Renal System Examination – OSCE Guide

geekymedics.com/renal-system-examination-osce-guide/

Leah November 12, 2019

Argus

A renal system examination involves looking for clinical clues and signs related to end-stage
renal disease (e.g. fistula, dialysis catheter, renal transplant), renal failure complications (e.g. fluid
overload, uraemia), transplant immunosuppression side effects (e.g. tremor, striae, steroid facies)
and causes of renal disease (e.g. diabetes, hypertension, polycystic kidney disease).

This OSCE guide provides a generic overview of the potential signs you may identify in a patient with
renal disease. The commonest renal patients you’ll come across will be those with polycystic kidney
disease, a kidney transplant and/or end-stage renal disease on dialysis.

Download the renal system examination PDF OSCE checklist, or use our interactive OSCE checklist.
You may also be interested in our abdominal examination guide.

Introduction
Introduce yourself to the patient including your name and role.

Confirm the patient’s name and date of birth.

Briefly explain what the examination will involve using patient-friendly language.

Gain consent to proceed with the examination.

Adjust the head of the bed to a45° angle and ask the patient to lay on the bed.

Wash your hands.

Adequately expose the patient’s abdomen for the examination from the waist up (offer a blanket
to allow exposure only when required). Exposure of the patient’s lower legs can also be helpful to
assess for peripheral oedema.

Ask the patient if they have any pain before proceeding with the clinical examination.

General inspection
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Clinical signs
Inspect the patient from the end of the bed whilst at rest, looking for clinical signs suggestive of
underlying pathology:

Decreased level of consciousness: can be a feature of end-stage renal disease.

Obvious scars: may provide clues regarding previous abdominal surgery.
Pallor: a pale colour of the skin that can suggest underlying anaemia (e.g. erythropoietin
deficiency).
Shortness of breath: may be due to pulmonary oedema secondary to advanced renal
disease. Tachypnoea may also be due to metabolic acidosis secondary to renal failure.
Oedema: typically presents as swelling of the limbs (e.g. pedal oedema) and abdomen (i.e.
ascites). In the context of a renal system examination, possible causes could include nephrotic
syndrome and end-stage renal disease (due to anuria).
Cachexia: ongoing muscle loss that is not entirely reversed with nutritional
supplementation. Cachexia is commonly associated with end-stage renal failure due to
protein-energy wasting (PEW).
Uraemic complexion: a yellow colour of the skin caused by uraemia in advanced chronic
kidney disease.
Cushingoid appearance: in the context of a renal system examination this may be due to
the use of high dose corticosteroids for renal transplant immunosuppression or
glomerulonephritis.

Objects and equipment

Look for objects or equipment on or around the patient that may provide useful insights into their
medical history and current clinical status:

Medical equipment: examples include supplemental oxygen, intravenous medications,

urinary catheters, nephrostomy drains and haemodialysis/peritoneal dialysis machines.
Mobility aids: items such as wheelchairs and walking aids give an indication of the patient’s
current mobility status.
Vital signs: charts on which vital signs are recorded will give an indication of the patient’s
current clinical status and how their physiological parameters have changed over time.
Fluid balance: fluid balance charts will give an indication of the patient’s current fluid
status which may be relevant if a patient appears fluid overloaded or dehydrated.
Prescriptions: prescribing charts or personal prescriptions can provide useful information
about the patient’s recent medications.

General inspection

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 Pedal oedema 1

Uraemic frost 2

Haemodialysis machine 3

Peritoneal dialysis 4

Hands
The hands can provide lots of clinically relevant information and therefore a focused, structured
assessment is essential.

Inspection
Inspect the hands for any of the following signs:

Pallor: indicative of underlying anaemia (e.g. erythropoietin deficiency).

Fingerprick marks: secondary to repeated capillary blood glucose tests in patients with
diabetes.
Gouty tophi: nodular masses of monosodium urate crystals deposited in the soft tissues of
the body, common in advanced chronic kidney disease.
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 Tremor: can be caused by immunosuppressive medications such as ciclosporin in renal
transplant patients.

Nail signs
Inspect the nails for any of the following signs:

Koilonychia: spoon-shaped nails, associated with iron deficiency anaemia (e.g.

erythropoietin deficiency).
Leukonychia: whitening of the nail bed, associated with hypoalbuminaemia (e.g. end-stage
renal disease, nephrotic syndrome).
Splinter haemorrhages: a longitudinal, red-brown haemorrhage under a nail that looks
like a wood splinter. Causes include local trauma, infective endocarditis (e.g. dialysis catheter-
associated infections), sepsis, vasculitis and psoriatic nail disease.
Beau’s lines: one or more palpable transverse ridges in the nail plate extending across the
nail associated, in some cases, with malnutrition and systemic disease.
Muehrke’s lines: one or more pale transverse bands (not palpable like Beau’s lines)
extending all the way across the nail associated with hypoalbuminaemia.
Lindsay’s half-and-half nails: white discolouration of the proximal portion of the nail and
red/brown discolouration of the distal portion with a sharp line of demarcation between the
halves. Commonly present in haemodialysis patients.

Peripheral pallor 5

Gouty tophi 6

Koilonychia 7

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 Leukonychia 8

Splinter haemorrhages

Beau's lines 9

Muehrcke's lines

Lindsay's nails 10

Asterixis (flapping tremor)

Asterixis (also known as ‘flapping tremor’) is a type of negative myoclonus characterised by
irregular lapses of posture causing a flapping motion of the hands. In the context of a renal system
examination, the most likely underlying cause is uraemia secondary to renal failure. CO2 retention
secondary to type 2 respiratory failure and hyperammonemia secondary to liver failure are also
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causes of asterixis.

To assess for asterixis:

1. Ask the patient to stretch their arms out in front of them.

2. Then ask them to cock their hands backwards at the wrist joint and hold the position for 30
seconds.

3. Observe for evidence of asterixis during this time period.

Skin turgor
Assess skin turgor by gently pinching a fold of skin (this can be done on the back of the hand),
holding for a few seconds and then releasing the skin. Well-hydrated skin should spring back
to its previous position immediately, whereas dehydrated skin will slowly return to normal
(known as decreased skin turgor).

Assessment of skin turgor is useful as part of an overallassessment of hydration.

Asterixis

Arms

Inspect the arms

Excoriation
Excoriation may indicate pruritis secondary to uraemia (e.g. end-stage renal disease).

Bruising
Bruising may be due to excessive corticosteroid use (e.g. immunosuppression in the context of
renal transplant) or platelet dysfunction secondary to uraemia.

Skin lesions
Inspect for obvious warts or skin cancers which can be associated with immunosuppression
(e.g. renal transplant patients).

Arteriovenous fistula
Inspect for an arteriovenous (AV) fistula in the wrist (radio-cephalic fistula) and antecubital
fossa (brachio-cephalic or brachio-basilic fistula) or the presence of asynthetic PTFE graft in the
antecubital fossa (now commonplace in haemodialysis). If an AV fistula is present it indicates that
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the patient is receiving haemodialysis.

Visible needle marks over the AV fistula indicates recent use.

Palpate the AV fistula for a thrill and auscultate for a bruit (both absent if the fistula is
thrombosed or surgically ligated such as after renal transplantation).

Radial pulse
Palpate the patient’s radial pulse, located at the radial side of the wrist, with the tips of
your index and middle fingers aligned longitudinally over the course of the artery.

Once you have located the radial pulse, assess the rate and rhythm.

Blood pressure
Offer to measure the patient’s blood pressure:

Blood pressure should NOT be performed on the side of an AV fistula if present.

Causes of hypertension can include chronic kidney disease, renal transplant rejection,
corticosteroid use and tacrolimus or ciclosporin use for renal transplant immunosuppression.
Rarely, pulsus paradoxus (change in BP >10mmHg during breathing) can occur due to
uraemic cardiac tamponade (associated with low jugular venous pressure).
See our blood pressure measurement guide for more details.

Arteriovenous fistula 11

Palpate the radial pulse

Face

General

Skin colour and skin lesions

Inspect the patient’s complexion and note any skin lesions:
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 Yellowish complexion (also known as a uraemic complexion): associated with chronic
renal failure.
Uraemic frost: crystallized urea deposits found on the skin of patients with chronic kidney
disease who are chronically uraemic.
Skin lesions: may develop secondary to immunosuppression (e.g. squamous cell carcinoma,
basal cell carcinoma, herpetic gingivostomatitis).

Cushingoid facial appearance

Inspect the patients face for cushingoid features (i.e. a moon-shaped appearance) caused by
treatment with high-dose corticosteroids (e.g. renal transplant immunosuppression, treatment
of glomerulonephritis).

Hypertrichosis
Hypertrichosis refers to the excessive hair growth over and above the normal for the age, sex
and race of an individual. Hypertrichosis is a side effect of ciclosporin treatment for renal
transplant immunosuppression.

Hearing aid
If the patient is wearing a hearing aid, consider Alport syndrome. Alport syndrome is a genetic
disorder characterised by glomerulonephritis, end-stage kidney disease and hearing loss.

Eyes

Conjunctival pallor
Ask the patient to gently pull down their lower eyelid to allow you toinspect the conjunctiva
for pallor indicative of anaemia.

Anaemia is common in patients with chronic renal failure due to erythropoietic deficiency.

Band keratopathy
Band keratopathy is a corneal disease caused by the deposition of calcium in the central
cornea. Symptoms include eye pain and reduced visual acuity .

Band keratopathy has a wide range of causes, but in the context of a renal system examination
chronic hypercalcaemia is the most likely cause.

Periorbital oedema
Periorbital oedema (swelling around the eyes) is a common clinical feature ofnephrotic
syndrome.

Mouth

Gingival hypertrophy
Gingival hypertrophy is an increase in the size of the gingiva which can be caused by
gingival disease as well as certain medications such as ciclosporin.

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Uraemic fetor
Uraemic fetor is a urine-like (i.e. ammonia) smell of the breath typically associated with
end-stage renal disease.

Basal cell carcinoma 12

Squamous cell carcinoma

Melanoma 13

Cushingoid facial appearance 14

Conjunctival pallor

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 Band keratopathy 15

Periorbital oedema 16

Gingival hyperplasia 17

Neck
Jugular venous pressure (JVP) provides an indirect measure of central venous pressure. This is
possible because the internal jugular vein (IJV) connects to the right atrium without any intervening
valves, resulting in a continuous column of blood. The presence of this continuous column of blood
means that changes in right atrial pressure are reflected in the IJV (e.g. raised right atrial pressure
results in distension of the IJV).

The IJV runs between the medial end of the clavicle and the ear lobe, under the medial aspect of the
sternocleidomastoid, making it difficult to visualise (its double waveform pulsation is, however,
sometimes visible due to transmission through the sternocleidomastoid muscle).

Because of the inability to easily visualise the IJV, it’s tempting to use the external jugular vein (EJV)
as a proxy for assessment of central venous pressure during clinical assessment. However, because
the EJV typically branches at a right angle from the subclavian vein (unlike the IJV which sits in a
straight line above the right atrium) it is a less reliable indicator of central venous pressure.

See our guide to jugular venous pressure (JVP) for more details.

Measure the JVP

1. Position the patient in a semi-recumbent position (at45°).

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2. Ask the patient to turn their head slightly to the left.

3. Inspect for evidence of the IJV, running between the medial end of the clavicle and the ear lobe,
under the medial aspect of the sternocleidomastoid (it may be visible between just above the clavicle
between the sternal and clavicular heads of the sternocleidomastoid. The IJV has a double waveform
pulsation, which helps to differentiate it from the pulsation of the external carotid artery.

4. Measure the JVP by assessing the vertical distance between thesternal angle and the top of
the pulsation point of the IJV (in healthy individuals, this should be no greater than 3 cm ).

JVP interpretation
An elevated JVP indicates increased central venous pressure secondary to fluid overload.
Patients with end-stage renal disease become anuric and often develop fluid overload,
resulting in a raised JVP.

Other things to look for in the neck

Inspect for the presence of an indwelling dialysis catheter at the base of the neck or on the
anterior aspect of the chest wall (also note any scars in these locations suggestive previous
dialysis catheter insertion).

Inspect for a small horizontal scar at the base of the neck suggestive of a previous
parathyroidectomy (performed for renal hyperparathyroidism).

Assess the JVP

Central venous access 18

Chest

Inspection

Excoriation
Excoriation may indicate pruritis secondary to uraemia (e.g. end-stage renal disease).
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Bruising
Bruising may be due to excessive corticosteroid use (e.g. immunosuppression in the context of
renal transplant) or platelet dysfunction secondary to uraemia.

Skin lesions
Inspect for obvious warts or skin cancers which can be associated with immunosuppression
(e.g. renal transplant patients).

Percussion
Percussion of the chest involves listening to thevolume and pitch of percussion notes across
the chest to identify underlying pathology. Correct technique is essential to generating effective
percussion notes.

Percussion technique
1. Place your non-dominant hand on the patient’s chest wall.

2. Position your middle finger over the area you want to percuss, firmly pressed against the chest
wall.

3. With your dominant hand’s middle finger, strike the middle phalanx of your non-dominant
hand’s middle finger using a swinging movement of the wrist.

4. The striking finger should be removed quickly, otherwise, you may muffle the resulting
percussion note.

Areas to percuss
Percuss the following areas of the chest, comparing side to side as you progress:

Supraclavicular region: lung apices

Infraclavicular region
Anterior chest wall: percuss over 3-4 locations bilaterally
Axilla
Posterior chest wall: percuss over 3-4 locations bilaterally including the lung bases

Interpretation
A stony dull percussion note is indicative of pleural effusion which may occur in patients with
fluid overload (e.g. end-stage renal disease) or nephrotic syndrome (hypoalbuminaemia).

Percuss the lung fields

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 Percuss the anterior chest wall

Chest percussion locations

Percussion locations on the posterior chest wall

Palpate

Apex beat
Palpate the apex beat with your fingers placed horizontally across the chest.

In healthy individuals, it is typically located in the5th intercostal space in the midclavicular

line. Ask the patient to lift their breast to allow palpation of the appropriate area if relevant.

Displacement of the apex beat from its usual location can occur due toventricular
hypertrophy.

Palpate the apex beat

Auscultate the heart

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A systematic routine will ensure you remember all the steps whilst giving you several chances to
listen to each valve area. Your routine should avoid excess repetition whilst each step should
‘build’ upon the information gathered by the previous steps. Ask the patient to lift their breast to
allow auscultation of the appropriate area if relevant.

1. Palpate the carotid pulse to determine the first heart sound.

2. Auscultate ‘upwards’ through the valve areas using the diaphragm of the stethoscope whilst
continuing to palpate the carotid pulse:

Mitral valve: 5th intercostal space in the midclavicular line.

Tricuspid valve: 4th or 5th intercostal space at the lower left sternal edge.
Pulmonary valve: 2nd intercostal space at the left sternal edge.
Aortic valve: 2nd intercostal space at the right sternal edge.

3. Repeat auscultation across the four valves with the bell of the stethoscope.

Interpretation
The presence of a gallop rhythm (additional S3 and S4 heart sounds) is associated withheart
failure.

A friction rub may be noted in uraemic pericarditis.

Auscultate the mitral valve

Auscultate the tricuspid valve

Auscultate the pulmonary valve

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 Auscultate the aortic valve

Auscultate the lung bases

Auscultate the lung fields posteriorly:

Coarse crackles are suggestive of pulmonary oedema (e.g. fluid overload in end-stage
renal disease, hypoalbuminaemia in nephrotic syndrome).
Absent air entry and stony dullness on percussion are suggestive of an
underlying pleural effusion.

Auscultate the posterior lung fields

Abdomen
Position the patient lying flat on the bed, with their arms by their sides and legs uncrossed for
abdominal inspection and subsequent palpation.

Inspect the patient’s abdomen for signs suggestive of renal pathology:

Scars: there are many different types of abdominal scars that can provide clues as to the
patient’s past surgical history (see below for examples).
Abdominal distension: may be caused by an intrabdominal mass (e.g. polycystic kidneys),
ascites (e.g. secondary to nephrotic syndrome) or indwelling peritoneal dialysis fluid (look for
a peripheral dialysis catheter).
Nephrostomy tube(s): a catheter inserted through the flank musculature and into the
renal pelvis enabling diversion of urinary drainage in the context of obstruction (e.g.
secondary to malignancy).
Striae (stretch marks): caused by tearing during the rapid growth or overstretching of skin
(e.g. ascites, intrabdominal malignancy, Cushing’s syndrome, obesity, pregnancy).

Scars relevant to renal pathology

Rutherford-Morrison (‘hockey-stick’) scar: suggestive of a previous renal transplant.
Bilateral iliac fossae scars: suggestive of a simultaneous pancreas-kidney transplant (for a
patient with type 1 diabetes).
Umbilical scar: suggestive of previous peritoneal dialysis catheter insertion.
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 Flank scar: suggestive of a previous nephrectomy.
Lipodystrophy marks: caused by repeated insulin injection in diabetic patients.

Inspect the abdomen

Abdominal surgical incision sites

Ascites 19

Nephrostomy tube

Striae 20

Preparation
Before beginning abdominal palpation:
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 The patient should already be positioned lying flat on the bed.
Ask the patient if they are aware of any areas of abdominal pain (if present, examine these
areas last).
Kneel beside the patient to carry out palpation and observe their face throughout the
examination for signs of discomfort.

Light palpation of the abdomen

Lightly palpate each of the nine abdominal regions, assessing for clinical signs suggestive of
renal disease:

Tenderness: note the abdominal region(s) involved and the severity of the pain.
Masses: large or superficial masses (e.g. hernias) may be noted on light palpation.

Deep palpation of the abdomen

Palpate each of the nine abdominal regions again, this time applyinggreater pressure to identify
any deeper masses. Warn the patient this may feel uncomfortable and ask them to let you know if
they want you to stop. You should also carefully monitor the patient’s face for evidence of discomfort
(as they may not vocalise this).

If any masses are identified during deep palpation, assess the following characteristics:

Location: renal masses are typically palpable in the flank.

Size and shape: assess the approximate size and shape of the mass.
Consistency: assess the consistency of the mass (e.g. enlarged polycystic kidneys may be
irregular in their consistency).
Mobility: renal masses will be fixed and they’ll move superiorly and inferiorly with
respiration.

Perform light abdominal palpation

Perform deep abdominal palpation

Ballot the kidneys

1. Place your left hand behind the patient’s back, below the ribs and underneath the right flank.
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2. Then place your right hand on the anterior abdominal wall just below the right costal margin in
the right flank.

3. Push your fingers together, pressing upwards with your left hand and downwards with your right
hand.

4. Ask the patient to take a deep breath and as they do this feel for the lower pole of the kidney
moving down between your fingers. This bimanual method of kidney palpation is known as
balloting.

5. If a kidney is ballotable, describe its size and consistency.

6. Repeat this process on the opposite side to ballot the left kidney.

In healthy individuals, the kidneys are not usually ballotable, however, in patients with a low body
mass index, the inferior pole can sometimes be palpated during inspiration.

Causes of enlarged kidneys

Bilaterally enlarged, ballotable kidneys can occur in polycystic kidney disease or amyloidosis.
A unilaterally enlarged, ballotable kidney can be caused by a renal tumour.

Ballot the kidneys

Percussion

Shifting dullness
Percussion can also be used to assess for the presence of ascites by identifying shifting
dullness:

1. Percuss from the umbilical region to the patient’s left flank. If dullness is noted, this may suggest
the presence of ascitic fluid in the flank.

2. Whilst keeping your fingers over the area at which the percussion note became dull, ask the
patient to roll onto their right side (towards you for stability).

3. Keep the patient on their right side for 30 seconds and then repeat percussion over the same area.

4. If ascites is present, the area that was previously dull should now be resonant (i.e. the dullness
has shifted).

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 Assess for shifting dullness

Assess for shifting dullness

Auscultation

Listen for bruits

Auscultate over the renal arteries to identify vascular bruits suggestive of turbulent blood
flow:

Auscultate 1-2 cm superior to the umbilicus and slightly lateral to the midline on each side.
A bruit in this location may be associated with renal artery stenosis (a possible cause of
hypertension and renal failure).

Auscultate for renal artery bruits

Peripheral and sacral oedema

Assess the patient’s lower legs and sacrum evidence of pitting oedema which may suggest
hypoalbuminaemia (e.g. end-stage renal disease, nephrotic syndrome).

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 Assess sacral oedema

Assess for pedal oedema

Pedal oedema 1

To complete this examination…

Explain to the patient that the examination is nowfinished.

Thank the patient for their time.

Wash your hands.

Summarise your findings.

Further assessments and investigations

Blood pressure measurement: if not already performed (do not perform on the side of an
arteriovenous fistula).
Fundoscopy: to assess for evidence of retinopathy (e.g. diabetic, hypertensive).
Urinalysis: to screen for urinary tract infection and to assess for haematuria/proteinuria
which is associated with glomerular disease.
24-hour urine collection: to assess various urinary compounds and assist in the
calculation of protein-creatinine and/or albumin-creatinine ratio.
Urine culture: if a urinary tract infection is suspected.
U&Es: to assess renal function.
Bicarbonate: to assess for evidence of acidaemia.

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 Bone profile: to assess the levels of calcium, phosphate and PTH (to screen for secondary
and tertiary hyperparathyroidism).

Reviewers

Dr Ian Logan
Consultant Nephrologist

Dr Paul Callan
Consultant Cardiologist

References
Show references
1. James Heilman, MD. Adapted by Geeky Medics. Pedal oedema. Licence:CC BY-SA. Available
from [LINK].
2. Fythrion. Adapted by Geeky Medics. Uraemic frost. Licence:CC BY-SA. Available from
[LINK].
3. Shanelkalicharan. Adapted by Geeky Medics. Haemodialysis machine. Licence:CC BY-
SA. Available from [LINK].
4. Blausen.com staff. Medical gallery of Blausen Medical 2014. Adapted by Geeky Medics.
Peritoneal dialysis. Licence: CC BY. Available from: [LINK].
5. James Heilman, MD. Adapted by Geeky Medics. Peripheral pallor. Licence:CC BY-SA.
Available from [LINK].
6. Michael. Adapted by Geeky Medics. Gouty tophi of the fingertips. Licence:CC BY 2.0.
Available from: [LINK].
7. CHeitz. Adapted by Geeky Medics. Koilonychia. Licence:CC BY 2.0. Available from: [LINK].
8. BrotherLongLegs. Adapted by Geeky Medics. Leukonychia. Licence: CC BY-SA. Available
from: [LINK].
9. LynnMcCleary. Adapted by Geeky Medics. Beau’s lines. Licence:CC BY-SA. Available from:
[LINK].
10. Nickyay. Adapted by Geeky Medics. Lindsay’s nails. Licence:CC BY-SA. Available from:
[LINK].
11. Pravdaz. Adapted by Geeky Medics. AV fistula. Licence:CC BY-SA. Available from: [LINK].
12. James Heilman, MD. Adapted by Geeky Medics. Basal cell carcinoma. Licence:CC BY.
Available from: [LINK].
13. Klaus D. Peter, Gummersbach, Germany. Adapted by Geeky Medics. Melanoma. Licence:CC
BY 3.0 DE. Available from: [LINK].
14. Ozlem Celik, Mutlu Niyazoglu, Hikmet Soylu and Pinar Kadioglu. Adapted by Geeky Medics.
Cushingoid facial appearance. Licence: CC BY. Available from: [LINK].
15. Imrankabirhossain. Adapted by Geeky Medics. Band keratopathy. Licence:CC BY-SA.
Available from: [LINK].
16. Nephrotic syndrome. Adapted by Geeky Medics. Licence:CC BY-SA. Available from: [LINK].
17. Adapted by Geeky Medics. Gingivitis. Licence: CC BY-SA. Available from: [LINK].
18. Blausen.com staff. Medical gallery of Blausen Medical 2014. Adapted by Geeky Medics.
Central venous catheter. Licence: CC BY. Available from: [LINK].

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19. James Heilman, MD. Adapted by Geeky Medics. Ascites. Licence:CC BY 3.0. Available from:
[LINK].
20. PanaromicTiger. Adapted by Geeky Medics. Striae. Licence:CC BY-SA. Available from [LINK].

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