History Taking –

Renal System
Rajesh Kumar Sharma
Associate Professor
Himalayan College of Nursing
Lesson Objectives
At the end of the class students will be able to:
• Know the basics of renal system related to history collection.
• Collect history of the patient suffering with renal diseases in OPD or
IPD.
 Functions of the Kidney
• Controls volume, osmolarity and acid-base balance of plasma and EC
fluid, as well as the level of electrolytes
• Recovers small molecules filtered by the nephron, such as amino acids
and sugars
• Excretes nitrogenous waste from protein metabolism, mainly urea, uric
acid and creatinine
• Excretes toxic metabolites and excess electrolytes and water
• Maintains red cell production by the secretion of erythropoietin
• Maintains calcium balance by production of the active form of Vitamin D
• Controls blood pressure
Cardinal symptoms of diseases of the urinary
tract – presenting complaint/s

• Abnormalities of micturition
• Pain presentations
• Alteration in the appearance of urine
• Alteration in the amount of urine
• General symptoms of abnormal renal function
ABNORMALITIES OF MICTURITION
• Dysuria
• Frequency and nocturia
• Urgency
• Hesitancy, decreased stream and dribbling
• Retention
• Incontinence
Dysuria
• Dysuria = pain / discomfort during micturition
• Often referred to as burning on micturition
• Associated with cystitis or urethritis
Frequency and nocturia

• Frequency = the need to pass small amounts of urine frequently

• Due to bladder irritation – may be caused by infection, stone, tumour
• Nocturia = waking up to pass urine at night (pregnancy - pressure,
diabetes – associated with polyuria)
Hesitancy, decreased stream
and dribbling
• Hesitancy = delay /difficulty in initiating micturition
• Poor stream Dribbling = terminal dribbling after passage of urine
• Associated with urinary obstruction – often associated with
prostatism or bladder outflow obstruction in elderly men
Urgency & Retention
• Urgency = a sudden compelling need to urinate
• Caused by local irritation or inflammation
• Retention of urine - due to obstructive lesions such as stricture,
benign prostatic hypertrophy or BPH, tumour
• May be heralded by the phase of hesitancy
Incontinence
• Incontinence is the inability to hold urine in the bladder voluntarily 
• Spinal cord lesions are associated with retention and overflow
neurogenic incontinence
• Prostatic enlargement is associated with overflow incontinence –
dribbling incontinence after incomplete urination
• Stress incontinence – more common in women – leakage of urine
after sudden increase in intra-abdominal pressure eg due to coughing
or sneezing, and associated with bladder prolapse
• Urgency incontinence – associated with urgency and caused by local
irritation or inflammation
PAIN PRESENTATIONS
(Renal, ureteric, vesical,
urethral)
• Renal angle pain - dull ache between 12th rib and erector spinae muscle
on the side of the affected kidney – pyelonephritis. (Refer renal angle
tenderness)
• Renal colic – due to ureteric obstruction – a severe pain – lumbar region;
radiates to abdomen, groin, testes, thigh – due to stone or tumour
• Ureteric colic – spasmodic, severe pain during the passage of a renal
calculus; radiation path of renal colic; may be associated with vomiting,
sweating.
• Suprapubic pain from bladder / urethra is referred to lower abdomen,
perineum and glans penis in males
ALTERATION IN URINE APPEARANCE
• Change in colour - e.g.

• Orange (Rifampicin)
• Red (blood)
• Black (malaria)
ALTERATION IN AMOUNT OF
URINE
• Polyuria
• Oliguria
• Anuria
Polyuria

• Passage of > 3 litres of urine per day

• Physiological – ingestion of large quantities of fluid or substances
containing diuretics
• Pathological
- Chronic renal failure or CRF – associated polydipsia
- Diabetes mellitus – associated polydipsia
- Diabetes insipidus – neurohypophyseal or nephrogenic
- Oedematous states – after administration of diuretics
Oliguria

• Passage of < 500ml of urine per day

• Physiological - under conditions of water deprivation
• Prerenal conditions – shock, dehydration, haemorrhage
• Renal – Acute renal failure or ARF
Anuria

• Passage of <50 mls of urine in a day

• Some causes:
Renal infarct
Dissecting aneurysm
Complete ureteric obstruction
Notes Renal Failure
• Occurs when glomerular filtration is compromised May also be the
consequence of abnormal tubular function
• Prerenal – due to decreased renal perfusion eg hypotension due to massive
blood loss or cardiac failure
• Renal – due to disease of nephron, glomeruli, microvasculature ( DM) or
tubules (acute tubular necrosis)
• Postrenal – due to obstruction to outflow or recurrent ascending infections
• Acute renal failure – sudden deterioration of renal function, usually reversible
• Chronic renal failure – longstanding and progressive impairment of renal
excretory function – may be insidious in onset
Clinical consequences of renal
failure
• Hypertension – renin secreted in response to impaired perfusion –
activates ACE to convert angiotensin I – II – vasoconstriction –
aldosterone secretion – sodium and water retention (renin-
angiotensin-aldosterone system) 
• Anaemia – erythropoietin deficiency
• Hypoproteinaemia due to protein loss – wasting and malnutrition
• Renal osteodystrophy from failure of hydroxylation of Vitamin D to
active form (2º hyperparathyroidism)
• Other metabolic complications eg gout (defective excretion of uric
acid), endocrine and neurological complications
 HISTORY-TAKING

• History of presenting complaint to be in detail – chronology is

important, especially in chronic conditions
• Don’t forget the systems enquiry – to cover specific relevant
aspects
Opening the consultation
• Introduce yourself – name/role
• Confirm patient details – name/DOB
• Explain the need to take a history
• Gain consent
• Ensure the patient is comfortable
Presenting complaint
• It’s important to use open questioning to elicit the patient’s presenting
complaint
“So what’s brought you in today?”   or  “Tell me about your symptoms”

• Allow the patient time to answer, trying not to interrupt or direct the
conversation.
• Facilitate the patient to expand on their presenting complaint if required.
“Ok, so tell me more about that”  “Can you explain what that pain was like?”
History of presenting complaint
Pain – if pain is a symptom, clarify the details of the pain using SOCRATES
• Site – where is the pain 
• Onset – duration? / sudden vs gradual?
• Character – sharp / dull ache / burning
• Radiation – does the pain move anywhere else? 
• Associations – other symptoms associated with the pain (e.g. fever)
• Time course – worsening / improving / fluctuating 
• Exacerbating / Relieving factors – does anything make the pain worse or better?
• Severity – on a scale of 0-10 how severe is the pain?
Key urological symptoms:
• Dysuria 
• Frequency
• Urgency
• Nocturia
• Haematuria 
• Hesitancy and terminal dribbling
• Poor urinary stream 
• Incontinence
• Fever/rigors – suggestive of infection/urosepsis
• Nausea/vomiting – often associated with pyelonephritis 

If any of the above symptoms are present, gain further details as per questions
mentioned in next slide………….
• Onset – When did the symptom start? / Was the onset acute or gradual?
• Duration – Minutes / hours / days / weeks / months / years
• Severity – i.e. If the symptom was frequency – how many times a day?
• Course – Is the symptom worsening, improving, or continuing to fluctuate?
• Intermittent or continuous? – Is the symptom always present or does it
come and go?
• Precipitating factors – Are there any obvious triggers for the symptom?
• Relieving factors – Does anything appear to improve the symptoms?
• Previous episodes – Has the patient experienced this symptom previously?
Past History
• Past medical history
• Urological diseases:
• Recurrent urinary tract infections (UTIs)
• Incontinence – stress incontinence / functional incontinence
• Prostate issues – benign prostatic hypertrophy / prostate cancer
• Renal  – renal stones / pyelonephritis / chronic renal failure
• Other medical conditions – e.g. diabetes predisposes to UTIs
• Surgical history – cystoscopy / bladder surgery / renal surgery
• Acute hospital admissions? – when and why?
• Medications
(Remember to ask about OTC drugs and herbal medications as well)
Steroids
Immunosuppressants
Antibiotics
Anti-hypertensives (know which drugs to avoid eg tetracyclines, NSAIDs)
• Diet – protein, fluid, salt restriction
• Family History
DM, hypertension
Inherited forms of renal disease eg adult polycystic kidney disease
- inherited as an autosomal dominant;
Alport’s Syndrome - inherited as an X-linked recessive
• Social History Employment –
occupational exposures
eg. heavy metals such as Cadmium Home circumstances,
Family support Impact of chronic illness,
Dialysis Smoking and alcohol use
Systemic enquiry –
• Systemic enquiry involves performing a brief screen for symptoms in other body
systems.
• This may pick up on symptoms the patient failed to mention in the presenting
complaint.
• Some of these symptoms may be relevant to the diagnosis (e.g. back pain with
renal stones).
• Choosing which symptoms to ask about depends on the presenting complaint and
your level of experience.
• Cardiovascular – Chest pain / Palpitations  / Dyspnoea /
 Syncope / Orthopnoea  / Peripheral oedema 
• Respiratory – Dyspnoea / Cough / Sputum / Wheeze /
Haemoptysis / Chest pain
• GI – Appetite / Nausea / Vomiting / Indigestion / Dysphagia / Weight loss
/ Abdominal pain / Bowel habit 
• CNS – Vision / Headache / Motor or sensory disturbance/ Loss
of consciousness / Confusion
• Musculoskeletal – Bone and joint pain / Muscular pain 
• Dermatology – Rashes / Skin breaks / Ulcers / Lesions
Thank You
Next Class Assessment of Renal System