Inspection
Inspection of the patient should give the physician the idea of the gravity of the patient's condition. Very grave condition with loss of consciousness may be due to severe affections of the kidneys attended by renal insufficiency and uraemic coma; the condition may be satisfactory or of moderate gravity (in milder cases). It is necessary to pay attention to the patient's posture in bed: active (at initial stages of many diseases of the kidneys), passive (in uraemic coma), or forced (in paranephritis; the patient may lie on his side with the leg flexed, bringing the knee to the abdomen on the affected side). In the presence of renal colic the patient is restless, tosses in bed, groans or even cries from pain. Convulsions are observed in the presence of uraemic coma, renal eclampsia, and nephropathy of pregnancy (toxaemia of late pregnancy with involvement of the kidneys).
Oedema is characteristic of acute and chronic glomerulonephritis, nephrotic syndrome, and amyloidosis of the kidneys. The appearance of the patient with oedema of the renal origin is quite specific (Fig. 101). The face is pallid, swollen, with oedematous eyelids and narrowed eye-slits (facies nephritica). In patients with more pronounced signs of pathology, oedema affects the upper and lower extremities and the trunk (anasarca).
The colour of the patient's skin is also important. Oedematous skin in
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chronic nephritis is pallid due to the spasm of skin arterioles, and anaemia which attends this disease. The skin is wax-pallid in amyloidosis and lipoid nephrosis. It should be remembered that in cardiac oedema (as distinct from renal oedema) the skin is more or less cyanotic.
When inspecting a patient with chronic nephritis, it is possible to observe scratches on the skin and coated dry tongue; an unpleasant odour of ammonia can be felt from the mouth and skin of the patient (factor uremicus). All these signs characterize chronic renal insufficiency (uraemia).
Inspection of the abdomen and the loin does not usually reveal any noticeable changes. But in the presence of paranephritis, it is possible to notice swelling on the affected side of the loin. In rare cases, an especially large tumour of the kidney may be manifested by protrusion of the abdominal wall. Distended bladder can be protruded over the pubic bone in thin persons. The distension can be due to overfilling of the bladder, for example, due to retention of urine in adenoma or cancer of the prostate.
PALPATION
The posterior location of the kidneys, and also the absence of anterior approach to them due to the interference of the costal arch, makes palpation of the kidneys difficult. Relaxation of the prelum and pronounced
Fig. 102. Palpation of the right kidney of the lying patient. -I
cachexia can be attended by certain ptosis of the kidneys and make them accessible to palpation even in healthy subjects. But the results of palpation can only be reliable in considerable enlargement of the kidneys (at least 1.5—2 times, e.g. due to formation of a cyst or a tumour), or their displacement by a tumour, or in cases with a floating kidney. Bilateral enlargement of the kidneys is observed in polycystosis.
It is necessary to remember that the kidneys can move about in the range of 2-3 cm in the proximal and distal directions when the subject changes his position from horizontal to vertical, and also during respiratory movements of the diaphragm. Passive movements of the kidneys transmitted from the diaphragm during inspiration and expiration should be taken into consideration during palpation: the Obraztsov-Strazhesko palpation method should be used. The patient should be palpated in the lying or standing position. When the patient is in the horizontal position, his kidneys sfre better palpated because the strain of the prelum is absent. But the movable kidney can be palpated in the standing patient because it hangs by gravity and is displaced downward by the pressure of the low diaphragm.
During palpation of the patient in the lying position (Fig. 102), his legs should be stretched and the head placed on a low pillow; the prelum is relaxed and the arms are freely placed on the chest. The physician should assume his position by the right side of the patient with his left hand under the patient's loin, slightly below the 12th rib so that the finger tips be near the spinal column. During palpation of the left kidney, the physician's
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hand should be moved further, beyond the vertebral column, to reach the left part of the lumbar region. The right hand should be placed on the abdomen, slightly below the corresponding costal arch, perpendicularly to it and somewhat outwardly of the rectus abdominis muscles. The patient is asked to relax the abdominal muscles as much as possible and breathe deeply and regularly. The physician's right hand should press deeper with each expiration to reach the posterior abdominal wall, while the left hand presses the lumbar region to meet the fingers of the right hand. When the examining hands are as close to each other as possible, the patient should be asked to breathe deeply by "the abdomen" without straining the prelum. The lower pole of the kidney (if it is slightly descended or enlarged) descends still further to reach the fingers of the right hand. As the physician feels the passing kidney, he presses it slightly toward the posterior abdominal wall and makes his fingers slide over the anterior surface of the kidney bypassing its lower pole. If ptosis of the kidney is considerable, both poles and the entire anterior surface of the kidney can be palpated. The physician should assess the shape, size, surface (smooth or tuberous), tenderness, mobility, and consistency of the kidneys. Bimanual palpation of the kidney can also be done with the patient lying on his side.
In contrast to other organs, an enlarged or ptosed kidney can be examined by ballottement (Guyon's sign): the right hand feels the kidney while the fingers of the left hand strike rapidly the lumbar region in the angle between the costal arch and the longissimus thoracic muscles: the fingers of the right hand feel vibration of the kidney. In deranged urine outflow through the ureter and in pronounced distension of the renal pelvis by the accumulated urine or pus, liquid fluctuation can be felt during palpation of the kidney.
If the physician palpates some formation where he expects to find a kidney, he must check reliably if this is actually a kidney because it is easy to mistake for the kidney an overfilled and firm part of the large intestine, tumor of perirenal cellular tissue (lipoma, fibroma), an enlarged right lobe of the liver, the gall bladder (during palpation of the right kidney), or an enlarged or displaced spleen (during palpation of the left kidney). The kidney is a bean-shaped body with a smooth surface, slipping upwards from under the palpating fingers and returning to normal position, tossed up by ballottment and giving tympany during percussion over the kidney (by overlying intestinal loops). Protein and erythrocytes appear in the urine after palpation. But all these signs are of only relative importance. For example, if a malignant tumour develops, the kidney may lose its mobility due to proliferation of the surrounding tissues; its surface becomes irregular and the consistency more firm; if the tumour is large, the kidney moves apart the intestinal loops and percussion gives dullness. But the
kidney can nevertheless be identified by the mentioned signs by differentiating it from the neighbouring organs and other formations.
Palpation of the kidneys in the standing patient was proposed by S. Botkin. During palpation the patient stands facing the physician who sits on a chair. The prelum muscles should be relaxed and the trunk slightly inclined forward.
Palpation can be used to diagnose ptosis of the kidneys. Three degrees of nephroptosis can be distinguished: the lower pole of the kidney can be palpated in cases with ptosis of the first degree; the entire kidney can be palpated in the second degree; and the kidney freely moves about in all directions to pass beyond the vertebral column, to the side of the other kidney, and to sink downwards to a considerable distance, in the third-degree ptosis.
Palpation is also used to examine the bladder. If it contains much urine, especially in persons with thin abdominal wall, the urinary bladder can be palpated over the pubic bone as an elastic fluctuating formation. If the bladder is markedly distended, its superior border reaches the umbilicus.
Tenderness in palpation of the ureter along its course and sensitive loin over the kidneys (sensitive to pressure exerted in the angle between the 12th rib and the longissimus thoracic muscles) is of certain diagnostic importance. The area overlying the ureter extends on the anterior abdominal wall between the superior ureter point (at the edge of the rectus abdominis muscle at the level of the umbilicus) and the inferior point (at the intersection of the bi-iliac line and the vertical line passing the pubic tubercle).
PERCUSSION
It is impossible to percuss the kidneys in a healthy subject because they are covered anteriorly by the intestinal loops which give tympany. Dullness can only be determined in the presence of very marked enlargement of the kidneys.
A much more informative method for examination of the kidneys is tapping. The physician places his left hand on the patient's loin and using his right hand (palm edge or fingers) taps with a moderate force on the right hand overlying the kidney region on the loin (Fig. 103). If the patient feels pain, the symptom is positive (Pasternatsky's symptom). This symptom is also positive in nephrolithiasis, paranephritis, inflammation of the pelvis, and also in myositis and radiculitis. This decreases the diagnostic value of Pasternatsky's symptom.
A full urinary bladder gives a dull sound on percussion of the suprapubic region. The percussion is carried out from the umbilicus downward; along the median line; the pleximeter-finger is placed parallel to the pubic bone.
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Fig. 103. Determining Pasternatsky's symptom.