Renal Cell Cancer

Patient Tools

Read, save, and share this guide

Use these quick tools to make this medical article easier to read, print, save, or share with a family member.

On this page13 sections

Article Summary

Renal cell cancer, or kidney cancer, begins in the lining of the kidney's tubules. These are small tubes that help filter waste and excess fluids from the blood. When cells in the kidney grow out of control, they can form a tumor, which may be benign (non-cancerous) or malignant (cancerous). Pathophysiology Structure of the Kidney: Location: The kidneys are located on either side of the...

Key Takeaways

  • This article explains Pathophysiology in simple medical language.
  • This article explains Types of Renal Cell Cancer in simple medical language.
  • This article explains Causes of Renal Cell Cancer in simple medical language.
  • This article explains Symptoms of Renal Cell Cancer in simple medical language.
Before reading

RX Patient Tools

Use these quick guides before reading the article, or return to them when you need help preparing questions for a doctor.

Start here Choose the right pathway for symptoms, reports, medicines, or urgent warning signs. Disease article roadmap Read this topic step by step: meaning, symptoms, warning signs, diagnosis, treatment, prevention, and follow-up. Treatment planner Prepare questions about treatment choices, benefits, risks, side effects, and follow-up. Family & caregiver guide Organize symptoms, reports, medicines, questions, and follow-up safely. Nutrition & diet guide Prepare food, hydration, supplement, and medicine-timing questions safely. Prevention guide Organize risk factors, protective habits, screening, and warning signs. Recovery guide Prepare a safe plan for activity, rehabilitation, warning signs, and follow-up.
Educational health guideWritten for patient understanding and clinical awareness.
Reviewed content workflowUse writer and reviewer profiles for stronger trust.
Emergency safety firstUrgent warning signs are highlighted below.
Choose your reading view

Patient View highlights a simple learning journey. Clinical View reveals structure, evidence, and editorial completeness.

Definition

cell cancer, or cancer, begins in the lining of the kidney’s tubules. These are small tubes that help filter waste and excess fluids from the blood. When cells in the kidney grow out of control, they can form a , which may be (non-cancerous) or (cancerous).

Pathophysiology

Structure of the Kidney:

  • Location: The are located on either side of the spine, just below the .
  • Components: Each kidney has three main parts: the outer cortex, the inner medulla, and the .

Blood Supply:

  • The kidneys receive blood through the renal , which branch off the abdominal .
  • Blood is filtered in the , the kidney’s functional units, and waste is sent to the .

Nerve Supply:

  • The renal plexus supplies nerves to the kidneys, regulating functions such as blood flow and filtration.

Types of Renal Cell Cancer

  1. Clear Cell : The most common type, characterized by a clear appearance under a microscope.
  2. Papillary Carcinoma: Usually develops in one of the kidney’s tubules and is less aggressive than clear cell carcinoma.
  3. Chromophobe Carcinoma: Represents about 5% of cases; has a distinct appearance and typically a better .
  4. Collecting Duct Carcinoma: A rare type that arises from the collecting ducts in the kidney.
  5. Renal : A rare form that starts in the connective tissue of the kidney.

Causes of Renal Cell Cancer

While the exact cause isn’t known, several factors can increase the risk of developing RCC:

  1. Smoking: Doubles the risk.
  2. Obesity: Higher body weight is linked to a greater risk.
  3. : High blood pressure may increase the risk.
  4. : factors can play a role.
  5. Age: More common in people over 50.
  6. Gender: Men are more likely to develop RCC than women.
  7. Occupational Exposures: Certain chemicals, like asbestos and cadmium.
  8. : Long-term kidney problems can increase risk.
  9. Genetic Syndromes: Conditions like von Hippel-Lindau disease.
  10. Dialysis: Long-term dialysis can increase the risk.
  11. Radiation Exposure: Previous radiation treatment in the abdominal area.
  12. Hormonal Factors: Estrogen exposure may have a link.
  13. Diet: High-fat diets and low fruit and vegetable intake.
  14. Physical Inactivity: Sedentary lifestyle can contribute to obesity and other risk factors.
  15. Acidic Urine: Higher acidity can damage the lining of the kidneys.
  16. Kidney Stones: issues may increase risk.
  17. Disease: Increased risk with .
  18. Previous Cancer: Having had other cancers increases risk.
  19. Inflammatory Diseases: Conditions like or other diseases.
  20. Use of Certain Medications: Long-term use of relievers or diuretics.

Symptoms of Renal Cell Cancer

Symptoms may vary but can include:

  1. : , a common sign.
  2. : Especially on one side.
  3. Weight Loss: Unexplained weight loss without trying.
  4. Fatigue: Feeling tired without a reason.
  5. Fever: A persistent fever that isn’t caused by an infection.
  6. Loss of Appetite: Decreased interest in food.
  7. Night Sweats: Excessive sweating during the night.
  8. Swelling: In the abdomen or legs.
  9. High Blood Pressure: New or worsening hypertension.
  10. Bone Pain: If the cancer spreads to bones.
  11. Anemia: Low red blood cell count.
  12. Nausea: Feeling sick to the stomach.
  13. Constipation: Changes in bowel habits.
  14. Shortness of Breath: Difficulty breathing.
  15. Liver Issues: Symptoms like jaundice.
  16. Neurological Symptoms: If it spreads to the brain.
  17. Abdominal Mass: A lump in the abdomen.
  18. Skin Changes: Such as yellowing or rash.
  19. Increased Urination: Frequent urination, especially at night.
  20. Itching: Persistent itchiness without a rash.

Diagnostic Tests for Renal Cell Cancer

  1. Urinalysis: Checking for blood or other abnormalities in the urine.
  2. CT Scan: Imaging to get detailed pictures of the kidneys.
  3. MRI: Magnetic resonance imaging for better soft tissue details.
  4. Ultrasound: Sound waves to visualize the kidneys.
  5. X-ray: Imaging to check for kidney problems.
  6. Biopsy: Taking a sample of kidney tissue for testing.
  7. Blood Tests: Checking kidney function and for tumor markers.
  8. Chest X-ray: To check for cancer spread to the lungs.
  9. Bone Scan: To check if cancer has spread to bones.
  10. Genetic Testing: To identify hereditary cancer syndromes.
  11. Endoscopy: Looking inside the urinary tract.
  12. Laparoscopy: Minimally invasive surgery for diagnosis.
  13. PET Scan: Positron emission tomography for assessing cancer spread.
  14. Angiography: Imaging blood vessels around the kidney.
  15. Cystoscopy: Checking the bladder and urethra.
  16. Complete Blood Count (CBC): To assess overall health.
  17. Liver Function Tests: To assess liver health.
  18. Staging Tests: To determine the extent of cancer.
  19. Electrolyte Tests: To assess kidney function.
  20. Tumor Markers: Specific blood tests for renal cancer markers.

Non-Pharmacological Treatments

  1. Dietary Changes: Eating a balanced diet to support overall health.
  2. Exercise: Regular physical activity to improve well-being.
  3. Weight Management: Maintaining a healthy weight.
  4. Hydration: Drinking enough fluids.
  5. Stress Management: Techniques like meditation or yoga.
  6. Support Groups: Connecting with others facing similar challenges.
  7. Physical Therapy: To manage pain and improve mobility.
  8. Counseling: Psychological support for emotional health.
  9. Acupuncture: Alternative therapy for pain relief.
  10. Nutritional Supplements: Under guidance, to support health.
  11. Mindfulness: Practices to enhance mental well-being.
  12. Spiritual Support: Engaging in spiritual practices for comfort.
  13. Palliative Care: Supportive care for symptom relief.
  14. Holistic Therapies: Integrative approaches for well-being.
  15. Herbal Remedies: Caution advised; consult with a healthcare provider.
  16. Homeopathy: Alternative treatment; effectiveness varies.
  17. Massage Therapy: For relaxation and pain relief.
  18. Yoga and Tai Chi: Gentle movements for stress reduction.
  19. Art Therapy: Creative expression for emotional health.
  20. Music Therapy: Using music for relaxation and well-being.
  21. Sleep Hygiene: Improving sleep quality.
  22. Mind-Body Techniques: Practices like guided imagery.
  23. Avoiding Toxins: Limiting exposure to harmful substances.
  24. Sun Protection: Protecting skin from UV damage.
  25. Smoking Cessation: Programs to quit smoking.
  26. Limiting Alcohol: Reducing intake for overall health.
  27. Regular Check-ups: Monitoring health with healthcare providers.
  28. Community Involvement: Engaging in local support activities.
  29. Education: Learning about the disease for informed decisions.
  30. Healthy Cooking Classes: Learning to prepare nutritious meals.

Drugs Used in Treatment

  1. Sunitinib (Sutent): A targeted therapy for advanced RCC.
  2. Pazopanib (Votrient): Used for advanced renal cancer.
  3. Axitinib (Inlyta): Targeted therapy for advanced RCC.
  4. Nivolumab (Opdivo): An immune checkpoint inhibitor.
  5. Ipilimumab (Yervoy): Used in combination with nivolumab.
  6. Everolimus (Afinitor): Used for advanced RCC after other treatments.
  7. Temsirolimus (Torisel): A treatment for advanced renal cancer.
  8. Bevacizumab (Avastin): A targeted therapy that inhibits blood vessel growth.
  9. Cabozantinib (Cabometyx): Used for advanced kidney cancer.
  10. Lenvatinib (Lenvima): A targeted therapy for advanced RCC.
  11. Sorafenib (Nexavar): Used in some cases of advanced RCC.
  12. Pembrolizumab (Keytruda): An immune therapy for advanced RCC.
  13. Interferon-alpha: Used to stimulate the immune system.
  14. Interleukin-2 (IL-2): For advanced RCC to boost immune response.
  15. Dexamethasone: A steroid to manage side effects.
  16. Analgesics: Pain relievers for symptom management.
  17. Antibiotics: To treat infections.
  18. Antiemetics: For nausea management.
  19. Hormonal Therapies: If hormones affect cancer growth.
  20. Clinical Trial Medications: Experimental drugs under investigation.

Surgical Options

  1. Partial Nephrectomy: Removing part of the kidney.
  2. Radical Nephrectomy: Removing the entire kidney.
  3. Laparoscopic Surgery: Minimally invasive kidney surgery.
  4. Robotic Surgery: Using robotic assistance for precision.
  5. Ablation: Destroying cancer cells with heat or cold.
  6. Embolization: Blocking blood supply to the tumor.
  7. Cytoreductive Surgery: Reducing tumor size before other treatments.
  8. Transplantation: Replacing a kidney in suitable cases.
  9. Retroperitoneal Lymph Node Dissection: Removing lymph nodes if cancer spreads.
  10. Palliative Surgery: To relieve symptoms, not cure cancer.

Preventive Measures

  1. Avoiding Tobacco: Quitting smoking reduces cancer risk.
  2. Maintaining a Healthy Weight: Reducing obesity through diet and exercise.
  3. Controlling Blood Pressure: Regular check-ups and management.
  4. Healthy Diet: Eating fruits, vegetables, and whole grains.
  5. Regular Exercise: Engaging in physical activity consistently.
  6. Limiting Alcohol: Reducing intake to moderate levels.
  7. Staying Hydrated: Drinking plenty of water.
  8. Occupational Safety: Avoiding exposure to harmful chemicals.
  9. Genetic Counseling: If there’s a family history of RCC.
  10. Regular Check-ups: Monitoring kidney health.

When to See a Doctor

  • Persistent Symptoms: If experiencing blood in urine, back pain, or unexplained weight loss.
  • Family History: If there’s a family history of kidney cancer.
  • New Symptoms: Any sudden changes in health or new symptoms should prompt a visit.
  • Routine Check-ups: Regular health screenings, especially over age 50 or with risk factors.

Frequently Asked Questions (FAQs)

  1. What causes renal cell cancer?
    • The exact cause isn’t known, but several risk factors can contribute.
  2. What are the early symptoms of RCC?
    • Common early symptoms include blood in urine, back pain, and weight loss.
  3. How is renal cell cancer diagnosed?
    • Diagnosis typically involves imaging tests, urine tests, and sometimes a biopsy.
  4. What treatment options are available?
    • Treatments can include surgery, targeted therapies, and immunotherapy.
  5. Can renal cell cancer be prevented?
    • While there’s no sure way to prevent it, reducing risk factors can help.
  6. Is renal cell cancer hereditary?
    • Some genetic syndromes can increase risk, so family history matters.
  7. What lifestyle changes can help?
    • Eating healthy, exercising, and avoiding tobacco are beneficial.
  8. What is the prognosis for RCC?
    • Prognosis depends on the cancer stage at diagnosis and individual health factors.
  9. Are there alternative treatments?
    • Some non-pharmacological approaches can support health but should complement, not replace, medical treatment.
  10. How often should I get checked if I’m at risk?
    • Regular screenings and consultations with a healthcare provider are important.
  11. What support is available for patients?
    • Support groups, counseling, and educational resources are available.
  12. Can RCC spread to other organs?
    • Yes, RCC can metastasize to bones, lungs, and other organs.
  13. What should I do if I notice symptoms?
    • Consult a healthcare provider promptly for evaluation.
  14. Are there any clinical trials for RCC?
    • Many clinical trials are available for new treatments; talk to a doctor.
  15. What is the role of diet in managing RCC?
    • A balanced diet supports overall health and can help manage symptoms.

This overview provides a structured summary of renal cell cancer and its many aspects. For an in-depth article, each section could be expanded with more details, statistics, and patient stories to enhance engagement and understanding.

 

Authors

The article is written by Team Rxharun and reviewed by the Rx Editorial Board Members

More details about authors, please visit to  Sciprofile.com 

Last Update: October 25, 2024.

 

Disclaimer: Each person’s journey is unique, treatment plan, life style, food habit, hormonal condition, immune system, chronic disease condition, geological location, weather and previous medical  history is also unique. So always seek the best advice from a qualified medical professional or health care provider before trying any treatments to ensure to find out the best plan for you. This guide is for general information and educational purposes only. Regular check-ups and awareness can help to manage and prevent complications associated with these diseases conditions. If you or someone are suffering from this disease condition bookmark this website or share with someone who might find it useful! Boost your knowledge and stay ahead in your health journey. We always try to ensure that the content is regularly updated to reflect the latest medical research and treatment options. Thank you for giving your valuable time to read the article.

 

  1. https://pubmed.ncbi.nlm.nih.gov/27887750/
  2. https://pubmed.ncbi.nlm.nih.gov/34175022/
  3. https://pubmed.ncbi.nlm.nih.gov/31573641/
  4. https://pubmed.ncbi.nlm.nih.gov/30571025/
  5. https://www.ncbi.nlm.nih.gov/books/NBK535404/
  6. https://pubmed.ncbi.nlm.nih.gov/15882252/
  7. https://pubmed.ncbi.nlm.nih.gov/29168475/
  8. https://pubmed.ncbi.nlm.nih.gov/34739697/
  9. https://pubmed.ncbi.nlm.nih.gov/31399958/
  10. https://pubmed.ncbi.nlm.nih.gov/38052474/
  11. https://pubmed.ncbi.nlm.nih.gov/29431364/
  12. https://pubmed.ncbi.nlm.nih.gov/27383068/
  13. https://pubmed.ncbi.nlm.nih.gov/26055354/
  14. https://pubmed.ncbi.nlm.nih.gov/38490803/
  15. https://medlineplus.gov/skinconditions.html
  16. https://en.wikipedia.org/wiki/Category:Kidney_diseases
  17. https://kidney.org.au/your-kidneys/what-is-kidney-disease/types-of-kidney-disease
  18. https://www.niddk.nih.gov/health-information/kidney-disease
  19. https://www.kidney.org/kidney-topics/chronic-kidney-disease-ckd
  20. https://www.kidneyfund.org/all-about-kidneys/types-kidney-diseases
  21. https://www.aad.org/about/burden-of-skin-disease
  22. https://www.usa.gov/federal-agencies/national-institute-of-arthritis-musculoskeletal-and-skin-diseases
  23. https://www.cdc.gov/niosh/topics/skin/default.html
  24. https://www.mayoclinic.org/diseases-conditions/brain-tumor/symptoms-causes/syc-20350084
  25. https://www.ninds.nih.gov/Disorders/Patient-Caregiver-Education/Understanding-Sleep
  26. https://www.cdc.gov/traumaticbraininjury/index.html
  27. https://www.skincancer.org/
  28. https://illnesshacker.com/
  29. https://endinglines.com/
  30. https://www.jaad.org/
  31. https://www.psoriasis.org/about-psoriasis/
  32. https://books.google.com/books?
  33. https://www.niams.nih.gov/health-topics/skin-diseases
  34. https://cms.centerwatch.com/directories/1067-fda-approved-drugs/topic/292-skin-infections-disorders
  35. https://www.fda.gov/files/drugs/published/Acute-Bacterial-Skin-and-Skin-Structure-Infections—Developing-Drugs-for-Treatment.pdf
  36. https://dermnetnz.org/topics
  37. https://www.aaaai.org/conditions-treatments/allergies/skin-allergy
  38. https://www.sciencedirect.com/topics/medicine-and-dentistry/occupational-skin-disease
  39. https://aafa.org/allergies/allergy-symptoms/skin-allergies/
  40. https://www.nibib.nih.gov/
  41. https://rxharun.com/resources/category/resources/rxharun/article-types/skin-care-beauty/skin-diseases-types-symptoms-treatment/
  42. https://www.nei.nih.gov/
  43. https://en.wikipedia.org/wiki/List_of_skin_conditions
  44. https://en.wikipedia.org/?title=List_of_skin_diseases&redirect=no
  45. https://en.wikipedia.org/wiki/Skin_condition
  46. https://oxfordtreatment.com/
  47. https://www.nidcd.nih.gov/health/
  48. https://consumer.ftc.gov/articles/w
  49. https://www.nccih.nih.gov/health
  50. https://catalog.ninds.nih.gov/
  51. https://www.aarda.org/diseaselist/
  52. https://www.ninds.nih.gov/Disorders/Patient-Caregiver-Education/Fact-Sheets
  53. https://www.nibib.nih.gov/
  54. https://www.nia.nih.gov/health/topics
  55. https://www.nichd.nih.gov/
  56. https://www.nimh.nih.gov/health/topics
  57. https://www.nichd.nih.gov/
  58. https://www.niehs.nih.gov
  59. https://www.nimhd.nih.gov/
  60. https://www.nhlbi.nih.gov/health-topics
  61. https://obssr.od.nih.gov/
  62. https://www.nichd.nih.gov/health/topics
  63. https://rarediseases.info.nih.gov/diseases
  64. https://beta.rarediseases.info.nih.gov/diseases
  65. https://orwh.od.nih.gov/

 

RX Medical Knowledge Graph

Explore this medical topic

Continue through verified related conditions, investigations, medicines, and patient guides. These links are educational and do not replace professional medical advice.

RX Clinical Pathway Engine

Continue through a complete learning pathway

Move from understanding the topic to symptoms, tests, treatment, medicines, monitoring, and prevention.

Search the complete library
  1. Understand the condition Begin with the essential facts and a clear explanation of the topic.
  2. Recognize symptoms Learn common symptoms, signs, and patterns of presentation.
  3. Know when to seek help Review urgent warning signs and when professional assessment may be needed.
  4. Understand causes and risks Explore causes, risk factors, mechanisms, and contributing conditions.
  5. Explore tests and diagnosis Learn how clinicians assess the condition and which investigations may be discussed.
  6. Learn treatment approaches Review general treatment categories and management principles.
  7. Understand medicines safely Continue to medicine education, uses, precautions, and monitoring.
  8. Plan monitoring and follow-up Understand monitoring, complications, rehabilitation, and follow-up learning.
  9. Review prevention and self-care Explore prevention, healthy routines, and questions to discuss with a clinician.

Conditions & Diseases

Background, symptoms, causes, diagnosis, and care.

Explore this library

Tests & Investigations

Laboratory, imaging, screening, and diagnostic education.

Explore this library

Medicines

Uses, safety, monitoring, and related medicine knowledge.

Explore this library

Cancer Knowledge

Cancer types, screening, oncology, and treatment education.

Explore this library
Doctor visit helper

Prepare before seeing a doctor

A simple rural-patient checklist to help you explain symptoms clearly, ask better questions, and avoid unsafe self-treatment.

Safety note: This is not a prescription or diagnosis. For severe symptoms, pregnancy danger signs, children with serious illness, chest pain, breathing difficulty, stroke-like weakness, or major injury, seek urgent care.

Which doctor may help?

Start with a registered doctor or the nearest qualified health center.

What to tell the doctor

  • Write when the problem started and how it changed.
  • Bring old prescriptions, investigation reports, and current medicines.
  • Write allergies, pregnancy status, diabetes, kidney/liver disease, and major past illnesses.
  • Bring one family member if the patient is weak, elderly, confused, or a child.

Questions to ask

  • What is the most likely cause of my symptoms?
  • Which danger signs mean I should go to hospital quickly?
  • Which tests are necessary now, and which can wait?
  • How should I take medicines safely and what side effects should I watch for?
  • When should I come for follow-up?

Tests to discuss

  • Vital signs: temperature, pulse, blood pressure, oxygen saturation
  • Basic physical examination by a clinician
  • CBC, urine test, blood sugar, or imaging only when clinically needed

Avoid these mistakes

  • Do not use antibiotics, steroid tablets/injections, or strong painkillers without proper medical advice.
  • Do not hide pregnancy, kidney disease, ulcer, allergy, or blood thinner use.
  • Do not delay emergency care when danger signs are present.

Medicine safety and first-aid guide

This section is for patient education only. It does not replace a doctor, pharmacist, or emergency care.

Safe first steps

  • Avoid heavy lifting, sudden bending, and prolonged bed rest.
  • Use comfortable posture and gentle movement as tolerated.
  • Discuss physiotherapy, X-ray, or MRI only when clinically needed.

OTC medicine safety

  • For mild back pain, pain-relief medicine may be discussed with a doctor or pharmacist.
  • Avoid repeated painkiller use if you have kidney disease, stomach ulcer, uncontrolled blood pressure, or are taking blood thinners.

Avoid these mistakes

  • Do not start antibiotics without a proper medical decision.
  • Do not use steroid tablets or injections casually for quick relief.
  • Do not delay emergency care because of home remedies.

Get urgent help if

  • Back pain with leg weakness, numbness around private area, loss of urine/stool control, fever, cancer history, or major injury needs urgent care.
Medicine names, dose, and timing must be decided by a qualified clinician or pharmacist after checking age, pregnancy, allergy, other diseases, and current medicines.

For rural patients and family caregivers

Patient health record and symptom diary

Write your symptoms, medicines already taken, test results, and questions before visiting a doctor. This note stays on your device unless you print or copy it.

Doctor to discuss: Orthopedic / spine specialist, physical medicine doctor, or qualified clinician
Tests to discuss with doctor
  • Neurological examination for leg power, sensation, reflexes, and straight leg raise
  • X-ray only if injury, deformity, long-lasting pain, or doctor suspects bone problem
  • MRI discussion if severe nerve symptoms, weakness, bladder/bowel problem, or persistent symptoms
Questions to ask
  • What is the most likely cause of my symptoms?
  • Which warning signs mean I should go to emergency care?
  • Which tests are really needed now?
  • Which medicines are safe for my age, pregnancy status, allergy, kidney/liver/stomach condition, and current medicines?
  • Is physiotherapy, posture correction, or activity modification needed?

Emergency warning signs such as chest pain, severe breathing difficulty, sudden weakness, confusion, severe dehydration, major injury, or loss of bladder/bowel control need urgent medical care. Do not wait for online information.

Safe pathway to proper treatment

Care roadmap for: Renal Cell Cancer

Use this simple roadmap to understand the next safe steps. It is educational and does not replace examination by a doctor.

Go to emergency care if you notice:
  • Severe or rapidly worsening symptoms
  • Breathing difficulty, chest pain, fainting, confusion, severe weakness, major injury, or severe dehydration
Doctor / service to discuss: Qualified healthcare provider; specialist depends on symptoms and examination.
  1. Step 1

    Check danger signs first

    If danger signs are present, seek emergency care and do not wait for online information.

  2. Step 2

    Record the symptom story

    Write when symptoms started, severity, medicines already taken, allergies, pregnancy status, and test results.

  3. Step 3

    Visit a qualified clinician

    A doctor, nurse, or qualified healthcare provider can examine you and decide which tests or treatment are needed.

  4. Step 4

    Do only useful tests

    Do tests after clinical assessment. Avoid unnecessary tests, random antibiotics, or repeated medicines without diagnosis.

  5. Step 5

    Follow up and return early if worse

    If symptoms worsen, new warning signs appear, or treatment is not helping, return for review quickly.

Rural patient practical tips
  • Take a written symptom diary and all previous prescriptions/test reports.
  • Do not hide medicines already taken, even herbal or over-the-counter medicines.
  • Ask which warning signs mean urgent referral to hospital.

This roadmap is for education. A real diagnosis and treatment plan requires history, examination, and clinical judgment.