnea (increased respiratory rate) might be present as a compensatory mechanism for metabolic acidosis. Careful observation of breathing patterns and auscultation of the lungs may be necessary to rule out pulmonary complications related to renal pathology.
- Skin Changes: Inspect for uraemic complexion (yellowish discoloration of the skin), which indicates advanced chronic kidney disease. Assess the skin for signs of dehydration, such as decreased skin turgor, which can occur due to fluid losses or reduced intake. Excoriations from pruritus (itching) may also be present due to uraemia, reflecting the accumulation of nitrogenous waste products that are irritating to the skin.
- Cachexia: Muscle wasting may be observed, particularly in patients with long-term kidney disease and protein-energy wasting. Cachexia is often a sign of end-stage renal disease and may reflect poor nutritional status or ongoing catabolism. Noting muscle mass loss can help assess the overall prognosis and nutritional needs of the patient.
Costovertebral Angle (CVA) Tenderness
Costovertebral angle tenderness, also known as Goldflam’s sign, is an important indicator of renal pathology. The clinician assesses this by placing one hand over the costovertebral angle and gently striking it with a closed fist. Pain elicited during this process may indicate pyelonephritis, renal calculi, or urinary tract obstruction. This part of the examination is crucial for evaluating the upper urinary tract. The presence of CVA tenderness suggests inflammation or infection involving the kidney, which requires further diagnostic evaluation, such as imaging or laboratory testing. This sign is a key clinical indicator of upper urinary tract involvement, particularly in differentiating between renal and lower urinary tract conditions.
Abdominal Examination
Inspection
The abdomen is carefully inspected for any signs of distension, surgical scars, or visible masses. Distension could be due to bladder enlargement, ascites, or other intra-abdominal masses. The presence of scars may provide insight into prior surgical interventions, such as nephrectomy, renal transplantation, or bladder surgery, which may be relevant to the patient’s current urinary symptoms. Any abnormalities in contour, symmetry, or visible pulsations should be documented.
Percussion
- Bladder Percussion: Percuss the suprapubic region to assess for bladder distension. A dull sound upon percussion can suggest significant bladder filling or urinary retention. Normally, even a full bladder should not extend significantly above the symphysis pubis. Determining the upper border of dullness helps gauge the degree of bladder distension and can help differentiate between urinary retention and other causes of lower abdominal swelling.
- Kidney Percussion: Percussion of the flanks can sometimes be helpful to detect underlying masses or areas of dullness that may suggest hydronephrosis or a perinephric abscess.
Palpation
- Bladder Palpation: Palpate the suprapubic region to confirm bladder distension or tenderness. A palpable bladder could indicate urinary retention, potentially due to an obstruction or neurological condition. The clinician should also assess for bladder tenderness, which may suggest cystitis or other forms of bladder inflammation. Deep palpation should be performed carefully to avoid unnecessary discomfort.
- Kidney Palpation: Palpate each flank to assess for kidney enlargement or tenderness. This is often performed using bimanual palpation, especially in thin individuals where the kidneys may be more accessible. Hydronephrosis, polycystic kidney disease, or large renal masses may make the kidney palpable. In cases where the kidneys are palpable, note their size, shape, and any associated tenderness or irregularities.
Rectal Examination (Male Patients)
A digital rectal examination (DRE) is important for assessing the prostate gland, especially in patients presenting with lower urinary tract symptoms. This examination can provide key information regarding the cause of symptoms such as urinary frequency, nocturia, or dysuria:
- Prostate Gland: The clinician palpates the prostate through the anterior wall of the rectum, assessing its size, shape, and consistency. A tender, boggy prostate may indicate prostatitis, while a hard, nodular prostate may suggest malignancy. A symmetrically enlarged, rubbery prostate is typically consistent with benign prostatic hyperplasia (BPH). Assessing the prostate’s mobility and surface texture is also crucial for differentiating benign from malignant conditions. This step is key in evaluating male patients with obstructive urinary symptoms.
Groin and Genital Examination
Male Patients
- Penis and Urethral Meatus: Inspect the penis, including the glans and urethral meatus, for signs of discharge, erythema, ulcers, or lesions. Discharge may indicate urethritis, while other abnormalities could signal infections or congenital conditions such as hypospadias or epispadias. Inspection should be thorough to detect any visible abnormalities that may explain symptoms such as dysuria or urinary urgency.
- Testes and Epididymis: Palpate each testicle and the epididymis for tenderness, swelling, or masses. Conditions like epididymitis, orchitis, or testicular torsion can present with pain and swelling. The cremasteric reflex should also be tested by lightly stroking the inner thigh; an absent reflex may suggest testicular torsion, which is a surgical emergency. Assessing testicular size, symmetry, and consistency is also crucial for identifying other conditions, such as tumors or atrophy.
- Inguinal Examination: Palpate the inguinal area for lymphadenopathy or hernias. Inguinal hernias may explain symptoms such as scrotal pain or swelling, and the examination can help differentiate between direct and indirect hernias. The presence of lymphadenopathy may indicate infection or malignancy.
Female Patients
- Pelvic Examination: In women with urinary symptoms, a pelvic examination may be required. This includes inspection of the external genitalia for erythema, discharge, or lesions, and assessment for pelvic organ prolapse, such as a cystocele or rectocele, which may contribute to urinary symptoms like incontinence or retention. Palpation of the bladder through the anterior vaginal wall may help assess for bladder tenderness, which could be indicative of interstitial cystitis or other bladder conditions.
Lower Extremity Examination
Assess the lower extremities for signs of fluid overload, which can be indicative of renal dysfunction:
- Edema: The clinician assesses for pitting edema by pressing over the bony prominences of the ankles and shins. Pitting edema is often associated with nephrotic syndrome, chronic kidney failure, or fluid retention due to impaired renal function. Assessing the extent and distribution of edema helps in understanding the severity of volume overload and can assist in monitoring the response to diuretic therapy. In cases of severe edema, consider the presence of ascites or pleural effusion as part of the systemic fluid accumulation.
Auscultation
- Renal Arteries: Auscultate the area over the renal arteries, located just lateral to the umbilicus, to detect bruits. The presence of a bruit suggests renal artery stenosis, which can lead to secondary hypertension. Auscultation should be done bilaterally, and any noted bruits should prompt further investigation, such as Doppler ultrasound or imaging studies. Auscultation findings can provide important diagnostic clues about underlying vascular abnormalities affecting the kidneys.
Additional Signs
- Asterixis (Flapping Tremor): Ask the patient to extend their arms with wrists dorsiflexed and fingers spread. Observe for any irregular flapping motions, known as asterixis. Asterixis may indicate uraemia or significant metabolic disturbances related to renal failure, such as hypercapnia or hyperammonemia. This sign can be an important indicator of the severity of renal dysfunction and the need for immediate intervention.
- Skin and Nail Changes: Inspect the hands for pallor, which is indicative of anemia, and the nails for leukonychia(white discoloration) or splinter hemorrhages, which can be associated with chronic kidney disease. Look for excoriations from uraemic pruritus, as well as signs of calcinosis or gouty tophi in patients with advanced disease. Other nail changes, such as Muehrcke’s lines (paired white lines) or Lindsay’s nails (half-and-half nails), may also be indicative of hypoalbuminemia or chronic renal disease.