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The history of a patient with suspected renal disease should include a review of recent clinical events and an inventory of all the patient's prescription and nonprescription medications. In both outpatients and hospitalized patients, important information includes blood pressure, pulse rate, alterations in daily weights, daily fluid intake, and urine output. The physical examination will also be helpful in assessing evidence for manifestations of systemic disease. For example, the abdominal and pelvic examinations may disclose a distended bladder suggestive of obstructive uropathy, peripheral vascular disease, inflammatory or neoplastic masses, or an enlarged uterus, all of which can affect renal function. In the skin, palpable purpura or livedo reticularis suggests vasculitis; nonpalpable purpura raises the question of thrombotic thrombocytopenic purpura or hemolytic uremic syndrome, which are associated with vascular compromise of the kidney.
The history and physical examination can help in categorizing the probable type of renal disease. Prerenal azotemia (hypoperfusion of the kidneys) often occurs in patients with a history of cardiac disease or those with conditions associated with extracellular fluid volume depletion. Postrenal (obstructive) nephropathy is observed in patients with a history of cancer of the bladder, pelvic cavity, or prostatic disease. Intrarenal disease is glomerular or tubulointerstitial. The former complicates systemic disease such as diabetes or polyarteritis; the latter is frequently drug-related or seen after a hypotensive episode (acute tubular necrosis).
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