Medical Semiology Guide of the Renal System 0128196394, 9780128196397

Table of contents :
Cover
MEDICAL SEMIOLOGY GUIDE OF THE RENAL SYSTEM
Copyright
About the Author
Manuela Stoicescu
Motto
Thank you all my students!
Scientific Activity
ACCOMPLISHMENTS
Publications 51
BOOKS 7
PUBLICATIONS 56
CONFERENCES 2018
CONFERENCES 2019
Introduction
The History of the Patient
1 PERSONAL DATA
2 PLACE OF BIRTH AND HOME (ADDRESS)
3 ALLERGY?
4 THE REASON FOR HOSPITALIZATION
4 Example No. 1
4 Example No. 2
4 Example No. 3
4 Example No. 4
5 THE HISTORY OF THE CURRENT DISEASE
6 FAMILY HISTORY
7 PERSONAL PATHOLOGICAL HISTORY
8 PERSONAL PHYSIOLOGICAL ANTECEDENTS
9 LIFE CONDITIONS
A The housing conditions
B Eating
Toxic consumptions
C Alcohol consumption
C Smoking
C Coffee
C Drugs
10 WORKING CONDITIONS
11 GENERAL MANIFESTATIONS
1 - Questionnaire
Macroscopic Hematuria
Urinary Probe for Macroscopic Hematuria
Two Big Stones in the Bladder of a Patient With Painful Hematuria
Bladder Cancer—painless Hematuria
Abnormal Urine
Abnormal Urine
2 - The Symptoms of Kidney Disease
2.1 The Pain—Lumbar Pain
2.1.1 The Irradiation of Pain in Renal Colic
The Irradiation of Pain in Renal Colic
2.2 Macroscopic Hematuria
2.2.1 The Stone in the Urine
2.2.2 The Stone in the Urine Removed After Renal Colic
Stone in the Urine Removed After Renal Colic
Stone in the Urine Removed After Renal Colic
Stone in the Urine Removed After Renal Colic
2.2.3 The Shape of the Stone is Cylindrical
2.2.4 Dark Color
Hydronephrosis—Dilatation of the Renal Calyxes: Abdominal Echography
The Normal Kidney
2.2.5 Hydronephrosis—Dilatation of the Calyxes
2.2.6 The Normal Kidney
2.2.7 Hydronephrosis Degree III—Enlargement of the Bassinet
Hydronephrosis Degree III
2.2.8 Hydronephrosis Degree II
Hydronephrosis Degree II
Hydronephrosis Degree II
The Normal Kidney
2.2.9 Hydronephrosis Degree I
Hydronephrosis Degree I
Hydronephrosis Degree II
Hydronephrosis Degree I
Hydronephrosis Degree III
The Normal Kidney
Hydronephrosis Degree III
2.3 Clinical Case
Tattoo as Irradiation of the Pain in Left Renal Colic
3 - The Objective Examination
3.1 Edema in Renal Diseases
3.2 Pitted Edema—White and Soft
3.3 Macroscopic Hematuria
3.4 Eyelid Edema in the Morning
4 - The Objective Examination of the Kidney
4.1 The Inspection
4.1.1 Left Lumbar Scar
4.1.2 Left Lumbar Scar after Left Nephrectomy
Left Lumbar Scar after Left Nephrectomy
Left Lumbar Scar after Left Nephrectomy
4.1.3 Left Lumbar Scar after Left Nephrectomy - Eventration
4.1.4 Lipoma Soft at Palpation
Lipoma
4.1.5 Enlarged Lipoma
Enlarged Lipoma
4.1.6 Glob Bladder
4.1.7 Urinary Probing
4.2 The Palpation of the Kidney
4.2.1 Guyon Method—Bimanual Method
4.2.2 Glenard Method—Monomanual Method
4.2.3 Israel Method—Bimanual Method
4.3 The Sensibility of Kidney
4.3.1 Giordano Maneura
4.3.2 Giordano Maneura of the Right Kidney
4.3.3 Giordano Maneura of the Left Kidney
4.3.4 Right Costovertebral Point
4.3.5 Left Costovertebral Point
4.3.6 Right Costomuscular Point
4.3.7 Left Costomuscular Point
4.4 The Ureteral Points
4.4.1 Superior Ureteral Point – Bazin
4.4.2 Medium Ureteral Point – Tourneaux
4.4.3 Inferior Ureteral Point
4.5 Palpation of the Bladder
4.6 Rectal Touch
4.6.1 Adenoma of the Prostate
4.6.2 Cancer of the Prostate
4.7 Urethral Palpation
4.8 The Percussion of the Kidney
4.9 Percussion of the Bladder
4.10 The Auscultation of the Renal Artery Stenosis
5 - The Paraclinic Examination
5.1 Examination of the Urine
Collection of the Urine
Macroscopic Examination
5.1.1 The Volume of Urine
5.1.1.1 Polyuria
5.1.1.2 Oliguria
5.1.1.3 Anuria
5.1.1.4 Nocturia
5.1.1.5 Equality between nocturnal and diurnal uresis
5.2 The Macroscopic Urine Examination
5.2.1 Urine Examination—Macroscopic Appearance of the Urine
5.2.1.1 Concentrated Urine
5.2.1.2 Dilute Urine
5.2.1.3 Color of dilute urine
Concentrated Urine
5.2.1.4 Normal Color of Urine
5.2.1.5 Concentrated Urine
Concentrated Urine
5.2.1.6 Dilute Urine
5.2.1.7 Hyperchromic Urine—Choluric Urine
5.2.1.8 Black Urine
Black Urine
5.2.1.9 Macroscopic Hematuria
5.2.1.10 The three glass Test
Macroscopic Hematuria
5.2.1.11 Macroscopic Hematuria After Urinary Catheterization
5.2.1.12 Choluric Urine due to Bilirubin
5.2.1.13 Thick Urine
5.2.1.14 Troubled Urine
Troubled Urine
Troubled Urine
5.2.1.15 Black Urine
5.2.2 The Physicochemical Examination of Urine
5.2.2.1 Urine PH Test
5.2.2.2 Urine Density
5.2.2.3 Proteinuria
5.2.2.3.1 Edema of the Legs
5.2.2.3.2 Pitting Edema
5.2.2.3.3 Ascites at Abdominal Echo
Ascites at Abdominal Echo
5.2.2.3.4 Macroscopic Urine
5.2.2.3.5 Dipstick Test
5.2.2.3.6 Dipstick Test Positive for Proteinuria
5.2.2.3.7 Renal Edema
5.2.2.3.8 Edema of the Eyelids in the Morning
5.2.2.3.9 Edema of the Legs
Edema of the Legs
5.2.2.3.10 Push With the Thumb on Anterior Tibia
5.2.2.3.11 Indentation—Pitting Edema
Push With the Thumb on Anterior Tibia
Indentations—Pitting Edema
5.2.2.3.12 Edema of The Eyelids in the Morning
5.2.2.3.13 Renal Edema
Renal Edema
Swelling of the eyelids in the morning
5.2.2.4 Pyuria
Doné Reaction
5.2.2.5 Glycosuria
Trommer Reaction
5.2.2.6 Ketonuria
Legal Reaction
5.2.2.7 Bilirubinuria
5.2.2.8 Urobilinogenuria
Ehrlich’s Reagent
5.2.3 Macroscopic Appearance of a Stone In Urine
5.3 The Microscopic Urine Examination
5.3.1 Red Blood Cells
5.3.2 White Blood Cells
5.3.3 Epithelial Cells
5.3.4 Casts
5.3.4.1 Acellular Casts
5.3.4.1.1 Hyaline cast
5.3.4.1.2 Waxy Casts
5.3.4.1.3 Granular Casts
5.3.4.1.4 Fatty Casts
5.3.4.1.5 Pigment Casts
5.3.4.2 Cellular Casts
5.3.4.2.1 Red Cell Casts
5.3.4.2.2 White Cell Casts
5.3.4.2.3 Epithelial Cell Casts
5.3.5 Crystals
5.3.5.1 Urate Crystals
Crystals From Urinary Sediment: Uric Acid
5.3.5.2 Oxalate Calcium Crystals
5.3.5.3 Phosphates Crystals
5.3.5.4 Cholesterol Crystals
5.3.5.5 Tyrosine Crystals
5.3.5.6 Leucine Crystals
5.3.5.7 Cystine Crystals
5.4 Bacteriologic Examination of the Urine
5.4.1 Urine culture positive with enterococcus
5.4.2 Enterococcus Culture
5.4.3 Nitriuria
6 - The Functional Exploration of the Kidney
6.1 Plasmatic Examination
6.1.1 Ureea
6.1.2 Creatinina
6.1.3 Uric Acid
6.1.4 Electrolitic Substance
6.2 Urine Examination
6.2.1 Densimetry
Preparation Two to Three Days Before
On The Day Of The Test Miction From Every 3 H In Different Receptacles
6.2.1.1 Normal
6.2.1.2 Pathological Situations
Paridensity
6.2.2 Urine pH
6.3 Comparing Evaluations Plasma-Urine
6.3.1 Clearance of Creatinine
7. Morphological Investigations of The Kidney
7.1 The Radiographic Examination
7.1.1 Polycystic Kidney
7.1.2 Tumor of the Kidney
7.1.3 Hydronephrosis
7.1.4 Congenital Kidney Hypoplasia
7.1.5 Kidney Hypoplasia Renal Artery Stenosis
7.1.6 Kidney Ptosis
7.1.7 Kidney Calcifications
7.1.8 Opaque Stones Calcium Oxalate
7.1.9 Bilateral Kidneys Stones
Bilateral Renal Stones
7.1.10 Coraliforme Lithiasis
Coraliform Stone
7.1.11 Ureteral Stone
7.1.12 Two Stones in Urinary Bladder
7.2 Intravenous Urography
7.2.1 Hydronephrosis and Hydroureter
7.2.2 Lacuna Image Tumor of The Kidney
7.2.3 Rigidly Narrow Kidney Tuberculosis
7.2.4 Lack of Kidney Function
7.2.5 Kidney Stone
7.2.6 Normal Intravenous Urography
7.2.7 More Beautiful Ureter
7.2.8 Stone Inside of Urinary Bladder
7.2.9 Bladder Carcinoma
7.3 The Abdominal Ultrasound
7.3.1 Normal Kidney
7.3.2 Small Congenital Kidney
7.3.3 Dilatations Of Calyxes
7.3.4 Two Small Cavities
Two Small Cavities
7.3.5 Four Small Cavities
Four Small Cavities
7.3.6 One Small Cavity
One Small Cavity
7.3.7 Simple Kidney Cyst
7.3.8 Enlarge Simple Kidney Cyst
7.3.9 Two Simple Kidney Cysts
7.3.10 Diammeter A And B Of The Simple Kidney Cyst
7.3.11 Simple Enlarge Kidney Cyst
7.3.12 Diammeter A of Kidney Cyst
7.3.13 Vertical Diammeter of Kidney Cyst
7.3.14 Oblique Cyst Diammeter
7.3.15 Abdominal Ultrasound Polycystic Kidney
7.3.16 The Abdominal Ultrasound Kidney Stone
7.4 Kidney Arteriography
7.5 Computed Tomography
7.5.1 Renal Cell Carcinoma
7.5.2 Renal Abscess
7.5.3 Perirenal Hematoma
7.6 Nuclear Magnetic Resonance
7.6.1 Renal Cell Carcinoma
7.7 The Renal Biopsy
7.8 Clinical Cases of the Kidney
7.8.1 Clinical Case No. 1
Macroscopic Hematuria
Abdominal Ultrasound—Polycystic Kidneys
Brother’s Abdominal Ultrasound—Polycystic Kidneys
The Diagnosis of the Patient
Polycystic Kidneys
7.8.2 Clinical Case No. 2
Abdominal Ultrasound: Enlarged Simple Kidney Cyst
Abdominal Ultrasound Enlarged Simple Kidney Cyst
7.8.3 Clinical case No. 3
Macroscopic Hematuria
Abdominal Ultrasound—Left Kidney Hydronephrosis
7.8.4 Clinical case No. 4
Giordano Maneuver Positive at the Left Kidney
Left Costovertebral Point Sensitive
Superior Ureteral Point Bazin
Medium Urethral Point Tourneaux Negative
The Abdominal Ultrasound
The Urography
The Macroscopic Appearance of the Stone
7.8.5 Clinical Case No. 5
Scar in Left Lumbar Area
7.8.6 Clinical Case No. 6
7.8.7 Clinical Case No. 7
Upper Eyelid Edema in the Morning
Swelling of the Lower Limbs
Indentation—Pitting Edema
Indentations—Pitting Edema
The Abdominal Ultrasound—Small Quantity of Free Fluid Inside the Abdominal Cavity—Ascites
7.8.8 Clinical Case No. 8
Edema of the Lower Limbs
Upper Eyelids Edema in the Morning—Green Makeup Pencil
Upper Eyelids Edema in the Morning—Green Makeup Pencil
Indentation
The Abdominal Ultrasound Free Fluid—Ascites
The Macroscopic Urine Examination
The Microscopic Examination
7.8.9 Clinical Case No. 9
Swelling of the Upper and Lower Eyelids in the Morning
The Lower Limbs of the Patient—Without Edema
7.8.10 Clinical Case No. 10
Macroscopic Hematuria
The Abdominal Ultrasound—Dorsal recumbent—Big Stone in the Bladder
The Abdominal Ultrasound—Left Lateral recumbent—Stone in the Bladder
7.8.11 Clinical Case No. 11
Adenoma of Prostate and Gall Bladder
Adenoma of Prostate After Evacuation of the Bladder by Urinary Catheterization
Index
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Back Cover

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MEDICAL SEMIOLOGY GUIDE OF THE RENAL SYSTEM

Dr. Manuela Stoicescu Consultant Internal Medicine PhD, Assistant Professor University of Oradea Faculty of Medicine and Pharmacy Medical Disciplines Department Romania

Academic Press is an imprint of Elsevier 125 London Wall, London EC2Y 5AS, United Kingdom 525 B Street, Suite 1650, San Diego, CA 92101, United States 50 Hampshire Street, 5th Floor, Cambridge, MA 02139, United States The Boulevard, Langford Lane, Kidlington, Oxford OX5 1GB, United Kingdom Copyright © 2020 Elsevier Inc. All rights reserved. No part of this publication may be reproduced or transmitted in any form or by any means, electronic or mechanical, including photocopying, recording, or any information storage and retrieval system, without permission in writing from the publisher. Details on how to seek permission, further information about the Publisher’s permissions policies and our arrangements with organizations such as the Copyright Clearance Center and the Copyright Licensing Agency, can be found at our website: www.elsevier.com/ permissions. This book and the individual contributions contained in it are protected under copyright by the Publisher (other than as may be noted herein). Notices Knowledge and best practice in this field are constantly changing. As new research and experience broaden our understanding, changes in research methods, professional practices, or medical treatment may become necessary. Practitioners and researchers must always rely on their own experience and knowledge in evaluating and using any information, methods, compounds, or experiments described herein. In using such information or methods they should be mindful of their own safety and the safety of others, including parties for whom they have a professional responsibility. To the fullest extent of the law, neither the Publisher nor the authors, contributors, or editors, assume any liability for any injury and/or damage to persons or property as a matter of products liability, negligence or otherwise, or from any use or operation of any methods, products, instructions, or ideas contained in the material herein. Library of Congress Cataloging-in-Publication Data A catalog record for this book is available from the Library of Congress British Library Cataloguing-in-Publication Data A catalogue record for this book is available from the British Library ISBN: 978-0-12-819639-7 For information on all Academic Press publications visit our website at https://www.elsevier.com/books-and-journals

Publisher: Stacy Masucci Acquisition Editor: Katie Chan Editorial Project Manager: Megan Ashdown Production Project Manager: Debasish Ghosh Cover Designer: Mark Rogers Typeset by TNQ Technologies

About the Author MANUELA STOICESCU Consultant Internal Medicine doctor, PhD, Assistant Professor at University of Oradea, Faculty of Medicine and Pharmacy Medical Disciplines Department, Romania Education: Philology-History High School, Oradea, Chemistry e Biology e field High school diploma University of Medicine and Pharmacy “Iuliu Hatieganu” Cluj-Napoca Faculty of Medicine and Pharmacy Romania - Physician University of Medicine and Pharmacy “Iuliu Hatieganu” Cluj-Napoca Romania - Residency Internal Medicine 5years - Certificate- Internal Medicine Specialist Feb 1996eOct 2001 Pe´dagogie training department, ClujeNapoca, Romania e Psychope´dagogie Certificate. Certificate of English language proficiency Residency e Internal Medicine Cluj Napoca e University of Medicine and Pharmacy ”Iuliu Hatieganu” Cluj-Napoca Romania, Department of Medical Semiology, Medical II Clinic e Cluj Napoca e City Internal Medicine Department, Medical II Clinic Cluj Napoca City. Assistant Professor at the University of Oradea e Medical Semiology Department e 2002epresent. Consultant Internal medicine doctor e 2006 Ph.D. thesis: "Hypertension in the young people - clinical features", -publication date Jul 28, 2010 publication description Obtained the title of doctor of medicine according to the Order of the Minister of Education, Research Nr.4542 on 28. 07. 2010. publication description Ph.D. Thesis: "Hypertension in the young people - clinical features", original work, Obtained the title of doctor of medicine according to the Order of the Minister of Education, Research, Youth and Sports Nr.4542 on 28. 07. 2010. PhD Consultant Internal Medicine doctor. PhD, Assistant Professor, University of Oradea, Faculty of Medicine and Pharmacy, Medical Disciplines Department Dates Employed: Jan 2001ePresent 2019; Employment Duration: 18 years 8 months; Location: Oradea - Romania She has been an invited speaker at 56 International Conferences in US and Europe, is Organizing Committee Member (OCM) in International Conferences in US and Europe, published 20 articles in prestigious journals in US and is Editorial Board Member in two prestigious ISSN journals in US: Journal of Developing Drugs and Surgery: Current Research.

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Motto

“Each patient is unique.We have to practice a personalized medicine”

“Semiology is a window that opens to the universe of internal medicine”

Thank you all my students!

I want to thank all my students because they exist; in this way I can continually perfect myself and remain young together with them through their enthusiasm.

Scientific Activity ACCOMPLISHMENTS Publications 51 Invited as speaker and Organizing Committing Member (OCM) at the 24th Annual Cardiologists Conference at Barcelona, Spain from June 11e13, 2018 - Manuela Stoicescu - “The cause of a young patient with third degree AV block”. Invited as speaker and Organizing Committing Member (OCM) at the 25th Annual Congress on Cardiology and Medical Interventions July 16e17, 2018 Atlanta, Georgia, USA - Manuela Stoicescu e“The hidden cardiovascular disease at a patient with pain in the left hypochondrium “ Invited as speaker Manuela Stoicescu at 17th Annual Conference on Nephrology” on December 04e05, 2017 Dallas, USA, publication dates 04 December, 2017 publication description:” Atypical urinary tract infection to a patient with unique kidney “. Invited as speaker Manuela Stoicescu at “International Conference on Biomarkers & Clinical Research” November 27e28, 2017 Atlanta, USA, publication date November 27, 2017, publication description: ”Noncorrelation between tumor biomarkers levels in peritoneal carcinomatosis”-volume 2, Issue 4. Invited as speaker Manuela Stoicescu and Committing Organizing Memberat “21st International Conference on Clinical & Experimental Cardiology” November 06e07, 2017 Las Vegas, USA, publication date November 06, 2017 publication description: “The risk of antidepressants drugs in patients with prolonged congenital QT syndrome “, volume 8, Issue 11, ISSN 2155e9880. Invited as speaker Manuela Stoicescu and Committing Organizing Member at “19th Annual Cardiology Conference” August 31 - September 01, 2017 Philadelphia, USA publication date August 31, 2017 publication description:“Silent ischemic heart disease - an ignored problem?!” Invited as speaker Manuela Stoicescu “15th International Conference on Nephrology” 28e30 August 2017 Philadelphia USA. Publication date August 30, 2017 publication description: “A simple renal cyst is really an innocent issue?”Volume 3, Issue 3: ISSN: 2472-1220. • Edit publication The risk of nitroglycerin drug administration in chronic diabetic patients Invited as speaker Manuela Stoicescu “4th Annual Congress on Drug Discovery & Designing” July 03e05, Bangkok, Thailand 2017 Publication title: “The risk of nitroglycerin drug administration in chronic diabetic patients” publication date July 3, 2017, Volume 6, Issue 3, ISSN: 2169-0138. • Edit publication The Liver - A victim at the Middle - due to Association of oral Antidiabetics Drugs with Statin Publication title - article “The Liver - A victim at the Middle - due to Association of oral Antidiabetics Drugs with Statin” Manuela Stoicescu Publication date May 11, 2017 publication description Journal of Developing Drugs ISSN 2329-6631 USA IF ¼ 0,97 • Edit publication “Surgical treatment of atrial fibrillation between benefit and risk” - Manuela Stoicescu - invited as speaker -“15th World Cardiac Surgery & Angiology Conference ” December 08e09, 2016 in Philadelphia, USA. Invited as speaker Manuela Stoicescu “15th World Cardiac Surgery & Angiology Conference ” December 08e09, 2016 in Philadelphia, USA. Publication title “Surgical treatment of atrial fibrillation between benefit and risk” Publication date Dec 8, 2016 publication description December 2016, Volume 7 Issue 10, ISSN: 2155-9880. • Edit publication “The surprise of diagnosis of a fluid collection around the spleen” - Manuela Stoicescu - Invited as speaker - 5th International Conference and Exhibition on Surgery - November 7e8, 2016 Alicante, Spain

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Scientific Activity

Invited as speaker Manuela Stoicescu“5th International Conference and Exhibition on Surgery” - November 7-8, 2016 Alicante, Spain Publication title “The surprise of diagnosis of a fluid collection around the spleen”Publication date November 7, 2016, Alicante Spain. • Edit publication “Early Predictive Markers Of Atherosclerosis In The Young” Manuela Stoicescu Publication title - article -“Early Predictive Markers Of Atherosclerosis In The Young” Manuela Stoicescu publication date September 30, 2016 publication description International Journal of Development Research Thomson Reuters - Impact factor 4,25 publication description Volume 06 Issue 09, September 2016, ISSN: 2230-9926 • Edit publication “The Risk of Sudden Decrease of Severe Arterial Hypertension” Manuela Stoicescu Publication title e article - “The Risk of Sudden Decrease of Severe Arterial Hypertension” Manuela Stoicescu Publication date July 31, 2016 publication description Journal of Clinical & Experimental Cardiology. USA, ISSN: 2155-9880 Journal Impact Factor 1.219*; 1.97* (5 Year Impact Factor) • Edit publication “Acanthosis Nigricans - early marker in cancer ” Manuela Stoicescu Publication title e article-“ Acanthosis Nigricans - early marker in cancer” Manuela Stoicescu Publication date July 15, 2016 publication description Asian Academic Research Journal of Multidisciplinary ISSN: 2319-2801 Thomson Reuters - IF ¼ 2,015 publication description Volume 3, Issue 7, July 2016 • Edit publication “Controversial in Menopausal Hormone Replacement Therapy” Manuela Stoicescu Publication title e article - “Controversial in Menopausal Hormone Replacement Therapy” Manuela Stoicescu publication date July 11, 2016 publication description Journal of Developing Drugs - USA. ISSN 2329-6631, IF ¼ 1,32 • Edit publication “The Unusual Cause of Dangerous Arrhythmias at the Young” Manuela Stoicescu Publication title - article-“The Unusual Cause of Dangerous Arrhythmias at the Young” Manuela Stoicescu publication date April 30, 2016 publication description Journal of Clinical & Experimental Cardiology USA, ISSN: 2155-9880 Journal Impact Factor 1.219*; 1.97* (5 Year Impact Factor) • Edit publication “Acute Pancreatitis after therapy with GABARAN” Manuela Stoicescu Publication title - article-“Acute Pancreatitis after therapy with GABARAN” Manuela Stoicescu publication date December 24, 2015 publication description Journal of Developing Drugs - USA. ISSN 2329-6631, IF ¼ 1,32 • Edit publication LAUNCH BOOK: “ Sudden cardiac in the young” - Manuela Stoicescu Invited as speaker Manuela Stoicescu “8th Global Cardiologists and Echocardiography Annual Meeting”- July 18-20, 2016 Berlin, Germany -LAUNCH BOOK: “Sudden cardiac in the young” - Manuela Stoicescu:publication date December 15, 2015 publication description book“ Sudden cardiac in the young”LAMBERT ACADEMIC PUBLISHING -LAP- GERMANY ISBN:978-3-659-81,073-2 Berlin, Germany July 2016 Volume 7, Issue 6, ISSN: 21559880. Invited as speaker Manuela Stoicescu and Committing Organizing Member at “ 6th International Conference on Clinical&Experimental Cardiology” November 30- December 02,2015 San Antonio, USA, - “ The Chest Pain with Normal EKG”, publication date November 30, 2015, San Antonio, USA. • Edit publication The Chest Pain with Normal EKG Invited as speaker Manuela Stoicescu and Organizing Committee Member at ”4th International Conference and Exhibition on Surgery”-October 05e07, 2015 Dubai, UAE • Publication title “Nodular Formations From The Hair Skin Of The Head”, publication date October 3, 2015 Dubai, UAE. https://www.linkedin.com/in/manuela-stoicescu-07974841/edit/publication/1478911795/ Invited as speaker Manuela Stoicescu - Workshop - Organizing Committee Member at ”4th International Conference on Nephrology & Therapeutics”- September 14e16, 2015 Baltimore, USA, Publication Workshop title: ”How We Can Protect The Kidney About The Side Effects Of Drugs?- publication date September 14, 2015, • Edit publication An Unusual Risk Factor in the Breast Cancer

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Invited as speaker Manuela Stoicescu and Organizing Committee Member-“World Congress on Cancer and Prevention Methods”- August 27e29, 2015, Dubai, UAE, Publication title “An Unusual Risk Factor in the Breast Cancer”, publication date August 27, 2015, Dubai, UAE. • Edit publication The Cause Of The Left Bundle Branch Block at a Young Patient Invited as speaker Manuela Stoicescu at the “5th International Conference on Clinical & Experimental Cardiology “- April 27e29, 2015 Philadelphia, USA, Publication title “The Cause Of The Left Bundle Branch Block at a Young Patient:publication date April 29,2015 Philadelphia, USA Invited as speaker Manuela Stoicescu and Organizing Committee Member-“Global Conference on Vaccines” April 13e15, 2015, Dubai, UAE, Publication title: “The Vital Importance of BCG Vaccination at the Newborns”: publication date April 13, 2015, Dubai, UAE. • Edit publication Beta- Human Chorionic Gonadotrophin (B-HCG total) as a tumor marker in pregnancy Invited as speaker Manuela Stoicescu “5th World Congress on Cell & Stem Cell Research” - March 23e25, 2015 Double Tree by Hilton ChicagoeNorth Shore, USA, Publication title: “Beta- Human Chorionic Gonadotrophin (B-HCG total) as a tumor marker in pregnancy”, publication date March 23, 2015 ChicagoeNorth Shore, USA. • Edit publication “The real cause of a patient with abdominal pain” Invited as speaker Manuela Stoicescu and Organizing Committee Member of the“3rd International Conference on Surgery and Anesthesia” from November 17e19 2014 at ChicagoeNorth Shore USA, Publication title: “The real cause of a patient with abdominal pain”, publication date November 17, 2014 at ChicagoeNorth Shore USA Invited as speaker Manuela Stoicescu at “4th World Congress on Cell Science & Stem Cell Research “e June 24e16, 2014 Valencia Conference Centre, Valencia, Spain. s” -Invited as speaker InPublication title:“Diagnosis traps in a rare hematologic disease”-publication date June 24, 2014 Valencia, Spain. • Edit publication -“The risk of coarctation of the aorta in pregnancy”Invited as speaker Manuela Stoicescu at “4th International Conference on Clinical & Experimental Cardiology” - April 14e16, 2014 Hilton San Antonio Airport, TX, USA. Publication title -“The risk of coarctation of the aorta in pregnancy”-, publication date April 14, 2014 San Antonio,TX, USA. Publication title - article - “Osteogenesis Imperfecta”- Manuela Stoicescu - Journal of Molecular and Genetic Medicine, USA., Published Date: February 26, 2014, ISSN: 1747-0862 Invited as speaker Manuela Stoicescu at “3rd World Congress on Cancer Science & Therapy” October 21-23, 2013 Double Tree by Hilton Hotel San Francisco Airport, CA, USA Publication title:“The risk of excessive vaccination in medullar thyroid carcinoma”, publication date October 21, 2013, San Francisco USA. • Edit publication “Onset of acute pancreatitis with transitory type II IN diabetes mellitus” Invited as speaker Manuela Stoicescu at “2nd International Conference on Surgery and Anesthesia, September 16-18, 2013, Hampton Inn Tropicana, Las Vegas, NV, USA. Publication title “Onset of acute pancreatitis with transitory type II IN diabetes mellitus”, publication date September 16, 2013, Las Vegas, Nevada, USA, • Edit publication “The Risk of administration plasma” Publication title-article - “The Risk of administration plasma”- Manuela Stoicescu, publication date July 23, 2013 publication description JOURNAL OF DEVELOPING DRUGS - ISSN 2329e6631, 2:106. https://doi.org/10.4172/ 2329-6631.1000106 Published July 23, 2013 USA. • Edit publication “Diagnosis Traps in Polyarteritis Nodosa” Publication title - article -“Diagnosis Traps in Polyarteritis Nodosa”- Manuela Stoicescu, publication date July 2013, publication description JOURNAL OF LIFE SCIENCES”- David Publishing Company e July 2013, Vol. 7, No. 7, pp. 749e753 ISSN 1934-7391, USA

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Scientific Activity

• Edit publication “The Risk of Breast Carcinoma with Interferon Plus Ribavarin Therapy during Treatment of Chronic Hepatitis C Virus Infection” Publication title - article -“The Risk of Breast Carcinoma after therapy with Interferon Plus Ribavarin during Treatment of Chronic Hepatitis C Virus Infection”-Manuela Stoicescu Published May 27, 2013.U S A. JOURNAL OF DEVELOPING DRUGS - ISSN: 2329e6631, Volume 2, Issue 1, 2:102. https://doi.org/10.4172/2329-6631.1000102. • Edit publication “Uncommon cardiac malformation in a rare genetic disease” Publication title - article - “Uncommon Cardiac Malformation in a Rare Genetic Disease”- Manuela Stoicescu publication date Apr 15, 2013: publication description JOURNAL OF CLINICAL & EXPERIMENTAL CARDIOLOGY SCOPUS U.S.A. J Clin Exp Cardiolog 2013, 4:51,000,244, ISSN: 2155e9880 JCEC,. 4:5 https://doi. org/10.4172/2155-9880.1000244, Volume 4, Issue 5, 1000244, ISSN: 2155e9880 JCEC. Publication title e article - “Kidney Tumor in Pregnancy” - Manuela Stoicescu publication date: July 29, 2013 publication description JOURNAL OF NEPHROLOGY & THERAPEUTICS 3: 138, https://doi.org/10.4172/2161-0959.1000138 2013 U S A. ISSN: 2161-0959. • Edit publication “Leyden V Syndrome and Hashimoto Thyroiditis”-original case report Invited as speaker Manuela Stoicescu at “Asian Clinical Congress”-Bangkok, Thailand, January 28e2013, Publication title: “Leyden V Syndrome and Hashimoto Thyroiditis”- publication date: January 28, 2013 Invited as speaker online Conference - Manuela Stoicescu. at” Target meeting, Draft Conference Program, TM’S 2 s world online Conference, January 8-11 2013, Innsbruck st, Bellaire, Texas, USA.-Publication title:”The real cause of a severely anemia syndrome”, Publication date January 8, 2013 Publication title - article -“The real intraoperative diagnosis of a patient with lipothymia and arterial hypotension”- Manuela Stoicescu, publication date November 26, 2012 publication description JOURNAL OF TRANSPLANTATION TECHNOLOGIES & RESEARCH- ISSN 2161-0991.U S A • Edit publication -“Avoiding Nephrectomy in an Unexpected Diagnosis in Case of Urographic Lack of Kidney Function” Publication title-article- “Avoiding Nephrectomy in an Unexpected Diagnosis in Case of Urographic Lack of Kidney Function”- Manuela Stoicescu - publication date November 22, 2012, USA. • Edit publication “High blood pressure in the young e a ignored problem?! ” Publication title“High blood pressure in the young e a ignored problem?! “Manuela Stoicescu publication date October 29, 2012 publication description University of Oradea Publishing House publication description Monography published: “High blood pressure in the young e a ignored problem?! ”. ISBN: 978-606-10-0755-4. • Edit publication “Carcinogenic risk of anabolic steroids in young athletes” Invited as speaker - Manuela Stoicescu - “Montreal 2012 International Anticancer Forum” eAugust 27e30, 2012., Publication title:“Carcinogenic risk of anabolic steroids in young athletes”, Publication date: August 27e30, 2012, Montreal, Canada Invited as speaker - Manuela Stoicescu - “8th International Stroke Summit (ISS8) World Stroke Organization (WSO)”, July 6-8 2012 Nanjing, China, Publication title “Neurological manifestations in systemic vasculitis” Publication date July 6, 2012 Nanjing, China. Publication title: “Clinical manifestations in primary erythrocytosis“-Manuela Stoicescu Publication date June 9, 2012 Xuzhou 2012 International Forum on Modern Medicine e June 9e10 2012, Xuzhou China. Invited as speaker - Manuela Stoicescu at “Montreal International Endoscopy Forum - International Forum on Biotechnology and Medicine” - May 24e25,2012 Montreal, Quebec, Canada, Publication titlee“The role of endoscopy in the diagnosis of Von Recklinghausen dissease” publication date May 24, 2012. • Edit publication -“Transiet ischaemic stroke attack at young age”-original case reportPublication title-“Transient ischemic stroke attack at young age” publication date March 15, 2012, publication description International Neuroscience Conference March 15e16, 2012, Toho University Omori Medical Center Tokyo, Japan. Publication description Invited as speaker Manuela Stoicescu -“Transient ischemic stroke attack at

Scientific Activity

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young age”-original case report-International Neuroscience Conference March 15e16, 2012, Toho University Omori Medical Center Tokyo, Japan. • Edit publication -“The Abusive Utilization of Paraclinical Investigations at Limits between Methods of Depistations and Iatrogenic Risk Factors for Cancer”- original case reportPublication title-“The Abusive Utilization of Paraclinical Investigations at Limits between Methods of Depistations and Iatrogenic Risk Factors for Cancer”- Manuela Stoicescu, Publication date January 13, 2012 publication description Hong Kong 2012 International Medical Summit, January 13e14, Hong Kong Community Healthcare and Healthcare Management Forum Hong Kong, China, January 13e14,2012. Publication description Invited as speaker Manuela Stoicescu -“The Abusive Utilization of Paraclinical Investigations at Limits between Methods of Depistations and Iatrogenic Risk Factors for Cancer”- original case report- Hong Kong 2012 International Medical Summit, January 13e14, Hong Kong Community Healthcare and Healthcare Management Forum Hong Kong, China, January 13e14,2012. • Edit publication “The dosage of plasma renin level-early marker in diagnosis of kidney carcinoma and pheochromocytoma in the young”- original research Publication title “The dosage of plasma renin level-early marker in diagnosis of kidney carcinoma and pheochromocytoma in the young”- original research Publication date January 12, 2012 publication description Target meeting, Draft Conference Program, TM’S 1st world online Conference, January 12e14, 2012, Innsbruck st, Bellaire, Texas, USA. publication description Invited as speaker online Conference - Manuela Stoicescu - “The dosage of plasma renin level-early marker in diagnosis of kidney carcinoma and pheochromocytoma in the young”original research eTarget meeting, Draft Conference Program, TM’S 1st world online Conference, January 12e14, 2012, Innsbruck st, Bellaire, Texas, USA. • Edit publication ”Determination of renin e early marker in the diagnosis of cancer at hypertensive young patients is important to become a screening test.”- original research Publication title”Determination of renin e early marker in the diagnosis of cancer at hypertensive young patients is important to become a screening test.”- Original research Publication date October 28, 2011 publication description EPS Global International Forum of Regional & Targeted Cancer Therapies Shanghai, China. Publication description Manuela Stoicescu - ”Determination of renin e early marker in the diagnosis of cancer at hypertensive young patients is important to become a screening test.”- original research - 3rd EPS Global International Forum of Regional & Targeted Cancer Therapies Shanghai, China. October 28e30, 2011 • Edit publication -“The role of increased plasmatic renin level in the pathogenesis of arterial hypertension in young adults.”- original research Publication title“The role of increased level of plasma renin in etiopathogenic arterial hypertension in the young “publication date 2011 publication description Volume 52 Number 1 ISSN 1220-0522. publication description Manuela Stoicescu, S. Bungau, C, Csepento, M. Gabriela: “The role of increased level of plasma renin in etiopathogenic arterial hypertension in the young” ROMANIAN JOURNAL OF MORPHOLOGY AND EMBRYOLOGY Volume 52 Number 1 e Supplement (new series) - 2011, ISSN 1220e0522 PhD. thesis: “Hypertension in the young people - clinical features”, Publication date July 28, 2010 publication description obtained the title of doctor of medicine according to the Order of the Minister of Education, Research Nr.4542 on 28.07.2010. Publication description PhD thesis: “Hypertension in the young people - clinical features”, original work, Obtained the title of doctor of medicine according to the Order of the Minister of Education, Research, Youth and Sports Nr.4542 on 28.07.2010. PhD.

BOOKS 7 “Clinical Cases for Students of the Faculty of Medicine”Publication date 2010 publication description University of Oradea University assistant Publishing House. Publication description “Clinical Cases for Students of the Faculty of Medicine”-author: Dr Manuela Stoicescu Internal Medicine MD, PhD, University of Oradea University assistant Publishing House, 2010 - ISBN 978-606-100198-9/publication in English languages- and Romanian. Language ISBN:978-606-10-0132-3.

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Scientific Activity

Book published: Manuela Stoicescu: “Sudden Cardiac Death in the Young” International Editure LAMBERT Academic Publishing e Germany e ISSN:978-3-659-81,073-2 -2015. Manuela Stoicescu e “Side effects of antiviral hepatitis treatment” International Editure LAMBERT Academic Publishing e Germany ISSN 978-3-659-47,428-6 - 2013. Book published: Manuela Stoicescu: “Tumor Markers in Hypertensive Young Patients” e OMICS PUBLISHING HOUSE, USA ISBN:978-1-63,278-041-6 e March 2015. Cardiovascular diseases: Causes, Risks, Management CVD 1 e Causes of Cardiovascular Diseases Manuela Stoicescu MD, PhD 1.5, 1.6- on Amazon, USA. High blood pressure in the young - an ignored problem?! e Manuela Stoicescu - monograph published Publishing House Oradea, Romania 2012 ISBN:978-606-10-0755-4. “Acute renal failure after therapy with Interferon” Publication description speaker and Co-chair Manuela Stoicescu - Member in Committing Organizing of the 3rd International Conference on Nephrology & Therapeutics (Nephro-2014) June 26e27, 2014 Valencia Conference Centre, Valencia, Spain. Publication description Invited as speaker and Co-chair Manuela Stoicescu - Member in Committing Organizing of the Conference e“Acute renal failure after therapy with Interferon”- 3rd International Conference on Nephrology & Therapeutics (Nephro-2014) June 26e27, 2014 Valencia Conference Centre, Valencia, Spain. Member in manes Committing Organizing International Conferences USA Member in Committing Organizing International Conference DUBAI Member in Committing Organizing International Conference SPAIN Editorial Board Member International Conference Cardiology

PUBLICATIONS 56 CONFERENCES 2018 Invited as speaker at the 27th World Oncologist Annual Conference on December 07-08, 2018, Chicago, USA, Theme: “Believe there is hope for a cure”dManuela Stoicescud“The pesticidesdcarcinogenic risk factor!“ Invited as speaker at the 12th International Conference on Hematology and Hematological Oncology on October 29-30, 2018, San Francisco, USAdManuela Stoicescud“The quantification of irradiant investigations important role in prophylaxis of hematologic diseases” Invited as speaker at the 4th "International Conference on Gastrointestinal Cancer and Therapeutics“d"Termination of GI Cancer by Novel and Innovative Technologies" on October 29-30, 2018, San Francisco, USAdManuela Stoicescud“The patients with hyperuricemia needs screening colonoscopy” Invited as speaker and Organizing Committing Member (OCM) at the American Heart CongressdCVD 27th International Conference on Clinical & Experimental, Cardiology Research on October 05-06, 2018, Los Angeles, California, USAdManuela Stoicescud“Hormone replacement therapy really protects a woman against myocardial infarction?” Invited as speaker at Euro Pharmaceutics 2018d17th Annual Congress on Pharmaceutics & Drug Delivery SystemsdSeptember 20-22, 2018, Prague, Czech RepublicdManuela Stoicescud“Drug abusedan uncontrollable phenomenon !?”

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CONFERENCES 2019 Invited as speaker and Organizing Committing Member (OCM) at the 31st Annual Cardiologists Conference on June 17-19, 2019, Rome, ITALY, Theme:“ Insights of Cardiology & Healthcared Manuela Stoicescud”The combination between digoxin, beta blocker and cordarone is dangerous” Invited as speaker at the 27th Annual Congress on Cardiology and Medical Interventions on July 31-August 01, 2019 Chicago, USA, Theme: “Prediction and Preventions” dManuela Stoicescud” Very severe bradycardia 10 bates/min after combination of drugs “

YOU ARE READY? I AM YOUR LADY TEACHER

WE WILL DISCUSS THE PATIENT’S HISTORY

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Introduction The History of the Patient The history of the patient represents the first contact and discussion of the physician with the patient and is very important. Taking a superficial history because of a lack of time is not excusable because it can generate mistakes. A serious and careful history of the patient will aid in a successful diagnosis. We must always ask a few typical questions, which are presented next.

Look at me how carefully I am talking to the patient and take notes!

In the first instance I will ask about personal information: name, age, gender.

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1. PERSONAL DATA What is your name? How old are you? I observe if the patient is a man or a woman, because I know that some diseases are more common in women and other diseases appear more often in men.

2. PLACE OF BIRTH AND HOME (ADDRESS) Where were you born? Where do you live? What is your address? What is your phone number?

3. ALLERGY? I will ask my patient if he or she is allergic to any drugs. If the answer is yes, I will ask what drugs have caused allergy in the past and I will mark it with red color in the personal papers of the patient. Very important! The administration of these drugs must to be avoided to prevent anaphylactic shock, Quincke edema, or sudden death. For example, I noticed: allergy to aspirin allergy to penicillin

So, I will never give this patient aspirin or penicillin!

4. THE REASON FOR HOSPITALIZATION The reason for hospitalization represents the main symptoms about which the patient came for consultation. There is always a major symptom; this is the leading symptom. The patient may also present with other symptoms. These must be put in order per anatomy and system.

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Example No. 1 -

Syncope is the leading symptom Dyspnea Chest pain Palpitations

Example No. 2 -

Hematuria is the leading symptom Pollakiuria Dysuria Chills Fever

Example No. 3 -

Hemoptysis is the leading symptom Dyspnea Chills Fever

Example No. 4 - Abdominal pain - Nausea - Vomiting

5. THE HISTORY OF THE CURRENT DISEASE In this section we need to describe in detail the history of the current disease of the patient. First, we need to specify: How did the disease start? Was it sudden or insidious? How long ago did it begin? What are the symptoms? What was the patient’s attitude toward the disease? Has the patient presented him- or herself to a doctor or stayed at home? Did the patient begin medical treatment on the advice of a physician or did he or she begin treatment alone? Or did the patient not follow any treatment? Did he or she start a drug treatment that had an influence on the disease? Was there improvement, aggravation, or any influence? Is this the first episode or have there been other similar episodes in the past? In this section it is necessary to describe in detail the actual history of the patient as regards what he or she is being hospitalized for, as complete as possible. If the patient currently has more than one disease, we have to take a history of each one, following the same elements presented before.

6. FAMILY HISTORY In this section we need to describe what diseases are in the patient’s family. What diseases have the mother, father, brothers, sisters had? This is because there exists a risk for genetic transmission, for example, arterial hypertension, diabetes mellitus, cancers at various locations, and genetic diseases with dominant or recessive transmission. These diseases are important because the patent has a genetic risk for developing these diseases at any point in time.

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7. PERSONAL PATHOLOGICAL HISTORY In this section we need to describe all the diseases that the patient had in the past and also surgical procedures, in chronological order, except for the current illness.

8. PERSONAL PHYSIOLOGICAL ANTECEDENTS In this section we need to describe all the physiological antecedents in women regarding menstrual cycles and pregnancies. At what age did the first cycle (menarche) occur? Normal age is between 12 and 14 years. Have menstrual cycles been regular? Once per month? Normal cycle is 28 days. How many days does the flow take? Normal is between 3 and 5 days. How do you estimate the amount of blood lost during the menstrual cycle? Normal is between 300 and 500 mL of blood. Have you ever had cycles longer than 10 days? This is called menorrhagia. This is specific for uterine fibroids. Have you ever had bleeding between menstrual cycles? This is called metrorrhagia. This is specific for uterine fibroids Have you had abnormal menstrual cycles with a quantity more than 500 mL? This is called hypermenorrhea. This is specific for uterine fibroids Have you had abnormal menstrual cycles with increased quantity and with blood clots and prolonged duration of more than 5 days? This is specific for uterine fibroids. How do you describe the color of the blood? Normal is fresh red. Have you ever had a dark bleeding that looks like coffee or coffee grounds? This is specific for uterine carcinoma. Have you ever had bleeding like juice in which meat was washed? This is specific for uterine carcinoma. Are you in menopause? At what age did menopause begin? Normal age for menopause is between 45 and 50 years. Are you in early menopause or artificial menopause after ovariectomy, radiotherapy, or chemotherapy? This is a risk factor for ischemic heart disease, because the woman has lost the protection of estrogen hormones against atherosclerosis. Have you had bleeding in menopause? This is specific for uterine carcinoma. Have you been pregnant, and how many times? Was the delivery at normal time, 9 months, or early or late? Have you had any abortions, and how many? Were the abortions spontaneous or induced? What did your babies weigh after delivery? Normal weight is between 3 and 4 kg. A baby bigger than 4 kg is a “big baby” or has macrosomia and represents a risk factor for diabetes mellitus of the mother in the future. A baby less than 3 kg is premature.

9. LIFE CONDITIONS The life conditions of the patient are very important. Especially important are the housing conditions, eating, and toxic consumptions.

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A. The housing conditions The housing conditions are very important because people spend most of their time at home. It is important to know how many persons live in a room and how many rooms are in the house. The infectious contagious diseases such as viruses, pneumonia, and tuberculosis are transmitted when the people cohabit. Another important condition is the cleanliness of the house. Is it a clean house or not? Is it an overcrowded house or not? Are people living together with cats, dogs, a parrot? Because animals can transmit diseases to the persons who live with the animals. Room air conditioning is a risk factor for respiratory tract infections and allergies as well.

B. Eating A person’s diet is very important. It must be nutritionally balanced in accordance with the physical effort. A normal diet should be varied and balanced in the content of proteins, carbohydrates, lipids, and vitamins. A unilateral diet excessive in glucoses and carbohydrates represents a risk factor for diabetes mellitus. A unilateral diet increased in animal lipids represents a risk factor for dyslipidemia, atherosclerosis, ischemic heart diseases, angina pectoris, and heart attack. Also, excess calories together with sedentary habits are a risk factor for obesity, high blood pressure, and diabetes mellitus. Deficiency in diet leads to weight loss. Failure to eat regular meals is a risk factor for the occurrence of gastritis and gastric or duodenal ulcers.

C. Toxic consumptions In this section, the patient should be asked about the toxic consumption of alcohol, smoking, coffee, and drugs. Alcohol consumption In terms of alcohol consumption the patient should be asked how often he or she consumes alcohol: every day or occasionally? The truth is that alcohol is often not recognized by the person concerned; usually the family is the one who informs the doctor about alcohol consumption. It is important to know the amount consumed and what kind of alcoholic beverages are consumed, hard alcohol or light alcohol, like beer or wine? Persons with chronic alcohol consumption have risks for many diseases, such as chronic alcoholic hepatitis, liver cirrhosis, gastric or duodenal ulcers, mental illnesses such as alcoholic dementia, and others. Smoking Smoking is another risk factor for many diseases. It is really important to ask the patient at what age he or she began smoking (how long?). What type of cigarette, with filter or without filter? How often? Daily? How many cigarettes per day? Pipe smokers are at risk for lip cancer. Smoking is an important risk factor for cardiovascular diseases such as ischemic heart disease, angina pectoris, acute myocardial infarction, cardiac arrhythmias, and sudden death; respiratory diseases such as chronic tobacco bronchitis, COPD, and bronchusepulmonary cancer; and digestive diseases such as gastric ulcer or duodenal ulcer. We must consider the state of the passive smoker. This is represented by peopledinnocent victimsdwho passively inhale cigarette smoke because they are around a person who smokes. The most innocent victims are children. Passive smokers are at risk for the aforementioned diseases in a percentage almost as great as active smokers! The younger the age at which smoking started, and the higher the number of cigarettes a day, the higher is the risk for the diseases mentioned. Coffee Coffee consumption has been known from the earliest times. This small daily vice is practiced around the world. Abuse of coffee consumption can cause palpitations, tachycardia, irritability, nervousness, and insomnia. It is also a risk factor for the occurrence of high blood pressure and dangerous arrhythmias. Drugs Drug consumption represents a risk factor for dangerous arrhythmias, myocardial infarction at a young age, and sudden death. Bacterial endocarditis represents another risk after drug consumption. Drug consumption must to be stopped, especially because many victims are young people.

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10. WORKING CONDITIONS Working conditions represent another important part of the history of the patient. Many risk factors are present at the workplace. For this reason it is very important to ask and to know the profession of the patient. How many hours are worked per day? Risk factors from work include dust, humidity, and noise. Does the patient work during the night? Work supplementary hours? How are his or her relationships with colleagues? Relationship with the boss? Everything is important!

11. GENERAL MANIFESTATIONS The history of the patient finishes with a few important questions regarding general manifestations such as: Appetite The weight curve - increasing? - decreasing? - stationary? The stool The urine Frequency of urination in 24 h? Diuresis? Sleep Do you sleep during the night? Do you have insomnia? The history of the patient is finished with these general manifestation questions.

I'm really happy! We're done with patient history!

ARE YOU READY? WE WILL TALK ABOUT

THE MEDICAL SEMIOLOGY GUIDE TO THE RENAL SYSTEM

C H A P T E R

1 Questionnaire O U T L I N E Macroscopic Hematuria

6

Bladder Cancerdpainless Hematuria

8

Urinary Probe for Macroscopic Hematuria

6

Abnormal Urine

Two Big Stones in the Bladder of a Patient With Painful Hematuria

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7

Abnormal Urine

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Medical Semiology Guide of the Renal System https://doi.org/10.1016/B978-0-12-819639-7.00001-9

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© 2020 Elsevier Inc. All rights reserved.

1. Questionnaire

3

4

1. Questionnaire

1. Do you have lumbar pain?

1. Questionnaire

2. Does the pain move to the ureter side, as in the following image?

3. Does the pain spread into the iliac fossa? 4. Do you urinate frequently? 5. Do you have pain or a burning sensation during urination? 6. Does your urine sometimes contain fresh blood, as in the following images?

5

6

1. Questionnaire

Macroscopic Hematuria

Urinary Probe for Macroscopic Hematuria

7. If you urinate with fresh blood (macroscopic hematuria), is it with pain or without pain? Painful hematuria suggests kidney stones or bladder stones.

Two Big Stones in the Bladder of a Patient With Painful Hematuria

Two Big Stones in the Bladder of a Patient With Painful Hematuria

Painless hematuria suggests cancer: kidney cancer or bladder cancer

7

8

1. Questionnaire

Bladder Cancerdpainless Hematuria

8. Does your urine ever contain pus, or appear abnormal, as in the following image ?

Abnormal Urine

Abnormal Urine

9. Do you urinate during the night? 10. Do you have to strain to urinate? 11. Have you ever urinated drop by drop? 12. Have you ever noticed a decrease in the urine force or usual speed? 13. Do you have any family members with adenoma or prostate adenocarcinoma? All these symptoms suggest the diagnosis of adenoma or adenocarcinoma of the prostate. 14. Do 15. Do 16. Do 17. Do 18. Do 19. Do

you you you you you you

have have have have have have

any family any family any family any family any family any family

members members members members members members

with kidney stones or kidney cancer? with polycystic kidney? with congenital kidney disease? with chronic renal failure? who have had a kidney transplant? with acute renal failure?

9

10 20. 21. 22. 23. 24. 25. 26. 27.

1. Questionnaire

Do Do Do Do Do Do Do Do

you you you you you you you you

work in conditions of high humidity, with excessive sweating that causes dehydration? sweat a lot at your workplace? have frequent urination, pain during urination, chills, and fever? work in an environment with pesticides? have any family members with tuberculosis? sometimes experience moments when you cannot urinate? sometimes experience a globular bladder, retention of the urine? sometimes experience the loss of bladder control (involuntary urination)?

This is urinary incontinence. 28. Do you sometimes have renal colic after traveling with trepidations? 29. Do you ever find a stone in your urine after renal colic, as in the image below?

30. Do you ever find sand in your urine? 31. Have you ever noticed abnormal urine, such as in the following image below?

Abnormal Urine

Abnormal Urine

Abnormal urine suggests a urinary tract infection 32. Have you had a kidney transplant? 33. Do you have any autoimmune diseases? 34. Do you have diabetes mellitus? 35. Do you have high blood pressure? 36. Have you been diagnosed with a lateral murmur of the umbilicus? This suggests a renal artery stenosis. 37. Have you undergone any surgical kidney procedures? 38. Have you undergone a lithotripsy procedure for the elimination of kidney stones? 39. Do you drink enough water (liquids), 1e2 L every 24 h?

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C H A P T E R

2 The Symptoms of Kidney Disease O U T L I N E 2.1 The PaindLumbar Pain 2.1.1 The Irradiation of Pain in Renal Colic

13 14

2.2 Macroscopic Hematuria 2.2.1 The Stone in the Urine 2.2.2 The Stone in the Urine Removed After Renal Colic 2.2.3 The Shape of the Stone is Cylindrical 2.2.4 Dark Color

15 16 17 19 20

2.2.5 HydronephrosisdDilatation of the Calyxes 2.2.6 The Normal Kidney 2.2.7 Hydronephrosis Degree IIIdEnlargement of the Bassinet 2.2.8 Hydronephrosis Degree II 2.2.9 Hydronephrosis Degree I

22 22

2.3 Clinical Case Tattoo as Irradiation of the Pain in Left Renal Colic

31 31

23 24 26

The main symptoms of kidney disease are pain and urinary disturbance.

2.1 The PaindLumbar Pain Renal colic is one of the most severe pains in medical practice. The pain starts in the lumbar area and irradiates into the right flank and right iliac area and also into the external genital organdtesticle or vulva. The irradiation of pain in renal colic is shown in the following images and is indicated with black arrows (Figures 1 and 2).

Medical Semiology Guide of the Renal System https://doi.org/10.1016/B978-0-12-819639-7.00002-0

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© 2020 Elsevier Inc. All rights reserved.

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2. The Symptoms of Kidney Disease

2.1.1 The Irradiation of Pain in Renal Colic

FIGURE 1 The irradiation of the pain starts from the lumbar area on the way to the ureter

FIGURE 2

The irradiation of pain in to the right flank, right iliac fossa and on to the testicle

2.2 Macroscopic Hematuria

15

The Irradiation of Pain in Renal Colic This pain is very intense, one of the most intense pains from a pathological view, and for this reason the patient tries to find a position that can decrease the pain, but cannot do so because it does not exist. The pain disappears after antispastic drugs, and warmth can also relieve the pain. Sometimes the pain disappears after antispastic therapy, whereas other times it does not. If the pain persists after correct antispastic therapy protocol management, this suggests a complication. Often there can be a blockage inside the ureter, with hydronephrosis, and this is a severe emergency and the patient must be hospitalized immediately in the urology department for extracorporeal lithotripsy protocol management. The symptoms and signs of renal colic are dysuria (painful urination), pollakiuria (frequent urination), sweating, nausea, vomiting, and sometimes painful macroscopic hematuria (blood in the urine), as shown in the following image (Figure 3).

2.2 Macroscopic Hematuria

FIGURE 3 Macroscopic hematuria (blood in urine).

16

2. The Symptoms of Kidney Disease

Sometimes, after urinary colic, the patient may eliminate the stone, or stones, and it can be seen in the urine if the patient looks carefully. This very strong pain occurs when the stone is mobilized from the kidney and moves into the ureter, which it can block, if the diameter of the stone is the same as the diameter of the ureter, or the stone can pass into the ureter if it is smaller. After moving to the bladder, it can stop there or, if the patient is lucky, it can pass through the urethra and be eliminated from the body. The patient can then see the stone if he or she urinates into a glass or the toilet. During this phenomenon urination is very painful (dysuria) and very frequent (pollakiuria), and sometimes painful macroscopic hematuria can also appear (blood in urine). After the crisis of urinary colic, the patient can see the stone in the urine, as in the following image (Figure 4), and after that the pain stops and the patient feels better.

2.2.1 The Stone in the Urine

FIGURE 4 The stone in the urine after it was eliminated when the urinary colic finished. This is a happy situation.

2.2 Macroscopic Hematuria

2.2.2 The Stone in the Urine Removed After Renal Colic

17

18

2. The Symptoms of Kidney Disease

Stone in the Urine Removed After Renal Colic

Stone in the Urine Removed After Renal Colic

2.2 Macroscopic Hematuria

Stone in the Urine Removed After Renal Colic

2.2.3 The Shape of the Stone is Cylindrical

19

20

2. The Symptoms of Kidney Disease

2.2.4 Dark Color

Urine that is dark brown in color suggests a slow and intermittent growth related to peaks of hyperoxaluriad excessive oxalic acid taken in with fooddand dehydration. Sometimes an unfortunate situation can appear when a stone is blocked in the ureter at some point, and for this reason the ureter becomes enlarged due to the obstacle; this situation is called hydroureter. The urine cannot pass beyond this obstacle. In this case, the urine collects behind the obstacle in the ureter and, more than that, into the bassinet and the calyxes. These become enlarged, a situation called hydronephrosis, and this can be detected after the abdominal ultrasound is performed, as shown in the following images (Figures 5e25).

2.2 Macroscopic Hematuria

21

HydronephrosisdDilatation of the Renal Calyxes: Abdominal Echography

FIGURE 5

Hydronephrosis after a blocked stone in the ureter round formations are dilatations of renal calyces, in compare with figure 6.

In the next images, we will see the comparison of a normal kidney with hydronephrosis after abdominal ultrasound is performed. The Normal Kidney

FIGURE 6

The normal kidney without hydronephrosis.

22

2. The Symptoms of Kidney Disease

2.2.5 HydronephrosisdDilatation of the Calyxes

FIGURE 7

Hydronephrosisin compare with figure 8.

2.2.6 The Normal Kidney

FIGURE 8 The normal kidney.

2.2 Macroscopic Hematuria

2.2.7 Hydronephrosis Degree IIIdEnlargement of the Bassinet

FIGURE 9 Hydronephrosis degree III.

Hydronephrosis Degree III

FIGURE 10

Hydronephrosis degree III.

23

24

2. The Symptoms of Kidney Disease

2.2.8 Hydronephrosis Degree II

FIGURE 11

Hydronephrosis degree II.

FIGURE 12

Hydronephrosis degree II.

Hydronephrosis Degree II

2.2 Macroscopic Hematuria

Hydronephrosis Degree II

FIGURE 13 Hydronephrosis degree II in compare with figure 14.

The Normal Kidney

FIGURE 14

The normal kidney.

25

26

2. The Symptoms of Kidney Disease

2.2.9 Hydronephrosis Degree I

FIGURE 15 Hydronephrosis degree I.

Hydronephrosis Degree I

FIGURE 16

Hydronephrosis degree I.

2.2 Macroscopic Hematuria

FIGURE 17 Hydronephrosis degree I.

Hydronephrosis Degree II

FIGURE 18 Hydronephrosis degree I.

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28

2. The Symptoms of Kidney Disease

FIGURE 19 Hydronephrosis degree I.

Hydronephrosis Degree I

FIGURE 20

Hydronephrosis degree I.

2.2 Macroscopic Hematuria

FIGURE 21

Hydronephrosis degree III.

FIGURE 22

Hydronephrosis degree III.

Hydronephrosis Degree III

29

30

2. The Symptoms of Kidney Disease

FIGURE 23

Hydronephrosis degree III.

The Normal Kidney

FIGURE 24

The normal kidney.

Hydronephrosis Degree III

FIGURE 25

Hydronephrosis degree III.

2.3 Clinical Case This case is a young and very beautiful 16-year-old girl who came for a consultation and was really worried, because after a routine laboratory test, there was an unexpected discovery that she was positive for hepatitis B virus, and at the objective examination the doctor saw a nice tattoo with a butterfly on the abdomen and a piercing in the umbilicus. I am sure that you are thinking that the contamination with hepatitis B virus occurred after she had obtained this tattoo and piercing, where there was the use of needles. But the next photo is there because the positioning of the butterflies in the tattoo spreads toward the ureter, exactly like where the pain is in urinary colic, for you to see and never forget (Figure 26). The tattoo design suggests the spreading of the pain in left renal colic.

Tattoo as Irradiation of the Pain in Left Renal Colic

FIGURE 26 Design (tattoo) suggests the spreading of the pain in the left renal colic.

C H A P T E R

3 The Objective Examination O U T L I N E 3.1 Edema in Renal Diseases

33

3.3 Macroscopic Hematuria

36

3.2 Pitted EdemadWhite and Soft

35

3.4 Eyelid Edema in the Morning

37

3.1 Edema in Renal Diseases In the case of a renal disease, the most frequent cause of edema is heavy loss of protein in the urine due to damaged kidney function. The main semiological characteristics of edema in renal diseases are puffy eyes in the morning. The patient wakes up in the morning with swollen upper and lower eyelids, but this phenomenon disappears in the afternoon; the next morning the phenomenon is repeated. You can see this in the following imagesdfirst with closed eyes (Figure 1) and second with open eyes (Figures 2e20).

FIGURE 1

Medical Semiology Guide of the Renal System https://doi.org/10.1016/B978-0-12-819639-7.00003-2

Swelling of the upper extremities in the morning

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3. The Objective Examination

The color of the edema is white, and this is a sign of lost protein in the urine due to damage of the glomerular membrane of the kidney. First proteins with low molecular density are lost in the urine, and after that proteins with high molecular density.

FIGURE 2

Swelling of the upper and lower eyelids in the morning

The aspects of the legs are shown in the following images, white and soft.

FIGURE 3

Swelling of the legsesymmetrical white color

3.2 Pitted EdemadWhite and Soft

3.2 Pitted EdemadWhite and Soft

FIGURE 4 Pressure with the finger on the tibia

FIGURE 5 Indentation - indicated with black arrow - suggests pitting edema

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36

3. The Objective Examination

3.3 Macroscopic Hematuria

FIGURE 6 Macroscopic Haematuria

Another patient with acute glomerulonephritis came for consultation with a facial appearance as shown in the next images.

3.4 Eyelid Edema in the Morning

FIGURE 7 Swelling of the eyelids in the morning

3.4 Eyelid Edema in the Morning

FIGURE 8 Swelling of the eyelids in the morning

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3. The Objective Examination

FIGURE 9

Swelling of the eyelids in the morning

In the photos, you can recognize the most important characteristic of edema in renal disease; there is only one type of edema that develops: swelling of the eyes (upper and lower eyelids) in the morning when the patient wakes up after a night’s sleep. The legs of the patient are shown in the following image.

FIGURE 10 The legs of the patient are swollen

In addition, edema in kidney disease appears at the level of lax conjunctive tissue, such as in the external genital organsdscrotum in the man and vulva in the woman. In conclusion, the main semiological characteristics of edema in renal disease are as follows: - White - Soft - Normal temperature of the skin

3.4 Eyelid Edema in the Morning

39

- Without pain - Appears typically at the eye extremities in the morning and disappears in the afternoon and this phenomenon is repeated daily. - Appears also in the legs, in the first instance at the ankles, and after that at the calves, and above that in the legs. - In severe forms, if the proteinuria is severe and increased in the urine, it means the appearance of anasarca is possibledthis signifies generalized edema and also serous collection in peritoneal ascites, in the pleural cavity (pleural effusion), or in the pericardial cavity (pericardial effusion). - It is possible to appear in an area with lax conjunctive tissue like the scrotum in the man and the vulva in the woman. - The intensity of edema is directly in concordance with the severity of proteinuria.

C H A P T E R

4 The Objective Examination of the Kidney O U T L I N E 4.1 The Inspection 4.1.1 Left Lumbar Scar 4.1.2 Left Lumbar Scar after Left Nephrectomy Left Lumbar Scar after Left Nephrectomy Left Lumbar Scar after Left Nephrectomy 4.1.3 Left Lumbar Scar after Left Nephrectomy Eventration 4.1.4 Lipoma Soft at Palpation Lipoma 4.1.5 Enlarged Lipoma Enlarged Lipoma 4.1.6 Glob Bladder 4.1.7 Urinary Probing

42 42 43 44 45

4.2 The Palpation of the Kidney 4.2.1 Guyon MethoddBimanual Method 4.2.2 Glenard MethoddMonomanual Method 4.2.3 Israel MethoddBimanual Method

54 54 55 55

4.3 The Sensibility of Kidney 4.3.1 Giordano Maneura 4.3.2 Giordano Maneura of the Right Kidney

56 56 57

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4.3.3 4.3.4 4.3.5 4.3.6 4.3.7

46 48 49 50 51 52 53

Giordano Maneura of the Left Kidney Right Costovertebral Point Left Costovertebral Point Right Costomuscular Point Left Costomuscular Point

58 59 59 60 60

4.4 The Ureteral Points 4.4.1 Superior Ureteral Point e Bazin 4.4.2 Medium Ureteral Point e Tourneaux 4.4.3 Inferior Ureteral Point

60 61 61 62

4.5 Palpation of the Bladder

62

4.6 Rectal Touch 4.6.1 Adenoma of the Prostate 4.6.2 Cancer of the Prostate

63 63 63

4.7 Urethral Palpation

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4.8 The Percussion of the Kidney

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4.9 Percussion of the Bladder

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4.10 The Auscultation of the Renal Artery Stenosis 65

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4. The Objective Examination of the Kidney

4.1 The Inspection During the inspection of the lumbar area, we may see a scar from a surgical intervention, like in the images below showing a patient who underwent a left nephrectomy for a congenital kidney malformation; for this reason the patient had only one kidney. This situation is a surgical unique kidney. It can be recognized at once. Patients in this category are very special and need to be carefully supervised periodically in terms of kidney function and to avoid nephrotoxic drugs, because there can develop an unexpected acute renal failure or in time a chronic renal failure, and the patient will become a candidate for dialysis and kidney transplant. In the following images, we can see a left lumbar scar after surgery due to a left nephrectomy. The scar is indicated with a red arrow.

4.1.1 Left Lumbar Scar

FIGURE 1 Left lumbar scar indicate with red arrow

4.1 The Inspection

FIGURE 2 Left lumbar scar indicate with red arrow

4.1.2 Left Lumbar Scar after Left Nephrectomy

FIGURE 3

Left lumbar scar indicate with red arrow e lateral incidence

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4. The Objective Examination of the Kidney

FIGURE 4

Left lumbar scar indicate with red arrow e posterior incidence

Left Lumbar Scar after Left Nephrectomy

FIGURE 5 Left lumbar scar indicate with red arrow e lateral incidence

4.1 The Inspection

FIGURE 6 Left lumbar scar indicate with red arrow - close image

Left Lumbar Scar after Left Nephrectomy

FIGURE 7 Left lumbar scar indicate with red arrow- lateral incidence

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4. The Objective Examination of the Kidney

FIGURE 8 Left lumbar scar indicate with red arrow- lateral incidence

4.1.3 Left Lumbar Scar after Left Nephrectomy - Eventration

FIGURE 9

Left lumbar scar after left nephrectomy and eventration

4.1 The Inspection

FIGURE 10

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Right lumbar scar after right nephrectomy and eventration

During the lumbar inspection, we can also see the elevation of this region (Figures 11e15) in a few kidney diseases, such as large kidney tumors; collection of pus, for example, in an abscess of the kidney; hydronephrosis; and pyonephrosis. In the image below, we can see elevation of the right lumbar area, which is indicated with a white arrow, because this patient had a grade 3 hydronephrosis of the right kidney.

FIGURE 11

Elevation in right lumbar area

During the inspection, we may also see tumefaction, or swelling, of the lumbar area like in the next images (Figures 12e15). In these images, we see a nodular formation in the right lumbar area, size 4/5 cm, with a regular border, soft consistency at palpation, and no pain during palpation. The patient had presented with this formation in the right lumbar area for 4 years, and the size had increased in dimension quickly in the past year, and it now looked like lipomada fatty deposit inside. This is a benign formation of fatty tissue, suggests dyslipidemia, and could have a genetic risk factor; many members of the same family could have the same problem. After this nodular formation was removed, the macroscopic appearance and histopathology examination confirmed the diagnosis, lipoma, which contained a fatty deposit. The appearance of the patient is seen in the images below.

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4. The Objective Examination of the Kidney

4.1.4 Lipoma Soft at Palpation

FIGURE 12 Lipoma indicate with red arrow

FIGURE 13 Palpation of the lipoma relieved soft consistence

4.1 The Inspection

Lipoma

FIGURE 14

Lipoma-posterior incidence indicate with red arrow

FIGURE 15 Lipoma - Lateral incidence indicate with red arrow

An enlarged lipoma on the right lateral lumbar area in the another patient (Figures 16e19).

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4. The Objective Examination of the Kidney

4.1.5 Enlarged Lipoma

FIGURE 16

e Enlarged lipoma indicate with red arrow

FIGURE 17

- Enlarged lipoma indicate with red arrow

4.1 The Inspection

51

Enlarged Lipoma

FIGURE 18

Enlarged lipoma indicate with red arrow

FIGURE 19

Soft consistency at the palpation

A globular bladder with retention of urine causes an elevation of the hypogastric area as in the following images (Figures 20 and 21).

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4. The Objective Examination of the Kidney

4.1.6 Glob Bladder

FIGURE 20

FIGURE 21

Elevation of hypogastric area in glob bladder

The confirmation of glob bladder at the abdominal echo

This patient needed urinary catheterization to evacuate the urine from the globular bladder and this is illustrated in the next image (Figure 22).

4.1 The Inspection

53

4.1.7 Urinary Probing

FIGURE 22

Urinary probing

The patient is being catheterized due to the need to evacuate the globular bladder. We can also see the macroscopic appearance of the urine. The color is normal, a yellow color, and the quantity evacuated in this moment is 1200 mL urine. Urinary catheterization is absolutely necessary in acute retention of urine and also in chronic retention of urine. Sometimes an emergency arises in obstructive anuriadno urine passagedthe patient cannot urinate in the context of adenoma of the prostate or adenocarcinoma of the prostate. This then develops a globular bladder, which can be seen during inspection as an elevation in the hypogastric area, and the doctor can also feel it during palpation in this region. But the disadvantage of urinary catheterization is the risk of infections, and protective antibiotic therapy is needed.

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4. The Objective Examination of the Kidney

4.2 The Palpation of the Kidney In normal conditions, we cannot palpate the kidney. If we can palpate the kidney, this signifies that it is enlargedd nephromegalydor down from the normal placednephroptosis. The methods of palpation of the kidney are as follows.

4.2.1 Guyon MethoddBimanual Method

FIGURE 23 Palpation of the right kidney with GUYON METHOD

Before we start the method of palpation of the kidney, we must put the patient in a correct position on the bed, with the legs flexed to relax the abdominal muscles. This is very important. The position of the doctor is on the side where he or she wants to palpate the kidney. In the image above, the doctor stayed on the right side of the patient to palpate the right kidney. In the Guyon method, the physician needs to put a hand under the back parallel to the 12th rib and below this, and the distal part of the third finger must correspond with the costal muscular point with the fingers kept flexed, and the second hand is put on the abdomen, parallel to the costal ribs and with the fingers parallel the median line, like in the image above (Figure 23). The patient must perform a deep inspiration. At the end of the deep inspiration, the anterior hand pushes the abdomen and tries to feel the kidney as it comes down and pushes the kidney to the posterior hand, which also feels the kidney. This is called lumbar contactdvery important. The posterior hand must have flexed fingers to produce kidney ballottement, and the doctor tries to hold the kidney between both hands, through which the mobility of the kidney is felt like the “core of a cherry.” With a similar technique the kidney can be palpated from the left side. This is the most common method of palpation of the kidney in medical practice.

4.2 The Palpation of the Kidney

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4.2.2 Glenard MethoddMonomanual Method

FIGURE 24 Palpation of kidney with GLENARD METHOD

The Glenard method is a monomanual method because the physician uses only one hand for palpation. The physician puts four fingers on the lumbar area of the patient and the thumb on the anterior wall of the abdomen (Figure 24). The physician tries to hold the kidney between the thumb and the four fingers in deep inspiration. This method is used in children and thin patients.

4.2.3 Israel MethoddBimanual Method

FIGURE 25 Palpation of kidney with ISRAEL METHOD

The Israel method is a bimanual method because two hands are used for palpation. This method is rarely used in medical practice. The correct position of the patient on the bed is the lateral position as shown in the image above (Figure 25), and the physician tries to hold and feel the kidney in deep inspiration.

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4. The Objective Examination of the Kidney

Thus, we can use these three methods to palpate the kidney. The Guyon method is the most common and frequently used in medical practice. The Glenard method is used on thin patients and children because only in these can we catch the abdomen with one hand. The Israel method is rarely used in medical practice. After we palpate the kidney, we have a few important criteria that help us to identify that what we palpated is the kidney and not other formations inside the abdomen. Arguments for kidney are posterior position and lumbar contact. The most common diseases in which we are able to palpate the kidney are tumor of the kidney, polycystic kidney, hydronephrosis, and renal ptosis grades 1, 2, or 3.

4.3 The Sensibility of Kidney Sensitivity of the lumbar area should be put in evidence with simple palpation of this area, or with the Giordano maneuver. This is the most important maneuver in medical practice by which we can check the sensitivity of the kidney. This practice is performed with repetitive percussions of the renal area with the external part of the hand. These percussions must be made with moderate intensity, because if the intensity of the movements is increased, it can cause shock. The most common diseases in medical practice that are Giordano maneuver positive are kidney stones, acute pyelonephritis, hydronephrosis, pyonephrosis, abscess of the kidney, and tuberculosis of the kidney. The maneuver is not 100% specific for kidney diseases, because it is also positive if the patient has a problem with the vertebral column, such as a disk hernia. The correct position of the hand for the Giordano maneuver is the lateral incidence of the hand and with the fingers opened as shown in the following images (Figures 26e30).

4.3.1 Giordano Maneura

FIGURE 26

The correct position of the hand and fingers for GIORDANO MANEURA

4.3 The Sensibility of Kidney

FIGURE 27 GIORDANO MANEURA- the doctor checks the sensibility of the right kidney

4.3.2 Giordano Maneura of the Right Kidney

FIGURE 28 GIORDANO MANEURA- the doctor checks the sensibility of the right kidney

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4. The Objective Examination of the Kidney

FIGURE 29 GIORDANO MANEURA

4.3.3 Giordano Maneura of the Left Kidney

FIGURE 30

The doctor checks the sensibility of the left kidney

If the patient feels pain after these movements, we can say that the Giordano maneuver is positive. If the patient says that he or she does not feel pain after these, we can say that the Giordano maneuver is negative. Sensitivity is frequently present at sensitive renal points. Two sensitive renal points exist: Costovertebral renal points are situated at the apex of the angle between the 12th rib and the vertebral column. Costomuscular points are situated at the apex of the angle between the 12th rib and the paravertebral muscle mass. The physician must check the sensitivity of these points at the right and left sides. If the patient feels pain, we can say that the points are sensitive, if not, the points are insensitive. These points and how the physician checks the patient for sensitivity of these points are shown in the following images (Figures 31e34).

4.3 The Sensibility of Kidney

4.3.4 Right Costovertebral Point

FIGURE 31

Sensibility of the right costovertebral point

4.3.5 Left Costovertebral Point

FIGURE 32

Sensibility of the left costovertebral point

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4.3.6 Right Costomuscular Point

FIGURE 33

Sensibility of the right costomuscular point

4.3.7 Left Costomuscular Point

FIGURE 34 Sensibility of the left costomuscular point

4.4 The Ureteral Points There are three sensitive ureteral points: 1. The superior ureteral point, or lateral from the umbilicus point of Bazin, is situated on the horizontal line passing through the umbilicus, at 4e5 cm lateral from the umbilicus. With one fingerdthe indexdthe physician puts deep pressure on this point as shown in the next image to check the sensitivity (Figure 35).

4.4 The Ureteral Points

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4.4.1 Superior Ureteral Point e Bazin

FIGURE 35

Sensitivity - right superior ureteral point e Bazin.

If the patient feels pain after this pressure with the finger at this point, we say that the superior ureteral point is sensitive. If the patient does not feel the pain in this area, we say that the superior ureteral point is insensitive. We must check these points in a symmetrical way at both sides. This point is sensitive unilaterally in ureteral stones at this level. 2. The medium ureteral point, or Tourneaux point, is situated at the intersection of the bispinoiliac lines with a vertical line from the point at the intersection 1/3 medial to the inside of the inguinal ligament. With one fingerdthe indexdthe physician puts deep pressure at this point as shown in the next image (Figure 36) to check the sensitivity.

4.4.2 Medium Ureteral Point e Tourneaux

FIGURE 36

Sensitivity - medium ureteral point e Tourneaux.

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4. The Objective Examination of the Kidney

If the patient feels pain after this pressure with the finger at this point, we say that the ureteral point is sensitive. If the patient does not feel pain at this point, we say that the urethral point is insensitive. We must check in a symmetrical way these points at both sides. This point is sensitive unilaterally in ureteral stones at this level. 3. The inferior ureteral point corresponds to the junction between the ureter and the bladder and is accessible only with rectal touch or vaginal touch. The most important idea is that this point is not down on the abdomen compared with the superior and medium points. It is possible to check the sensitivity of this point only after rectal touch or vaginal touch as shown in the image below (Figure 37).

4.4.3 Inferior Ureteral Point

FIGURE 37 The glove is prepared for rectal touch or vaginal touch

The inferior ureteral point is accessible with rectal touch or vaginal touch. This point is sensitive during rectal touch and vaginal touch. These points could be bilaterally sensitive at the same time in inflammation of the bladder and the bassinet.

4.5 Palpation of the Bladder Urinary globular bladder in the context of urinary retention is present at palpation like a hypogastric hemispheric formation up to the pubic symphysis, like the rising sun, very well delimited, elastic, sensitive, and with small mobility in the lateral incidence. In the moment of palpation of the globular bladder, this maneuver induces in the patient a sensation of urgent urination because of pressure on the bladder. Globular bladder in retention of urine must be differentiated from pregnancy uterus.

4.6 Rectal Touch

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4.6 Rectal Touch The rectal touch maneuver is very frequently used for exploration and investigation of the prostate gland. In adenoma of the prostate, the gland is enlarged with good delimitation, regular borders, and elasticity, without pain during palpation, and very importantly with the medium ditch missing as shown in the image below.

4.6.1 Adenoma of the Prostate

4.6.2 Cancer of the Prostate

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4. The Objective Examination of the Kidney

During inflammation of the prostate, the prostate is sensitive, and in the abscess of the prostate, the gland is very sensitive, and a collection of pus is present inside the prostate.

4.7 Urethral Palpation In inflammation of the urethra and sometimes after compression of the urethra, pus can be pushed outside, i.e., a clear secretion or like milk. Sometimes, we can palpate stones inside the urethra, after migration from the urinary tract in the context of urinary colic.

4.8 The Percussion of the Kidney Percussion of the kidney, such as in the classical method, is irrelevant because the anatomy of the kidney is very deep inside. For this reason, we cannot have access to the kidney by percussion. If there is percussion of the anterior abdomen, we will receive the tympanic sound of the abdomen, and if there is percussion on the back of the lumbar area, we will receive a dull sound because of the presence of the lumbar muscles. We cannot have access to the kidney by percussion.

4.9 Percussion of the Bladder The globular bladder determines the appearance of a hemispheric dullness with elevated convexity that can go up to the umbilicus and down to disappear under the pubic symphysis, and it disappears after the bladder is evacuated by urinary catheterization. The dullness with concavity is illustrated in the image below (Figure 38), in which the red arrows indicate the direction of percussion on the abdomen that can detect this.

FIGURE 38

Hemispheric dullness with convexity elevated, in glob bladder

4.10 The Auscultation of the Renal Artery Stenosis

65

The differential diagnosis of pregnancy or uterine fibromatosis could be performed clinically without other investigations. In this situation, the hemispheric dullness is with elevated concavity as shown in the next image (Figure 39).

FIGURE 39 Hemispheric dullness with concavity elevated, in uterine fibromatosis

4.10 The Auscultation of the Renal Artery Stenosis The method of auscultation is important to check the status of the renal artery. If renal artery stenosis or renal artery aneurism exists and the patient is thin, by putting the stethoscope on the abdomen 1e2 cm lateral to the umbilicus on the right and left sides, we can discover a systolic murmur or a bruit, which means there exists a renal artery stenosis or an aneurism of the renal artery. The method of auscultation of the renal artery is illustrated in the following images (Figures 40e43).

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4. The Objective Examination of the Kidney

FIGURE 40 Auscultation of the left renal artery at 1-2 cm left lateral from umbilicus. Systolic murmur in left renal artery stenosis (aneurism)

4.10 The Auscultation of the Renal Artery Stenosis

FIGURE 41

67

Auscultation of the right renal artery, at 1-2 cm right lateral from umbilicus. Systolic murmur in right renal artery stenosis

(aneurism)

FIGURE 42

Auscultation of the right renal artery, at 1-2 cm right lateral lumbar colon. Systolic murmur in right renal artery stenosis (aneurism)

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FIGURE 43

4. The Objective Examination of the Kidney

Auscultation of the left renal artery at 1-2 cm left lateral lumbar colon. Systolic murmur in left renal artery stenosis (aneurism)

C H A P T E R

5 The Paraclinic Examination O U T L I N E 5.1 Examination of the Urine Collection of the Urine Macroscopic Examination 5.1.1 The Volume of Urine 5.1.1.1 Polyuria 5.1.1.2 Oliguria 5.1.1.3 Anuria 5.1.1.4 Nocturia 5.1.1.5 Equality between nocturnal and diurnal uresis

70 70 71 71 72 73 73 74

5.2 The Macroscopic Urine Examination 5.2.1 Urine ExaminationdMacroscopic Appearance of the Urine 5.2.1.1 Concentrated Urine 5.2.1.2 Dilute Urine 5.2.1.3 Color of dilute urine 5.2.1.4 Normal Color of Urine 5.2.1.5 Concentrated Urine 5.2.1.6 Dilute Urine 5.2.1.7 Hyperchromic UrinedCholuric Urine 5.2.1.8 Black Urine 5.2.1.9 Macroscopic Hematuria 5.2.1.10 The three glass Test 5.2.1.11 Macroscopic Hematuria After Urinary Catheterization 5.2.1.12 Choluric Urine due to Bilirubin 5.2.1.13 Thick Urine 5.2.1.14 Troubled Urine 5.2.1.15 Black Urine 5.2.2 The Physicochemical Examination of Urine 5.2.2.1 Urine PH Test

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5.2.2.2 5.2.2.3 5.2.2.4 5.2.2.5 5.2.2.6 5.2.2.7 5.2.2.8

Urine Density Proteinuria Pyuria Glycosuria Ketonuria Bilirubinuria Urobilinogenuria

104 104 125 127 130 132 134

5.2.3 Macroscopic Appearance of a Stone In Urine 136 Macroscopic Appearance of a Stone In Urine 137 Macroscopic Appearance of a Stone In Urine 138 Macroscopic Appearance of a Stone In Urine 139

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75 76 76 77 81 82 84 87 88 89 95 96 98 99 99 102

104 104

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5.3 The Microscopic Urine Examination 5.3.1 Red Blood Cells 5.3.2 White Blood Cells 5.3.3 Epithelial Cells 5.3.4 Casts 5.3.4.1 Acellular Casts 5.3.4.2 Cellular Casts 5.3.5 Crystals 5.3.5.1 Urate Crystals 5.3.5.2 Oxalate Calcium Crystals 5.3.5.3 Phosphates Crystals 5.3.5.4 Cholesterol Crystals 5.3.5.5 Tyrosine Crystals 5.3.5.6 Leucine Crystals 5.3.5.7 Cystine Crystals

139 140 141 142 142 143 145 147 147 147 148 148 149 149 150

5.4 Bacteriologic Examination of the Urine 5.4.1 Urine culture positive with enterococcus 5.4.2 Enterococcus Culture 5.4.3 Nitriuria

150 151 152 153

© 2020 Elsevier Inc. All rights reserved.

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5.1 Examination of the Urine Collection of the Urine It is important to perform the examination of fresh urine collected in the morning during the middle outflow of the urine. Hence, the patient must urinate the first flow into the toilet and the second flow into the container for the collection of the urinedthis is for the analysisdand in the end continue to urinate completely in the toilet to empty the bladder. This is the correct method of collecting the urine for the examination in the laboratory. Of course, before the examination, the patient must correctly clean the genital region with water and soap. Women must avoid the collection of urine during the menstrual cycle, and the cleaning of the region must be very well and seriously performed before collecting the urine in the specified receptacle. Urine that stays in the bladder during the period of night can falsify the laboratory results, and for this reason, it is recommended that examination of the urine must be performed on the middle flow of the morning urine. The urinary sample must be put immediately into a clean receptacle for bacteriologic examination. Urine examination is: -

Macroscopic Physicochemical Microscopic Bacteriological

5.1 Examination of the Urine

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Macroscopic Examination At macroscopic examination of the urine, it is important to check the following elements: - the volume, the color, the appearance, and the smell.

5.1.1 The Volume of Urine The volume of urine in 24 h is diuresis. The normal volume of urine is 1000e1800 mL/24 h in men and 1000e1500 mL/24 h in women.

Women must avoid the collection of urine during the menstrual cycle because it looks like the next image, and of course we can confuse this with macroscopic hematuria. So we must avoid this situation in our medical practice.

The color of urine during the menstrual cycle looks macroscopically exactly like macroscopic hematuria The most important changes in the volume of urine are polyuria, oliguria, anuria, and nocturia. We will discuss these changes in urine volume because they are important and suggest to us different clinical diseases, which are important to be recognized or suspected in the context of these changes in urine volume.

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5.1.1.1 Polyuria Polyuria increases uresis to more than 2000 mL/24 h, which results in an increase in the glomerular filtration or decrease in the tubular reabsorption of water.

Polyuria could be occasional or permanent. Permanent or occasional polyuria can appear in a few special situations such as the following: -

Increased consumption of liquids Eating diuretic foodsdwatermelon, alcohol, coffee Very stressful or emotional situations because of increased levels of catecholamines in the circulation Exposure to cold because of vasoconstriction

In all these occasional physiological situations, polyuria could appear, but this is for a short period of time, only when these conditions exist, and after that the polyuria disappears and the volume of urine becomes normal. There also exist a few pathologic situations in which polyuria could appear occasionally: -

Paroxysmal arrhythmias Crisis of chest pain like pectoral angina or acute myocardial infarction Gallbladder colic, renourethral colic Epilepsy In patients with edema in the context of cardiac failure disease, after diuretic therapy

These are a few examples of pathologic situations during conditions of stress and increased catecholamine levels, which can induce an occasional polyuria, and at the end of crisis, the urine volume becomes normal. In persistent polyuria, the phenomenon is permanent and could be classified depending on the density of the urine in two important categories: - Hypotonic polyuria - Isotonic polyuria The difference between hypotonic and isotonic polyuria depends on the urine osmolality and the plasma osmolality, and these depend on the concentration of sodium in the plasma and urine as well. The definition of hypotonic polyuria states that the level of urine osmolality is decreased more than 200 mOsm/ 100 mL compared with the plasma osmolality. Hypotonic polyuria appears in the following diseases: -

Kidney insipid diabetes mellitus Kidney failure developing polycystic kidney disease, chronic pyelonephritis Metabolic imbalancedhypokalemia, hypercalcemia Intoxication with antibiotics like aminoglycosides or others

5.1 Examination of the Urine

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5.1.1.2 Oliguria OLIGURIA is the decrease in urinary volume to under 500 mL/24 h and appears because there is a decrease in the glomerular filtration due to decreased perfusion and pressure in the area of filtration or increased tubular reabsorption of water or urethral obstruction.

Hypertonic oliguria exists when the urine osmolality level is increased to more than 800e1100 mOsm. This could be physiological, after a diet or increased sweating, or pathological, in acute glomerulonephritis, diarrhea, initial phase of cardiac edema, renal or liver edema, arterial hypotension, or hypotonic oliguria/isotonic oliguria in the initial phase of renal failure or terminal phase of chronic renal failure. 5.1.1.3 Anuria Anuria or oligoanuria represents the decrease of uresis to under 50 mL/24 h and is the main symptom in acute renal failure.

Anuria is secretory, or true, when is realized by the stopped formation of urine at the level of kidney, and excretory, or false, when the cause is due to the impossibility of drainage of the urine.

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5.1.1.4 Nocturia The correct definition of nocturia is equality or inversion of rapport between nocturnal and diurnal uresis.

5.2 The Macroscopic Urine Examination

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5.1.1.5 Equality between nocturnal and diurnal uresis

Inversion between nocturnal and diurnal diuresis

The volume of the urine eliminated in the night is increased compared with the volume of urine eliminated during the day.

5.2 The Macroscopic Urine Examination 5.2.1 Urine ExaminationdMacroscopic Appearance of the Urine During the macroscopic examination of the urine, the following two features are important: - Volume - Color The normal appearance of urine is clear and the color is yellow because of the presence of urochrome pigment. Variation in the color of urine is possible and depends on diet, volume, and density of urine. The urine of people with vegetarian diets is lighter in color, and people with meat diets have reduced quantity of urine and the color is more concentrated (darker). In the next schemes, we can see the different colors of urine depending on the concentration of the urine. The second image represents the normal color of urine; on its left is the color of concentrated urine from people who eat a lot of meatdmeat dietdand on the right side is the color of diluted urine from people with a vegan diet because in these conditions the concentration of the urine is decreasedddiluteddand develops a light color. These schemes are a very good example to understand this situation.

76

5. The Paraclinic Examination

5.2.1.1 Concentrated Urine

Color of concentrated urine 5.2.1.2 Dilute Urine

Color of dilute urine

5.2 The Macroscopic Urine Examination

77

5.2.1.3 Color of dilute urine

Different colors of urine depending on different concentrations

Collection of urine in the morning from different patients

We can observe different colors of urine depending on the concentration: first in the upper left is normal, second concentrated, third normal, and fourth in front is dilute. These receptacles with urine were collected in the morning from different patients and will be sent to the laboratory for examination. In the following picture, we can see the

78

5. The Paraclinic Examination

same situation: many receptacles with urine collected from different patients in the morning, with different macroscopic colors due to different concentrations of urine and to be sent to the laboratory for examination.

Concentrated Urine

5.2 The Macroscopic Urine Examination

Dilute Urine

Dilute Urine

Different colors of urine after urinary catheterization depending on the concentration of the urine

79

80

5. The Paraclinic Examination

NORMAL COLOR OF URINE

5.2 The Macroscopic Urine Examination

5.2.1.4 Normal Color of Urine

81

82 5.2.1.5 Concentrated Urine

5. The Paraclinic Examination

5.2 The Macroscopic Urine Examination

Concentrated Urine

83

84 5.2.1.6 Dilute Urine

5. The Paraclinic Examination

5.2 The Macroscopic Urine Examination

Dilute Urine

Dilute Urine

85

86 Dilute Urine

Dilute Urine

5. The Paraclinic Examination

5.2 The Macroscopic Urine Examination

5.2.1.7 Hyperchromic UrinedCholuric Urine

Hyperchromic urinedcholuric urine

87

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5. The Paraclinic Examination

5.2.1.8 Black Urine

Black Urine

The urine appears red in macroscopic hematuria, hemoglobinuria, myoglobinuria, and porphyria, and after taking in artificial food colorants such as red candy or after therapy with drugs (phenolphthalein, phenothiazine).

5.2 The Macroscopic Urine Examination

89

5.2.1.9 Macroscopic Hematuria In macroscopic hematuria, the red urine is thick, similar to “water after meat is washed,” and after agitation develops a white spume, but in the other aforementioned cases the red color is clear. In the schemes below, we can see different intensities of red color in the urine.

The natural color of urine in macroscopic hematuria, when the urine is thick red like “water after meat is washed,” is seen in the next images; this is typical. Macroscopic Hematuria

90

5. The Paraclinic Examination

Macroscopic Hematuria

Macroscopic hematuria in a patient in atrial fibrillation following anticoagulant therapy (Trombostop)doverdose of anticoagulant

5.2 The Macroscopic Urine Examination

91

92

5. The Paraclinic Examination

Macroscopic Hematuria

Macroscopic hematuria in a patient during renal colic, while eliminating a kidney stone In hemoglobinuria and myoglobinuria, the color of the urine is similar to port wine, and in porphyria the presence of porphobilin confers a red cyclamen or brown color.

5.2 The Macroscopic Urine Examination

Macroscopic Hematuria

Macroscopic hematuria in a patient with tumor bladder Macroscopic Hematuria

93

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5. The Paraclinic Examination

Macroscopic Hematuria

Macroscopic hematuria in a patient with two stones inside the bladder Macroscopic Hematuria

5.2 The Macroscopic Urine Examination

95

5.2.1.10 The three glass Test Macroscopic Hematuria With the probe of three glasses, it is possible to establish the origin of bleeding, which determines the macroscopic hematuria. The patient urinates in three glasses, from the initial, middle, and end part of the miction, after which it is observed in which glass or glasses hematuria is present. There exist three possibilities: 1. Initial hematuria is present only in the first glass, by which it is determined that the urethra is the origin. This appears in the following diseases: adenoma of the prostate, carcinoma of the prostate, prostatitis, polyps, or broken urethra.

2. Terminal hematuria is present only in the last glass, by which it is determined that the bladder is the origin, because the red blood cells present at this level are sedimented and eliminated at the end of urination. It appears in bladder stones, bladder cancer, hemorrhagic cystitis, and foreign bodies in the bladder.

3. Total hematuria is present in all the glasses and is of renal origin because the urine has time to homogenize the blood, which suggests kidney cancer, tuberculosis of the kidney, acute diffuse glomerulonephritis, kidney trauma, polycystic kidney, and bleeding diseases.

There exists a special condition whereby the three glass test is falsified, which is massive macroscopic hematuria, when all the glasses are red, indifferent of the sodium of hematuria. Except for this situation the rules are valid.

96

5. The Paraclinic Examination

5.2.1.11 Macroscopic Hematuria After Urinary Catheterization

Macroscopic Hematuria

MACROSCOPIC HEMATURIA

5.2 The Macroscopic Urine Examination

MACROSCOPIC HEMATURIA Macroscopic Hematuria

MACROSCOPIC HEMATURIA

97

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Dark brown urine is illustrated in the next image.

Brown urine, or choluric urine, has a brown color similar to that of black beer. The brown color is due to the presence of bilirubin. After agitation, this type of urine is covered with green spume. It is present and appears in hepatic and posthepatic jaundice. 5.2.1.12 Choluric Urine due to Bilirubin

5.2 The Macroscopic Urine Examination

99

5.2.1.13 Thick Urine Urine may be thick immediately after emission. The appearance of thick urine suggests that in the end there would be sedimentation in the bottom of the receptacle. This is typical of pyuriadurinary tract infection. This conditiondurinary tract infectiondis the most common example of thick urine in medical practice, and it is more common in women compared with men because the urethra is short in women, and also is connected with sexual activity, which represents an important risk factor in the development of urinary tract infection in women. In the image below, we can see the macroscopic appearance of thick urine from a woman with a urinary tract infection. 5.2.1.14 Troubled Urine

Color of thick urine in urinary tract infection

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5. The Paraclinic Examination

Troubled Urine

Troubled urinedurinary tract infection

5.2 The Macroscopic Urine Examination

Troubled urinedurinary tract infection

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5. The Paraclinic Examination

Troubled urine is very easy to recognize, as in the images above, and suggests a urinary tract infection. In the above tube, you can see the troubled macroscopic appearance of the urine. This suggests urinary tract infection, and the diagnosis is confirmed after laboratory examination of the urine; shown in the right image above is the result summary for the urine. The presence of LEU ¼ þ3 and 500 cells/mL confirms the presence of white blood cells in the urine, which sustains the diagnosis of urinary tract infection, and more than that, the presence of PRO ¼ þ1 and BLD ¼ þ2 confirms the diagnosis of nephritic syndrome as well. Troubled Urine

5.2.1.15 Black Urine Black urine is a special condition. This is a rare situation in medical practice, but it is possible to appear in melanuriadmalignant melanoma. The color of the urine is really black, as shown in the following image.

This situation can also appear in hemosiderinuriadin hemolytic anemiadand after therapy with iron or metronidazole.

5.2 The Macroscopic Urine Examination

103

In melanuria, the color of the urine is black immediately after emission or, more exactly, from the moment of emission, and is very easy to recognize. Most of the time the patient becomes very worried. In the images below, we can see the black color of the urine from a patient with melanoma of the skin.

Black urine in skin melanoma

Black urine in skin melanomadclose imagedspume above after agitation

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5. The Paraclinic Examination

The smell of the urine is another important sign. Sometimes we can recognize that the smell of the urine is different compared with normal urine, and this suggests various diseases if we are careful. The normal smell of urine is faint. In urinary stasis, with bacteria that has fermented the urea, the smell becomes fetid, like “fish,” in urinary tract infection with Escherichia coli. In ketoacidosis in diabetes mellitus, inanition, and alcohol consumption and after repeated vomiting, the smell of the urine becomes like “acetone” or “green apples.” In neoplasm of the urinary bladder, the smell of urine becomes putrid.

5.2.2 The Physicochemical Examination of Urine 5.2.2.1 Urine PH Test In the normal condition, the pH of urine varies between 4.5 and 8. The pH of the urine is determined with a litmus test. Alkaline urine appears in lactovegetarians, in metabolic alkalosis, after repeated vomiting, and in infections that transform the urea into ammonia. In this situation, the pH is between 7.5 and 8, and the values in this range confirm the alkalosis of the urine. Acid urine appears after a diet of excessive meat, after excessive physical effort, in diabetic ketoacidosis, and in advanced chronic failure. A pH 100,000 UFC/mL Enterococcus spp. Antibiogram: Cefoxitin resistant Ciprofloxacin resistant Gentamicin resistant Levofloxacin resistant Nitrofurantoin sensitive The abdominal ultrasound showed unexpected polycystic kidney, as we can see in the images below. Abdominal UltrasounddPolycystic Kidney

Abdominal UltrasounddPolycystic Kidney

399

400

7. Morphological Investigations of The Kidney

Abdominal UltrasounddPolycystic Kidney

7.8 Clinical Cases of the Kidney

Abdominal UltrasounddPolycystic Kidney

401

402

7. Morphological Investigations of The Kidney

Abdominal UltrasounddPolycystic Kidney

7.8 Clinical Cases of the Kidney

Abdominal UltrasounddPolycystic Kidney

Abdominal UltrasounddPolycystic Kidney

403

404

7. Morphological Investigations of The Kidney

Abdominal UltrasounddPolycystic Kidney

7.8 Clinical Cases of the Kidney

405

Thus, the diagnosis of this patient is polycystic kidney, chronic renal failure, and urinary tract infection with Enterococcus spp. The parameters of the creatinine and urea were increased, but not so much as to be a candidate for dialysis, and of course the real solution for this patient is renal transplant from a compatible donor, but the patient did not have the possibility of undergoing a surgical transplant. The therapy for this case was difficult because the patient needed antibiotic therapy conforming to the antibiogram and all antibiotics pass through the kidney and can aggravate chronic renal failure or develop unexpectedly an episode of an acute renal failure. For this reason, the patient first started a protocol of rehydration with saline solutions to decrease the level of urea and creatinine and then started antibiotic therapy conforming to the antibiogram for urinary tract infection. The diagnosis of this patient was unique kidney and acute renal failure after antibiotics.

7.8.7 Clinical Case No. 7 The clinical case of a 68-year-old patient with diabetes mellitus type 2 starting 8 years earlier is presented. He followed therapy with the oral antidiabetic drug Sio at 1000 mg 1-0-1, but sometimes he neglected his therapy. At this time, he consulted the physician because there appeared swelling of the upper eyelids in the morning and edema of the soft white lower limbs, as shown in the following images. Upper Eyelid Edema in the Morning

The swelling of the upper eyelids is indicated with red arrows and represents a sign of proteinuria. In the next images, we can see the swelling of the lower limbs and how the physician checks if the edema is pitting.

406 Swelling of the Lower Limbs

7. Morphological Investigations of The Kidney

7.8 Clinical Cases of the Kidney

IndentationdPitting Edema

407

408

7. Morphological Investigations of The Kidney

IndentationsdPitting Edema

The edema makes the lower limbs white in color and soft. After pressure with the finger on the tibia, there remains the mark of the fingertip in the skindindentation. These are typical features of hypoproteinemic edema. Swelling of the eyelids in the morning, which disappears in the afternoon, and then repeats again the next morning, represents a typical feature of renal edema. In this patient, we must check the level of protein in the urine, because proteins can be lost in the urine in the context of diabetic nephropathy. The glomerular membrane filter gets damaged and after that proteins are lost in the urine. The summary of the urine examination of this patient showed that it was positive for proteins and the level of proteinuria was 2.1 mg/dL, less than 3.5 mg/dL, so a nephritic syndrome in the context of diabetic nephropathy was diagnosed. Because he felt an increase in volume of the abdomen, the patient underwent an abdominal ultrasound. The Abdominal UltrasounddSmall Quantity of Free Fluid Inside the Abdominal CavitydAscites

The level of proteins in the blood (proteinemia ¼ 5 g/dL) of this patient was decreased (normal range ¼ 6e8.3 mg/dL), so in the context of hypoproteinemia, there also appears edema and ascites. This patient was in anasarca.

7.8 Clinical Cases of the Kidney

409

In conclusion, the diagnosis of this patient was diabetes mellitus type 2, nonobese, per oral antidiabetic agentsd nephritic syndrome in the context of diabetic nephropathy. The diagnosis of this patient was diabetic nephropathy.

7.8.8 Clinical Case No. 8 The clinical case of a 56-year-old woman is presented. She came for a consultation because of swelling of the lower limbs, as we can see in the next image. Edema of the Lower Limbs

In the image above, we can see that both lower limbs are swollen symmetrically and the color of the skin is white. The temperature of the skin is normal. Usually white edemas are typical of hypoproteinemic edema. The patient experienced swelling of the lower limbs approximately 2 months earlier, but she neglected herself, did not go to consultation, and did not follow any therapy during this period of time. In addition, the patient observed that every morning when she looked in the mirror, her eyelids were swollen, and for this reason she used a green makeup pencil above the upper eyelid and lower eyelid, to hide the phenomenon, as we can see in the next photos. Upper Eyelids Edema in the MorningdGreen Makeup Pencil

410

7. Morphological Investigations of The Kidney

Upper Eyelids Edema in the MorningdGreen Makeup Pencil

7.8 Clinical Cases of the Kidney

411

She also observed that her abdomen became enlarged. At the objective examination, the physician observed the swelling of the lower limbs (edema), white and soft, and after pressure with the finger on the tibia there remained an indentation, as we can see in the images below.

412

Indentation

7. Morphological Investigations of The Kidney

7.8 Clinical Cases of the Kidney

413

Because the patient also presented with swelling of the abdomen and underwent abdominal ultrasound, the physician confirmed the presence of free fluid inside the abdominal cavitydascites. The Abdominal Ultrasound Free FluiddAscites

414

7. Morphological Investigations of The Kidney

The Macroscopic Urine Examination

The macroscopic examination of the urine showed that the color of the urine is light. This happens because the capacity of concentration of the kidney is decreased. The urinary densities in separate urinations were low: 1005, 1004, 1003, and 1002. This appears in chronic renal failure, when the capacity of kidney concentration decreases.

7.8 Clinical Cases of the Kidney

415

The Microscopic Examination Summary of the urine put in evidence: Density 1005 pH 7 Leukocytes negative Red blood cells negative Nitrates negative Ketones negative Bilirubin negative, Urobilinogen negative Proteins þþþ, Esbach method ¼ 4.2 mg/dL Glucose negative Ascorbic acid negative Urinary sediment showed: Leukocytes were rare and 8e10 epithelial cells per plate Thus, the patient presented an increase in the level of proteins in the urinedproteinuria >3.5 g/dLda nephrotic syndrome. The level of creatinine in the blood was 2.6 g/dL, and the level of urea was 96 mg/dLd in the context of chronic renal failure. The cause of edema of this patient represents the nephrotic syndrome, with severe proteinuria ¼ 4.2 mg/dL. The diagnosis of this patient was nephrotic syndrome, anasarca, and chronic renal failure. The most important question is, what is the cause of the nephrotic syndrome? Is it primary or secondary? The patient underwent a renal biopsy and after coloration with Congo red, the result was positive, which confirmed the diagnosis of amyloidosis. The final diagnosis of this patient was amyloidosis, secondary nephrotic syndrome, and chronic renal failure. The diagnosis of this patient was anasarca, nephrotic syndrome, chronic renal failure, and amyloidosis

7.8.9 Clinical Case No. 9 The clinical case of a 17-year-old boy from a children’s home is presented. He came for consultation because he noticed, beginning about 4 months earlier, swelling of the eyelids in the morning, as we can see in the picture below. Swelling of the Upper and Lower Eyelids in the Morning

416

7. Morphological Investigations of The Kidney

He did not know what happened or what caused this eyelid swelling. At the objective examination, the physician also checked the appearance of the lower limbs to see if edema was also present at this level, but the edema was missing, as we can see in the next image. The image of the lower limbs of this patient follows. The Lower Limbs of the PatientdWithout Edema

The results of blood tests were ESR ¼ 20/40, fibrinogen ¼ 408 mg/dL, ASLO ¼ 1200 UI, SNF positive for betahemolytic streptococcus group B, leukocytes ¼ 10,000/mm3; and the summary of the urine put in evidence: proteinuria þþ, hematuria þ. The level of proteins was 2.4 mg/dL, 20e40 red blood cells. The patient presented a nephritic syndrome after a streptococcus infection. The diagnosis of this patient is post-streptococcal glomerulonephritis. Because he lived communally with other children, he contracted this germ, beta-hemolytic streptococcus group B, and this damaged the kidney and developed post-streptococcus glomerulonephritis. The patient presented with proteinuria and hematuria in the urine, which represent a marker of nephritic syndrome. A level of proteinuria less than 3.5 g/dL represents a marker of nephritic syndrome and so does the eyelid edema we can see in the image above. The diagnosis of this patient was post-streptococcus glomerulonephritis

7.8.10 Clinical Case No. 10 The clinical case of a 68-year-old man is presented. He came for a consultation because he felt pain in the hypogastric area and urinated painfully with fresh blood, as we can see in the image below.

7.8 Clinical Cases of the Kidney

417

Macroscopic Hematuria

At the objective examination, the Giordano maneuver was negative bilaterally, the costovertebral and costomuscular points were insensitive, and the superior and middle urethral points were insensitive as well. Only after palpation of the abdomen did the patient feel pain in the hypogastric area. The blood pressure was normal, BP ¼ 130/ 80 mm Hg, auscultation of the heart showed HR ¼ 88 beats/min, rhythmic, and auscultation of the lung showed vesicular sound normal. The patient underwent an abdominal ultrasound, and the images of both kidneys looked normal; the image of the bladder is shown below. The Abdominal UltrasounddDorsal recumbentdBig Stone in the Bladder

The abdominal ultrasound shows a big hyperechoic image indicated with a red arrow and dorsal acoustic shadowing indicated with the next red arrow, suggestive of a big stone inside the bladder. The patient was examined in the dorsal recumbent position. Because the physician wanted to check the mobility of the formation inside the bladder, the patient was examined after that in the left lateral recumbent.

418

7. Morphological Investigations of The Kidney

The surprise appeared after the patient was moved to the left lateral recumbent; the image of the bladder at the abdominal ultrasound in this position unexpectedly put into evidence two big stones inside the bladder, which looked like two hyperechoic images with two dorsal acoustic shadows, as we can see in the next image. The Abdominal UltrasounddLeft Lateral recumbentdStone in the Bladder

In the image above, with the patient in the left lateral recumbent, appears the reality of two big hyperechoic images inside the bladder, with dorsal acoustic shadowing, which suggests the presence of two big mobile stones inside the bladder. So the cause of painful macroscopic hematuria in this patient was the presence of two big stones inside the bladder. The patient was hospitalized in the urology department, and the stones were broken through extracorporeal lithotripsy and were eliminated in the urine. In conclusion, one of the causes of painful macroscopic hematuria in medical practice can be the presence of stones inside the bladder. The diagnosis of this patient was macroscopic hematuria with stones in the bladder.

7.8.11 Clinical Case No. 11 The clinical case of a 76-year-old man, who presented with hypogastric pain and sudden onset of anuria, is presented. The patient needed urinary catheterization inside the bladder to start the evacuation of urine from the bladder. The objective examination of the patient put in evidence at inspection the elevation of the hypogastric area; during palpation the physician felt an elevation at this level, and the percussion put into evidence area a dullness with upward convexity. The abdominal ultrasound showed a globular bladder and adenoma of the prostate gland, as we can see in the next image.

7.8 Clinical Cases of the Kidney

419

Adenoma of Prostate and Gall Bladder

Adenoma of Prostate After Evacuation of the Bladder by Urinary Catheterization

The most common cause of obstructive anuria in men is adenoma of the prostate gland. The real solution to the problem represents of course the surgical removal of the prostate gland. The diagnosis of this patient was anuriadadenoma of the prostate.

Index

‘Note: Page numbers followed by “f” indicate figures.’

A Abdominal ultrasound after lithotripsy, 397, 397f dilatation of calyxes five small enlarged cavities, 194f four small cavities, 203 many small enlarged cavities, 196fe199f one small enlarged dilatation, 195, 195f, 196 three small enlarged cavities, 196f, 199fe201f two small enlarged cavities, 194f, 202, 202f dorsal decumbent, 417e418, 417f free fluiddascites, 413, 413f hydronephrosis. See Hydronephrosis kidney stone, 385, 385f left kidney hydronephrosis, 393 left lateral decumbent, 418, 418f normal kidney, 187, 187f polycystic kidney. See Polycystic kidney prostate gland adenoma, 418e419 simple kidney cyst. See Simple kidney cyst small congenital kidney, 187e193, 188fe193f Acellular casts fatty casts, 144, 144f granular casts, 144, 144f hyaline cast, 143, 143f pigment casts, 145, 145f waxy casts, 143, 143f Acid urine, 104 Acute glomerulonephritis, 155 Acute renal failure antibiotics administration, 398 creatinine clearance, 163 isosthenuria, 161 subisosthenuria, 161 urea, 156 Adenoma, prostate, 53, 63, 63f, 95, 418e419, 419f Alkaline urine, 104 Amorphous urates, 147 Anuria, 73e74, 73f, 398, 418e419 Arteriography, 385 Auscultation, renal artery stenosis, 65 left renal artery, 66f right renal artery, 67f systolic murmur, 65 Azotemia (uremia)

metabolic causes, 156 urea, 155 vascular causes, 156

B Bacteriologic examination, urine bacteriuria, 150 biochemical methods, 152e153 contamination, 150 enterococcus culture, 151e152 infections, 150 monoculture, 150 sterile pyuria, 150 urinary sediment, 150 urine culture, 150 Bacteriuria, 150 Bence Jones protein, 108 Bilirubinuria choluria, 132, 132f conjugate bilirubin, 132 dipstik test, 134, 134f Lugol solution test, 133, 133f Black urine, 88, 88f hemosiderinuria, 102 melanuria, 103, 103f Bladder cancer, 8, 8f palpation, 62 percussion, 64, 64f Bladder carcinoma, intravenous urography, 186, 186f

C Calcifications, 171, 171f Calcium oxalate stone, 171, 171f Casts acellular casts, 143e145 cellular casts, 145e146 Cellular casts epithelial cell casts, 146, 146f red cell casts, 145, 145f white cell casts, 146, 146f Choluria, 132, 132f Chronic renal failure creatinina, 156 creatinine clearance, 163 triode contrast substance, 176 uric acid, 157, 157f urinary densities, 104, 414f Clinistix test, 128e129

421

Computed tomography perirenal hematoma, 387, 387f renal abscess, 386, 386f renal cell carcinoma, 386, 386f Congenital kidney hypoplasia, 169, 169f Conjugate bilirubin dipstick test, 134f hiperbilirubinemia, 132 iodated Lugol solution test, 133, 133f Coraliform lithiasis, 173, 173f Costomuscular renal points, 58 left, 60, 60f, 394 positions, 58 right, 60, 60f Costovertebral renal points, 58 left, 59, 59f right, 59, 59f Creatinina glomerular rate filtrate, 156 muscle catabolism, 156e157, 157f nephron, 156 normal level, 156 and renal failure, 156 Creatinine clearance, 162e163, 162f

D Diabetic nephropathy, 409 Dipstick test bilirubinuria, 132f proteinuria, 114e115, 114fe115f Distended renal pelvis, 168 Diurnal uresis, 74e75, 74fe75f Dysuria, 398

E Edema characteristics, 33 eyelids, 37fe38f, 116e118, 121e123, 415e416, 415f lower eyelids, 34f upper eyelids, 33fe34f, 405, 405f, 409e410, 409fe411f legs, 34f, 38f, 110, 110f, 119 lower limbs, 406, 406f, 408, 411e412, 411fe412f pitting, 35f, 110e111, 111f, 120e121, 120f, 408 renal, 115, 115f, 123e125 Electrolitic substance, 158 Epithelial cells, 142, 142f casts, 146, 146f

422 F Fatty casts, 144, 144f

G Giordano maneuver hand and finger position, 56, 56f left costomuscular point, 394 left costovertebral point, 394 left kidney, 58, 58f right kidney, 57, 57f Glenard method, 55, 55f Glob bladder, 62 abdominal echo, 52f elevation of hypogastric area, 52f percussion, 64, 64f urinary probing, 53, 53f Glomerular filtration creatinina, 156 urea, 155 Glomerular proteinuria, 109 Glomerulonephritis, 109 Glycemia, 130 Glycosuria, 127e130 ketonuria, 130e131 definition, 127 glycemia, 130 normoglycemic glycosuria, 130 permanent, 130 temporary, 130 Trommer reaction, 127e130, 127f Granular casts, 144, 144f Guyon method, 54, 54f

H Hemoglobinuria, 92 Hemosiderinuria, 102 Hyaline cast, 143, 143f Hydronephrosis, 168e169, 168f abdominal ultrasound, 393 degree I, 26fe28f degree II, 24fe25f degree III, 23, 23f, 27f, 29fe30f dilatations of renal calyces, 21, 21fe22f clinical case, 392e393 intravenous urography, 178 vs. normal kidney, 21, 21f Hydroureter, 20 intravenous urography, 178 Hyperchromic urine, 87f Hyperoxaluria, 20, 20f Hypertonic oliguria, 73 Hypoplasia, 169, 169f Hypoproteinemic edema, 408e409, 409f Hypotonic oliguria, 73 Hypotonic polyuria, 72

I Immunoelectrophoresis, proteinuria, 108 Inferior ureteral point, 62, 62f Initial hematuria, 95 Inspection, kidney. See Lumbar scar, nephrectomy Intravenous urography bladder carcinoma, 186, 186f

Index

Leucine crystals, 149, 149f Lumbar contact, 54 Lumbar pain, 5 Lumbar scar, nephrectomy glob bladder, 51, 52f left, 43e45, 43fe44f and eventration, 46e47, 46f lateral incidence, 43e45, 43fe46f posterior incidence, 44f right enlarged lipoma, 50fe51f and eventration, 47f lipoma, 48e49, 48fe49f urinary probing, 53, 53f

intensities, 89 polycystic kidney, 389 renal colic, 92f terminal hematuria, 95, 95f total hematuria, 95, 95f tumor bladder, 93f Macroscopic urine examination chronic renal failure, 414 thick urine appearance, 99 urinary tract infection, 99e101, 99fe100f troubled urine, 99e102, 99fe101f urine color black urine, 88, 88f concentrated urine, 78f, 82e83, 82fe83f concentration, 76, 76f dark brown color, 71, 98, 98f dilute urine, 76, 76fe79f, 79, 84fe86f hyperchromic urine, 87f normal appearance, 75 normal color, 80fe81f red color. See Macroscopic hematuria urine smell, 104 urine volume anuria, 73e74, 73fe74f diuresis, 75, 75f nocturia, 74, 74f normal volume, 71 oliguria, 73, 73f polyuria, 72 Medium ureteral point, 61e62, 61f Melanuria, 103, 103f Metabolic causes, azotemia, 155 Microalbuminuria, 109 Microscopic hematuria, 140 Microscopic urine examination casts acellular casts, 143e145 cellular casts, 145e146 crystals cholesterol crystals, 148, 148f leucine crystals, 149, 149f oxalate calcium crystals, 147, 147f phosphate crystals, 148, 148f tyrosine crystals, 149, 149f urate crystals, 147, 147f epithelial cells, 142, 142f nephrotic syndrome, 415 red blood cells macroscopic hematuria, 141, 141f microscopic hematuria, 140 urinary sediment, 139 white blood cells, 141 Monoculture, 150 Myoglobinuria, 92

M

N

hydronephrosis and hydroureter, 178 hydrourether, 184f kidney stone, 181e182, 181fe182f, 185, 185f kidney tuberculosis, 179 lack of kidney function, 180, 180f large renal cell carcinoma, 178, 178f nephrogram, 177 normal, 183, 183f triode contrast substance, 176 Isosthenuria, 160e161, 161f Isotonic oliguria, 73 Isotonic polyuria, 72 Israel method, 55e56, 55f

K Ketonuria, 130e131, 130fe131f Kidney arteriography, 385 Kidney ptosis, 170 Kidney radiography bilateral kidney stones, 172, 172f bilateral renal stones, 172, 172f calcifications, 171, 171f calcium oxalate stone, 171, 171f congenital kidney hypoplasia, 169, 169f coraliforme lithiasis, 173, 173f coraliform stones, 173, 173f hydronephrosis, 168e169, 168f hypoplasia, 169e170, 169f polycystic kidney, 167, 167f ptosis, 170, 170f stones in urinary bladder, 175, 175f tumor, 168, 168f ureteral stones, 174, 174f Kidney stone abdominal ultrasound, 385, 385f intravenous urography, 181f in urine, macroscopic appearance, 136fe139f Kidney tuberculosis, intravenous urography, 179

L

Macroscopic hematuria, 6, 6f after urinary probing, 96e98, 96fe97f atrial fibrillation, 90e91 bladder stones, 94f, 418 clinical case, 416e417, 417f initial hematuria, 95

Nephritic syndrome, 416 Nephrogenous proteinuria, 109 Nephrotic syndrome cholesterol crystals, 148, 148f microscopic urine examination, 415 proteinuria, 125

423

Index

Nitriuria, 153, 153f Nocturnal and diurnal uresis, 74e75, 74fe75f Nonselective glomerular proteinuria, 109 Normal kidney, 22, 22f Normoglycemic glycosuria, 130 Nuclear magnetic resonance, renal cell carcinoma, 387e388, 388f

O Occasional polyuria, 72 Oliguria, 73, 73f Oxalate calcium crystals, 147, 147f

P Painful hematuria, 6e7, 7f Painless hematuria, 8, 8f Palpation bladder, 62 kidney diseases, 56 Glenard method, 55, 55f Guyon method, 54, 54f Israel method, 55e56, 55f urethral, 64 Paridensity acute renal failure, 161 hipostenuria, 160e161, 160f isostenuria, 161, 161f Zimnicki probe, 161 Patient’s history allergy, xxvi birth place and address, xxvi current disease history, xxvii family history, xxvii general manifestations, xxx hospitalization reasons, xxviexxvii life conditions, xxviiiexxix personal data, xxvi personal pathological history, xxviii personal physiological antecedents, xxviii working conditions, xxx Percussion glob bladder, 64, 64f kidney, 64 Perirenal hematoma, 387, 387f Permanent glycosuria, 130 Permanent polyuria, 72 Permanent proteinuria, 109 Persistent polyuria, 72 Phosphate crystals, 148, 148f Physicochemical urine examination bilirubinuria, 132e134 Clinistix test, 128e129 glycosuria, 127e130 ketonuria, 130e131, 130fe131f proteinuria. See Proteinuria pyuria, 125e126 urine density, 104 urine pH test, 104 urobilinogenuria, 134e135, 135f Pigment casts, 145, 145f Plasmatic examination creatinina, 156e157 electrolitic substance, 158

urea, 155e156 uric acid, 157 Pollakiuria, 398 Polycystic kidney, 365fe384f, 390f, 399fe404f, 403e405 congenital, 389e390 macroscopic hematuria, 389 Polyuria, 72 Post streptococcal glomerulonephritis, 416, 416f Prerenal proteinuria, 109 Primary gout, uric acid, 157, 157f Prostate adenoma, 53, 63, 63f, 95, 418e419, 419f inflammation, 64 Proteinuria Bence Jones protein, 107 definition, 104 dipstick test, 114e115, 114fe115f edema. See Edema Esbach method, 107e108 immunoelectrophoresis, 108 microalbuminuria, 109 nephrogen, 109 nephrotic syndrome, 109 nonselective glomerular, 109 permanent, 109 prerenal, 109 renal, 109 selective glomerular, 109 sulfur-salicylic acid reaction, 104, 105fe106f swollen eyelids, 109f transitory, 108 tubular, 109 Ptosis, 170, 170f Pyuria definition, 125 Done reaction, 126, 126f

R Rectal touch, prostate adenoma, 63, 63f Red cell casts, 145, 145f Renal abscess, 386, 386f Renal artery stenosis, 169e170, 169f Renal biopsy, 388 Renal cell carcinoma computed tomography, 386, 386f nuclear magnetic resonance, 388, 388f Renal colic antispastic drugs, 15 left, 31, 38 painful macroscopic hematuria, 15f pain irradiation, 14f stone removed after, 17fe19f symptoms and signs, 15 Renal failure acute. See Acute renal failure chronic. See Chronic renal failure electrolitic substance, 158 Renal proteinuria, 109 Renal system auscultation, renal artery stenosis, 65 left renal artery, 66f, 68f right renal artery, 67f

systolic murmur, 65 inspection. See Lumbar scar, nephrectomy palpation bladder, 62 Glenard method, 55, 55f Guyon method, 54, 54f Israel method, 55e56, 55f kidney diseases, 56 percussion glob bladder, 64, 64f kidney, 64 sensibility. See Sensibility; kidney

S Selective glomerular proteinuria, 109 Sensibility, kidney costomuscular point, 58 left, 60, 60f positions, 58 right, 60, 60f costovertebral renal points, 58 left, 59, 59f right, 59, 59f Giordano maneura hand and finger position, 56, 56f left kidney, 58, 58f right kidney, 57, 57f ureteral point inferior ureteral point, 62, 62f medium ureteral point, 61e62, 61f superior ureteral point, 61, 61f Simple kidney cyst, 239fe245f, 271fe291f, 311fe322f, 326fe338f, 351f in asymptomatic patient, 361fe363f clinical case, 390e393 cortical of kidney, 210fe214f diameter A, 327f diameter A and B, 310fe311f diastolic blood pressure, 348fe350f, 354f and dorsal acoustic enhancement, 206e207, 206fe209f enlarged, 220fe231f, 338fe340f, 343fe345f, 347fe356f horizontal diameter, 247fe248f medullar area, 215fe220f vs. normal kidney, 232fe238f, 252fe269f, 291fe307f, 310f, 323fe324f, 357fe360f oblique cyst diameter, 346fe347f perfect regular borders, 205f, 208fe215f round formation, 205, 205f two simple kidney cysts, 249fe251f, 258fe259f vertical diameter, 246f very enlarged, 220fe221f, 226fe228f Sterile pyuria, 150 Superior ureteral point, 60e61, 61f, 395, 395f

T Temporary glycosuria, 130 Tourneaux point, 61, 61f Transitory proteinuria, 108 Trommer reaction, 127, 127f

424 Troubled urine, 99e102, 99fe101f Tubular proteinuria, 109 Tumor, kidney, 168, 168f Tyrosine crystals, 149, 149f

U Urate crystals, 147, 147f Ureteral stones, 174, 174f Urethral palpation, 64 Uric acid, 147, 147f Urinary colic, 16, 16fe17f Urinary probing macroscopic appearance, 53 macroscopic hematuria, 6e7, 6f urine retention, 53 Urine crystals cholesterol crystals, 148, 148f

Index

leucine crystals, 149, 149f oxalate calcium crystals, 147, 147f phosphate crystals, 148, 148f tyrosine crystals, 149, 149f urate crystals, 147, 147f Urine density, 104 Urine examination densimetry, 158e161, 158f paridensity, 160e161, 160f pathological conditions, 160, 160f pH value, 162 probe miction, 159 probe preparation, 159, 159f urine collection, 70 Urine pH test acid urine, 104 alkaline urine, 104

normal condition, 104 Urobilinogenuria, 134e135, 135f Uterine fibromatosis, 64, 65f

V Vascular causes, azotemia, 155 Volhard method, 158, 158f

W Waxy casts, 143, 143f White blood cells, 141 White cell casts, 146, 146f

Z Zimnicki probe, 161