Basic methods of studying the kidneys

Inspection

When examining, it is necessary to pay attention to the features of general and physical development, the condition of the subcutaneous fat layer, muscles (weight loss, increase in body weight, including due to fluid retention), skin discoloration, hemorrhagic and other changes (striae, trophic disorders ).

Disturbances of consciousness are usually observed in patients with terminal renal failure, when uremic coma develops, accompanied by a smell of ammonia from the mouth and "large" noisy breathing of Kussmaul. Patients on programmatic hemodialysis sometimes experience psychosis or a peculiar dementia associated with aluminum retention when the water used is poorly cleaned.

In acute glomerulonephritis and nephropathy of pregnant women, excitation, short-term convulsive seizures with a bite of the tongue, impaired vision (renal eclampsia associated with hypertension, hypervolemia and cerebral edema) are observed.

Edema is an important and characteristic sign of kidney disease. Their severity is different: from the pastosity of the face, stop to anasarca with the detection of fluid in the cavities. Renal edema should be differentiated from cardiac, alimentary, metabolic-electrolyte and endocrine. Fluid retention may occur if there is no obvious edema. To detect such latent edema, it is necessary to monitor changes in body weight and compare it with the diuresis, conduct a bladder test of Aldrich (isotonic sodium chloride solution 0.2 ml, injected intradermally, resolves more quickly than 40 minutes).

Attention is paid to the pallor of the skin, which develops in the early stage of nephritis even in the absence of anemia. Anemic pallor, dryness and slight icteric-greenish tinge (staining with delayed urochromes) of the skin are noted in patients with severe chronic renal insufficiency.

When examining the patient, it is necessary to pay attention to the stigmata of disembriogenesis characteristic of genetic nephropathy: high sky, bone system anomalies (poly- and syndactyly, dysplasia of the patella and nails), cleft lip, wolf mouth, hearing and visual impairment.

Only a significant increase in the kidney (a large cyst, including parasitic, hydronephrosis, a large tumor of the kidney) can lead to asymmetry of the abdomen, and the accumulation of pus in the paranephric fiber (paranephritis) can cause smoothing of the corresponding half of the lumbar region. In the latter case, attention is drawn to the forced position of the patient - lying with the leg bent in the joints on the diseased side.

Palpation of the kidneys and bladder

Normally, the kidneys are almost never palpable. Only in very thin people asthenic constitution (often in women) sometimes it is possible to probe the lower pole of the right kidney, which is located in the retroperitoneal space somewhat lower than the left one. Most often, the kidneys are probed with their increase due to some disease (tumor, polycystosis, etc.) or when they drop (nephroptosis).

Palpation of the kidneys can be carried out at different positions of the patient: on the back, on the side (according to Israel), standing, sitting, in the knee-elbow position, etc. In most cases, however, the kidneys palpate in the horizontal position of the patient, as well as in the patient's standing position. In the first case, palpation of the kidneys is usually more convenient, since it is performed with greater relaxation of abdominal muscles. At the same time, when palpation of the kidneys in the standing position (according to the method of SP Botkin), sometimes it is better to identify their omission.

When palpation of the kidneys in a horizontal position according to the Obraztsov-Strazhesko method, the patient lies on his back with elongated legs; His hands are located on the chest, the abdominal muscles are as relaxed as possible. The doctor, as usual in such cases, sits on a chair to the right of the patient.

When palpation of the right kidney doctor puts the palm of his left hand under the lumbar region of the patient in such a way that the fingertips were near the spine, and the index finger was located just below the XII rib. With palpation of the left kidney, the palm is advanced further and located under the left lumbar region.

Several bent four fingers of the right hand are placed just below the costal arch perpendicular to the abdominal wall to the outside of the lateral edge of the corresponding (right or left) rectus abdominis muscle.

With the exhalation of the patient against the background of the relaxation of the muscles of the abdominal wall, the palpating fingers gradually dive deep into the abdominal cavity, while the palm of the left hand, on the contrary, is pressed onto 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 her fingers with the left hand is placed on the lumbar region. In practice, students often can not get such a feeling, as a result of which the entire technique of palpation of the kidneys remains for them sometimes not completely understandable.

Here it should be borne in mind that the term "sensation of the contact of two hands", used in the characterization of palpation of the kidneys, must be understood with some caution. It is easy to see that when palpation of the kidneys between the right and left hands of the doctor, respectively: a thick layer of lumbar muscles, intestinal loops filled with contents, muscles of the anterior abdominal wall, a layer of subcutaneous fat and skin itself. Having a "gasket" between two hands, which is often of impressive thickness, it is not so often possible to get the feeling of "contact" of two hands in practice. In this regard, some authors, in order to reduce the thickness of this "padding" quite rightly recommended the appointment of a laxative on the eve of 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 abdominal wall of the patient allow.

Having reached the "limit" of immersing the fingers of the right hand and pressing simultaneously with the palm of the left hand on the lumbar region, they ask the patient to take a deep breath "belly". If the kidney is accessible 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 down its front surface , feeling at the time of "slipping" the lower pole of the kidney.

At the time of palpation, it is also possible to determine the shape of the kidney (normal - bean-like), the value (normally the length of the kidney is about 12 cm, the diameter is about 6 cm), mobility, consistency (usually dense, elastic, elastic), smooth surface. As a rule, palpation of the kidney turns out to be painless for the patient, however, in some patients there may appear at the time of palpation an unpleasant sensation resembling nausea.

In those cases when the lower pole of the kidney is clearly felt, one can already speak of the presence of a degree I nephroptosis. With grade 11 nephroptosis, it is possible to palpate not only the lower, but also the upper pole of the kidney, and with nephroptosis of the third degree the mobility of the kidney increases so much that it can be determined in the inguinal region, sometimes turning even to the other half of the abdomen. In this case, as a rule, the mobility of the second kidney increases.

The above properties, obtained by palpating the kidney, can vary with various diseases. Thus, with a tumor lesion, and polycystosis, the kidney increases in size, and its surface becomes tuberous. With hydronephrosis, the kidney acquires a very soft consistency and gives, even in some cases, a sensation of fluctuation.

The palpable kidney should be distinguished from the liver, gall bladder, spleen, hepatic or splenic flexure of the colon. First of all, the kidney differs from these organs with its characteristic bean-shaped form, and from the gallbladder and colon - with its more dense consistency.

The liver, unlike the right kidney, is more superficial, and for its definition it is not necessary to immerse the palpating fingers deep into the abdominal cavity. From the spleen, the left kidney is distinguished by its more vertical and medial position. With palpation of the kidney, it seems that it seems to "slip" upward; when palpation of the liver and spleen, this sensation does not arise. Percussion over the area of the kidneys, covered by the loops of the intestine, gives, in contrast to percussion over the liver and spleen, a tympanic sound.

Finally, the kidney has the ability to ballot (reception of Guyon). In those cases where the kidney is palpable, it is possible to apply short fingers to the left hand with the fingers of the left hand in the lumbar region. Thus the kidney will come nearer to the palpating fingers of the right hand and, after hitting them, it will go back. Such balloting is not typical for palpation of the liver and spleen.

Palpation of the kidneys in the vertical position of the patient is carried out in a similar way. In this case, the patient becomes a person or slightly sideways to the doctor sitting on a chair.

The palpation method is sometimes used for the study of the bladder. An empty bladder is not probed. With a significant overflow of the bladder, it can be palpated in the pubic region in the form of a rounded elastic formation.

In some cases, in patients with urolithiasis, palpation reveals characteristic painful points. These include the costal-vertebral point (in the corner between the XII rib and the spine), the upper and lower ureteral points. The first of them is located at the outer edge of the rectus abdominis at the navel level, the second at the intersection of the line connecting the anterior superior awns of the iliac bones with a vertical line passing through the pubic tubercle.

Definition of Pasternatsky's symptom and percussion of the bladder

Percussion over the area of the kidneys, covered from the front with loops of the intestine, gives a normal tympanic sound. However, with a significant increase in the kidney, it pushes the loops of the intestine, so that a blunt sound may appear over it during percussion.

In the diagnosis of many kidney diseases, the method of effleurage is used -the definition of Pasternatsky's symptom . Assessing this symptom, the doctor puts his left hand on the area of the XII rib on the right and left of the spine and applies a short, gentle blow to the right hand with the edge of the palm (or the tips of the bent fingers). Symptom Pasternatsky usually determined in the patient's standing or sitting, but if necessary, you can check it in the position of the patient lying, putting his hands under the lumbar region and causing them tremors.

Depending on whether the patient is experiencing pain at the time of pain and how intense they are, the symptom of Pasternatsky is regarded as negative, weakly positive, positive and sharply positive. Positive symptom Pasternatsky noted with urolithiasis (especially at the time of hepatic colic), acute pyelonephritis, paranephritis, etc. It should be borne in mind, however, that a positive symptom of Pasternatsky 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 cavity (gall bladder, pancreas, etc.).

The method of percussion is also used to determine the position of the upper border of the bladder. At the same time, placing the finger-plessimetr horizontally, the percussion is conducted along the middle line in a direction from top to bottom, beginning approximately from the level of the navel. In those cases where the bladder is empty, the tympanic sound is maintained up to the pannus joint. When the bladder overflows with percussor in the area of its upper boundary, the transition of tympanic sound to a blunt sound is detected. The distance of the upper border of the bladder above the pubis is marked in cm.

Auscultation of the kidneys

It is very important to auscultate the kidneys, renal vessels, which is necessary for all patients with kidney disease, as well as for those who have elevated blood pressure figures, asymmetry of the pulse on the hands, but in fact, such auscultation of the abdomen in the pericardium on both sides should be mandatory when examining all patients.

The detection of noise (stenotic systolic) in the kidney area makes one think of a possible lesion of the renal arteries (congenital or acquired stenosis of the renal artery) or the aorta in this area (arteritis, atherosclerosis with the formation of plaques at the sites of the renal artery) that is then verified by a special angiographic study. Arterial pressure should be measured on both hands (asymmetry of the areertral pressure), and also on the legs.

[1], [2], [3], [4], [5], [6], [7], [8], [9], [10]