Basic methods of kidney examination

Inspection

During the examination, it is necessary to pay attention to the characteristics of general and physical development, the condition of the subcutaneous fat layer, muscles (weight loss, weight gain, including due to fluid retention), changes in skin color, the appearance of hemorrhagic and other changes (striae, trophic disorders).

Impaired consciousness is usually observed in patients with terminal renal failure, when uremic coma develops, accompanied by the smell of ammonia from the mouth and "large" noisy Kussmaul breathing. Patients undergoing program hemodialysis sometimes develop psychoses or a kind of dementia associated with aluminum retention due to poor purification of the water used.

In acute glomerulonephritis and nephropathy of pregnancy, agitation, short-term convulsive seizures with tongue biting, and visual impairment (the so-called renal eclampsia, associated with hypertensive syndrome, hypervolemia, and cerebral edema) are observed.

Edema is an important and characteristic sign of kidney disease. Its severity varies: from puffiness of the face, feet to anasarca with fluid in the cavities. Renal edema should be differentiated from cardiac, alimentary, metabolic-electrolyte and endocrine. Fluid retention can be observed in the absence of obvious edema. To detect such hidden edema, it is necessary to monitor changes in body weight and compare it with changes in diuresis, conduct the Aldrich blister test (isotonic sodium chloride solution 0.2 ml, administered intradermally, is absorbed in less than 40 minutes).

The paleness of the skin, which develops in the early stages of nephritis even in the absence of anemia, is noteworthy. Anemic paleness, dryness and a slight yellowish-greenish tint (staining by retained urochromes) of the skin are observed in patients with severe chronic renal failure.

When examining a patient, it is necessary to pay attention to the stigmas of dysembryogenesis characteristic of genetic nephropathy: high palate, anomalies of the skeletal system (poly- and syndactyly, dysplasia of the patella and nails), cleft lip, cleft palate, hearing and vision impairment.

Only a significant enlargement of the kidney (large cyst, including parasitic, hydronephrosis, large kidney tumor) can lead to abdominal asymmetry, and accumulation of pus in the paranephric tissue (paranephritis) can cause smoothing of the corresponding half of the lower back. In the latter case, the forced position of the patient is noteworthy - lying with the leg bent at the joints on the sore side.

Palpation of the kidneys and bladder

Normally, the kidneys are almost never palpated. Only in very thin people with an asthenic constitution (more often in women) is it sometimes possible to palpate the lower pole of the right kidney, which is located in the retroperitoneal space somewhat lower than the left. Most often, the kidneys are palpated when they are enlarged due to some disease (tumor, polycystic disease, etc.) or when they are lowered (nephroptosis).

Palpation of the kidneys can be performed with the patient in various positions: on the back, on the side (according to Israel), standing, sitting, in the knee-elbow position, etc. In most cases, however, the kidneys are palpated with the patient in a horizontal position, as well as with the patient standing. In the first case, palpation of the kidneys is usually more convenient, since it is performed with greater relaxation of the abdominal muscles. At the same time, when palpating the kidneys in a standing position (according to the S.P. Botkin method), their prolapse can sometimes be better identified.

When palpating the kidneys in a horizontal position using the Obraztsov-Strazhesko method, the patient lies on his back with his legs extended; his hands are placed on his chest, and his abdominal muscles are maximally relaxed. The doctor, as usual in such cases, sits on a chair to the right of the patient.

When palpating the right kidney, the doctor places the palm of his left hand under the patient's lumbar region so that the fingertips are near the spine and the index finger is located just below the 12th rib. When palpating the left kidney, the palm is moved further and placed under the left lumbar region.

The four fingers of the right hand, slightly bent, are placed slightly below the costal arch perpendicular to the abdominal wall, outward from the lateral edge of the corresponding (right or left) rectus abdominis muscle.

When the patient exhales, against the background of the resulting relaxation of the abdominal wall muscles, the palpating fingers gradually plunge deep into the abdominal cavity, while with the palm of the left hand, on the contrary, they press on the lumbar region, trying to bring it closer to the palpating right hand.

Many textbooks and manuals usually indicate that the immersion of the right hand continues until the sensation of contact of its fingers with the left hand placed on the lumbar region appears. In practice, students often fail to obtain such a sensation, as a result of which the entire technique of palpation of the kidneys sometimes remains not entirely clear to them.

Here it should be borne in mind that the term "sensation of contact of two hands" used to characterize palpation of the kidneys should be understood with some caution. It is easy to notice that during palpation of the kidneys, between the doctor's right and left hands, respectively, there will be: a thick layer of lumbar muscles, intestinal loops filled with contents, muscles of the anterior abdominal wall, a layer of subcutaneous fat and the skin itself. Having such a "pad" between the two hands, which is often impressively thick, it is not very often possible to obtain the sensation of "contact" of two hands in practice. In this regard, some authors, in order to reduce the thickness of the said "pad", quite rightly recommended prescribing a laxative the day before palpation of the kidneys. Therefore, in many cases, the fingers of the right hand are immersed deep into the abdominal cavity exactly as much as the relaxation of the abdominal muscles and the thickness of the patient's abdominal wall allow.

Having reached the "limit" of immersion of the fingers of the right hand and simultaneously pressing with the palm of the left hand on the lumbar region, ask the patient to take a deep breath "with the stomach". If the kidney is accessible to palpation, then its lower pole will fit under the fingers of the right hand. Pressing the kidney to the back wall of the abdominal cavity, the fingers make a sliding movement downwards along its front surface, clearly feeling the lower pole of the kidney at the moment of "sliding off".

During palpation, it is also possible to determine the shape of the kidney (normally bean-shaped), size (normally the length of the kidney is about 12 cm, the diameter is about 6 cm), mobility, consistency (usually dense, elastic, flexible), surface (smooth). As a rule, palpation of the kidney is painless for the patient, however, some patients may experience an unpleasant sensation resembling nausea during palpation.

In cases where the lower pole of the kidney is clearly palpated, we can already talk about the presence of grade I nephroptosis. With grade I1 nephroptosis, it is possible to palpate not only the lower but also the upper pole of the kidney, and with grade III nephroptosis, the mobility of the kidney increases so much that it can be determined in the groin area, sometimes even moving to the other half of the abdomen. In this case, as a rule, the mobility of the second kidney also increases.

The above properties obtained by palpating the kidney may change with various diseases. Thus, with tumor damage and polycystic disease, the kidney increases in size, and its surface becomes bumpy. With hydronephrosis, the kidney acquires a very soft consistency and even gives a feeling of fluctuation in some cases.

The palpable kidney must be distinguished from the liver, gall bladder, spleen, hepatic or splenic flexure of the colon. First of all, the kidney differs from the above organs by its characteristic bean-shaped form, and from the gall bladder and colon by its denser consistency.

The liver, unlike the right kidney, is located more superficially, and to identify it, it is not necessary to immerse the palpating fingers deep into the abdominal cavity. The left kidney differs from the spleen in its more vertical and medial position. When palpating the kidney, it seems as if it is "slipping" upward; when palpating the liver and spleen, such a sensation does not arise. Percussion over the area of the kidneys covered by intestinal loops produces, in contrast to percussion over the liver and spleen, a tympanic sound.

Finally, the kidney has the ability to ballot (Guyon's maneuver). In cases where the kidney is palpated, you can apply short, quick pushes to the lumbar region with the fingers of your left hand. In this case, the kidney will approach the palpating fingers of your right hand and, hitting them, move back. Such balloting is not typical when palpating the liver and spleen.

Palpation of the kidneys with the patient in a vertical position is performed in a similar manner. In this case, the patient stands facing or slightly to the side of the doctor sitting on a chair.

The palpation method is sometimes used to examine the bladder. An empty bladder cannot be felt. When the bladder is significantly full, it can be palpated in the pubic area as a round elastic formation.

In some cases, patients suffering from urolithiasis reveal characteristic painful points during palpation. These include the costovertebral point (in the angle between the 12th rib and the spine), the upper and lower ureteral points. The first of these is located at the outer edge of the rectus abdominis muscle at the level of the navel, the second - at the intersection of the line connecting the anterior superior iliac spines with the vertical line passing through the pubic tubercle.

Definition of Pasternatsky's symptom and percussion of the bladder

Percussion over the kidney area, covered in front by intestinal loops, normally produces a tympanic sound. However, if the kidney is significantly enlarged, it moves the intestinal loops, as a result of which a dull sound may appear over it during percussion.

In the diagnosis of many kidney diseases, the tapping method is used - determining the Pasternatsky symptom. When assessing this symptom, the doctor places his left hand on the area of the 12th rib to the right and left of the spine and with the edge of the palm (or the tips of the bent fingers) of the right hand makes short, light blows to it. The Pasternatsky symptom is usually determined with the patient standing or sitting, but if necessary, it can also be checked with the patient lying down, placing his hands under the lumbar region and pushing with them.

Depending on whether the patient experiences pain at the moment of the blows and how intense they are, Pasternatsky's symptom is assessed as negative, weakly positive, positive, and sharply positive. A positive Pasternatsky's symptom is observed in urolithiasis (especially during hepatic colic), acute pyelonephritis, paranephritis, etc. However, it should be borne in mind that a positive Pasternatsky's symptom can be observed in osteochondrosis of the spine with pronounced radicular syndrome, diseases of the ribs, lumbar muscles, and sometimes in diseases of the abdominal organs (gall bladder, pancreas, etc.).

The percussion method is also used to determine the position of the upper border of the bladder. In this case, with the pleximeter finger positioned horizontally, percussion is performed along the midline in the direction from top to bottom, starting approximately from the level of the navel. In cases where the bladder is empty, the tympanic sound is preserved up to the pubic symphysis. When the bladder is full, percussion in the area of its upper border reveals a transition from tympanic sound to dull. The protrusion of the upper border of the bladder above the pubis is noted in cm.

Auscultation of the kidneys

Auscultation of the kidney area and renal vessels is very important and must be performed in all patients with kidney disease, as well as in individuals with elevated blood pressure, asymmetry of the pulse in the arms, but in essence such auscultation of the abdomen in the perirenal area on both sides should be mandatory when examining all patients.

The detection of noise (stenotic systolic) in the kidney area makes one think about possible damage to the renal arteries (congenital or acquired stenosis of the renal artery) or the aorta in this area (arteritis, atherosclerosis with plaque formation at the origin of the renal artery), which is then verified by a special angiographic study. Blood pressure should be measured on both arms (asymmetry of arterial pressure), as well as on the legs.

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