Did very badly in today's practice. Missed not just one but two AVFs!
1. Wash hand, introduce and consent.
This renal transplant patient~!~!~~!
2. Exposed patient from waist up, and general inspection of surrounding, and patient as a whole. ?Cushingoid ?Pigmented ?Sallow appearance
3. "Is there any discomfort anywhere?"
4. "Can I have a look at your hands? Check for clubbing, leukonychia, palmar erythema, Duputrun's, Flapping tremor, tremor
5. Check for AVF on both upper limbs, if found, with three fingers to feel the thrill, and look for any recent puncture marks? Move up to see any tattoo, bruising, thinning of skin.
6. Check eyes - look up and look to the finger. Pallor, jaundice.
7. Check parotid swelling.
8. Open mouth for me, and stick out your tongue, show me your teeth, look for gingival hypertrophy.
9. Examine the chest - look for spide naevi.
10. Raise your arms to your head, and look at axillary hair
11. Check gynaecomastia
12. Inspect for scar (RIF scar?) and Palpate abdomen - soft then deep. Noted a mass and a note its size, bean shaped, tenderness, firm, percuss on the top, listen just next to it for bruit.
13.Liver, palpate the percuss.
14. Spleen, palpate, then precussed
15. Tap on the midline for any fluid. No ascites. Check sacral oedema.
16. Ballot for kidneys
17. Check pedal oedema.
18. Sit up and check LN and then check for proximal weakness.
19. Cover up and present.
I would like to end the examination by checking his urine dipstick and blood pressure measurement.
Mrs Lee has Cushingoid appearance with moon face, supraclavicular fat pad and dorsal humb. There are two AVFs on bilateral forearms with no thrills and recent puncture marks. Other examination reveals conjuctive pallor, hyperpigmented skin lesions on the left temporal measuring 2cmx1cm and gum hypertrophy.
Moving on the the abdomen, there is a scar at the RIF and a mass measuring 6x 4 cm beneath it which is firm and bean shaped. It is non tender, dull on percussion and there is no burit audible. The rest of the abdomen is soft, no hepato or splenomegaly. There is no ballotable kidneys. He has no ascites, scaral, pedal oedema.
In summary, Mr lee has a transplanted kidney for ESRF which is functioning well. Etiology for ESRF for this lady would need some further history as I could not find obvious signs of common causes such as DM, Hypertension, Glomerulonephritis or APCKD. There is no signs of fluid overload and uremic encephalopathy. In terms of immunosupression, she is likely to be on steroids and cyclosporin, with no lymphnodes palpable but there is a suspicious skin lesion on the left temporal which needs further work-up.