abdomen; IV degree - lien reaches to the right half of the abdominal cavity and the pelvic cavity.
The characteristic peculiarity of lien is one or several notches (incisures) on the anterior edge of the spleen can be palpated if its enlargement is considerable. The notches are used to identify the spleen (to differentiate it from other organs, e.g. from the left kidney, tumors originated from the left kidney, splendid curvature of a transverse colon and caudal part of pancreas).
A normal spleen is impalpable. It can only be palpated in rare cases of extreme splenoptosis, and more frequently in enlargement of the organ. The anterior surface of the enlarged spleen emerges from under the costal arch and also becomes palpable.
The spleen is enlarged in some acute and chronic infectious diseases (typhus, viral hepatitis, sepsis, malaria, etc.), in liver cirrhosis, thrombosis or compression of the splenic vein, and also in many diseases of the hemopoietic system (hemolytic anemia, thrombocytopenic purpura, acute and chronic leucosis). Considerable enlargement of the spleen is called splenomegaly. The greatest enlargement of the spleen is observed at the terminal stage of chronic myeloleucosis: it often occupies the entire left part of the abdomen, while its lower pole is found in the small pelvis.
The spleen is not firm in acute infectious diseases; it is especially soft (the consistency of dough) in sepsis. In chronic infectious diseases, liver cirrhosis, and leucosis the spleen is firm, especially in amyloidosis.
In most diseases the spleen is insensitive to palpation. It becomes tender in infarction, perisplenitis, and in distension of the capsule, due to the rapid enlargement, e.g. in venous blood congestion due to thrombosis of the splenic vein. The spleen surface is usually smooth; the edges and the surface are irregular in perisplenitis and old infarctions (depressions in the surface). In syphilitic gummas, echinococcosis, cysts and very rare tumours of the spleen its surface is tuberous.
The spleen is normally quite mobile, but the mobility becomes limited in perisplenitis. A markedly enlarged spleen remains motionless during respiration but it can however be displaced by the palpating fingers.
Subjective and objective examination of patients with diseases of kidneys and urinary tract
Inquiry (Subjective examination)
Complaints
Patients with diseases of the kidneys complain most commonly of pain in the lumbar region, disordered urination, edema, headache, and dizziness.
150
They may also complain of deranged vision, pain in the heart, dyspnea, absence of appetite, nausea, vomiting, and elevated body temperature. But diseases of the kidneys may also proceed without any symptoms of renal or general clinical insufficiency.
If the patient complains of pain, its location should first of all be determined. Pain of renal origin localizes frequently in the lumbar region. If the ureters are affected, the pain is felt by their course. If the bladder is involved, pain is suprapubical. Radiation of pain into the perineal region is characteristic of an attack of nephrolithiasis.
The character of pain should then be determined. It is necessary to remember that the renal tissue is devoid of pain receptors. The pain is felt when the capsule or the pelvis is distended. Dull and boring pain in the lumbar region occurs in acute glomerulonephritis, abscess of the perirenal cellular tissue, in heart decompensation ("congestive kidney"), in chronic pyelonephritis (usually unilateral) and less frequently in chronic glomerulonephritis. Pain arises due to distension of the renal capsule because of the inflammatory or congestive swelling of the renal tissue. Sharp and suddenly developing pain on one side of the loin can be due to the renal infarction. The pain persists for several hours or days and then subsides gradually. The pain is rather severe in acute pyelonephritis: inflammatory edema of the ureter interferes with the normal urine outflow from the pelvis and thus causes its distension. The pain is usually permanent. Some patients complain of attacks of severe piercing pain in the lumbar region or by the course of the ureter. The pain increases periodically and then subsides, i.e. has the character of renal colic. Obstruction of the ureter by a calculus or its bending (movable kidney) is the most common cause of this pain, which is usually attended by spasmodic contraction of the ureter, retention of the urine in the pelvis, and hence its distension. The spasmodic contractions and distension of the pelvis account for the pain. Pain in renal colic is usually unilateral. It radiates into the corresponding hypochondrium and most frequently by the course of the ureter to the bladder and to the urethra. This radiation of pain is explained by the presence of nerve fibres (carrying the impulses from kidneys, ureters, genital organs and the corresponding skin zones) in the immediate vicinity of the relevant segments of the spinal cord (DX-DXII and LI-LII). This facilitates propagation of the excitation. Patients with renal colic (like those with colic of other etiology) are restless; they toss in bed. Patients with severe pain of other etiology would usually lie quiet in their beds (movements may intensify the pain).
The conditions promoting pain should be established. For example, pain in nephrolithiasis can be provoked by taking much liquid, jolting motion, or the like; pain is provoked by urination in cystitis. Difficult and painful urination is observed in stranguria. Patients with urethritis feel a burning pain in the urethra during or after urination.
151
It is necessary also to establish the agent that lessens or removes the pain. For example, atropine sulphate, hot water-bottle or warm bath helps in renal colic. Since these remedies only help in spasmodic pain by removing spasms of the smooth muscles, their efficacy in renal colic confirms the leading role of the ureter contraction in the pathogenesis of this pain. Pain of the renal colic-type in patients with movable kidney may lessen with changing posture: urine outflow improves with displacement of the kidney. Pain slightly lessens in patients with acute paranephritis if an ice pack is placed on the lumbar region and if the patient is given analgesics.
Many renal diseases are attended by deranged urination: changes in the daily volume of excreted urine and in the circadian rhythm of urination.
Secretion of urine during a certain period of time is called diuresis. Diuresis can be positive (the amount of urine excreted exceeds the volume of liquid taken) or negative (the reverse ratio). Negative diuresis is observed in cases of liquid retention in the body or its excess excretion through the skin, by the lungs (e.g. in dry and hot weather). Positive diuresis occurs in resolution of edema, after administration of diuretics, and in some other cases. Deranged excretion of urine is called dysuria.
Increased amount of excreted urine (over 2 1 a day) is called polyuria. It can be of renal and extrarenal etiology. Polyuria is observed in persons who take much liquid, during resolution of edema (cardiac or renal), and after taking diuretics. Long-standing polyuria with a high relative density of urine is characteristic of diabetes mellitus. In this case polyuria arises due to a deranged resorption of water in renal tubules because of increased osmotic pressure of the urine rich in glucose. Polyuria occurs in diabetes incipidus because of insufficient supply of antidiuretic hormone secreted into blood by the posterior pituitary.
Polyuria also occurs in the absence of sensitivity of the tubules to the ADH, in affected interstice of the renal medulla of various nature, in hypokaliaemia, and hypoand hypercalcaemia.
Persistent polyuria with low specific gravity of urine (hyposthenuria) is usually a symptom of a severe renal disease, e.g. chronic nephritis, chronic pyelonephritis, renal arteriolosclerosis, etc. Polyuria in such cases indicates the presence of a neglected disease with renal insufficiency and decreased reabsorption in renal tubules.
Decreased amount of excreted urine (less than 500 ml a day) is called oliguria. It can be not connected directly with renal affections (extrarenal oliguria). For example, it can be due to limited intake of liquid, during staying in a hot and dry room, in excessive sweating, intense vomiting, profuse diarrhea, and during decompensation in cardiac patients. But in certain cases oliguria is the result of diseases of the kidneys and the urinary ducts (renal oliguria), such as acute nephritis, acute dystrophy of the kidneys in poisoning with corrosive sublimate, etc.
152
A complete absence of urine secretion and excretion is called anuria. Anuria persisting for several days threatens with possible development of uremia and fatal outcome. Anuria may be caused by the deranged secretion of urine by the kidneys (secretory anuria) which occurs in severe form of acute nephritis, nephronecrosis (poisoning with sublimate or other nephrotoxic substances), transfusion of incompatible blood, and also some general diseases and conditions such as severe heart failure, shock, or profuse blood loss.
In certain cases the secretion of urine is normal but its excretion is obstructed mechanically (obstruction of the ureters or the urethra by a calculus, inflammatory edema of the mucosa, proliferation of a malignant tumour). This is called excretory anuria. It is usually attended by strong pain in the loin and the ureters due to distension of the renal pelvis and the ureters. Excretory anuria is often attended by renal colic.
Renal (secretory) anuria can be of reflex origin, e.g. in severe pain (contusion, fractures of the extremities, etc). Anuria should be differentiated from ischuria, when the urine is retained in the bladder and the patient is unable to evacuate it. This occurs in compression or other affection of the spinal cord, and in loss of consciousness.
Pollakiuria (frequent micturition) is observed in certain cases. A healthy person urinates from 4 to 7 times a day. The amount of excreted urine during one micturition is from 200 to 300 ml (1000-2000 ml a day). But frequency of micturition may vary within wider range under certain conditions: it may decrease in limited intake of liquid, after eating much salted food, in excessive sweating, in fever, and the like, or the frequency may increase (polyuria) if the person takes much liquid, in getting cold, and the like circumstances. Frequent desire to urinate with excretion of scanty quantity of urine is the sign of cystitis. A healthy person urinates 4-7 times during the day time; a desire to urinate during night sleep does not arise more than once. In the presence of pollakiuria the patient feels the desire to urinate during both day and night. In the presence of chronic renal insufficiency and if the kidneys are unable to control the amount and concentration of excreted urine in accordance with the amount of liquid taken, physical exertion, the ambient temperature, or other factors important for the liquid balance in the body, the patient urinates at about equal intervals with evacuation of about equal portions of urine. This condition is called isuria.
Under certain pathological conditions, the frequency of urination is normal during the day time but increases during night. The amount of urine excreted during night often exceeds the amount of daily urine (nycturia). Nocturnal enuresis (nycturia) and oliguria during day time occur in cardiac decompensation and are explained by a better renal function at night, i.e. at rest (cardiac nycturia). Nycturia may concur with polyuria in renal dysfunction, at the final stage of chronic glomerulonephritis, chronic pyelitis,
153
vascular nephrosclerosis, and other chronic renal diseases (renal nycturia). In the presence of isuria and nycturia of renal origin, which arise due to the loss by the kidneys of their concentrating ability, the specific gravity of the urine is monotonous. The condition is known as isosthenuria. The specific gravity of urine is usually decreased (hyposthenuria). The specific gravity of urine varies from 1.009 to 1.011, i.e. approaches the specific gravity of primary urine (plasma ultrafiltrate) in patients with pronounced nephrosclerosis, which is the final stage of many chronic renal diseases.
Some diseases of the bladder and the urethra are attended by difficult and painful urination. The patient would complain of change in the colour of the urine, its cloudiness, and traces of blood.
Edema is observed in acute and chronic diffuse glomerulonephritis, nephrotic syndrome, amyloidosis, and acute renal excretory dysfunction (anuria). It is important to ask the patient about the site that was the first to be attacked by edema, the sequence of edema spreading, and the rate of intensification of this phenomenon.
Headache, dizziness, and heart pain may result from kidney affections. These symptoms occur in those renal diseases which are attended by considerable increase of arterial blood pressure, e.g. in acute and chronic glomerulonephritis or vascular nephrosclerosis. A pronounced and persistent increase in the arterial pressure can be among the causes of deranged vision (neuroretinitis).
Patients with diseases of the kidneys can complain of weakness, indisposition, impaired memory and work capacity and deranged sleep. Vision may be deranged along with skin itching and unpleasant breath. Dyspeptic disorders sometimes include loss of appetite, dryness and unpleasant taste in the mouth, nausea, vomiting, and diarrhea. All these phenomena are associated with retention in the body of protein decomposition products due to renal insufficiency which develops at the final stage of many chronic renal diseases, and sometimes in acute diseases attended by retention of urine during several days.
Fever is the common symptom of infectious inflammatory affections of the kidneys, the urinary ducts and perirenal cellular tissue.
History of the present disease
When questioning the patient, it is necessary to establish the connection of the present disease with previous infections (tonsillitis, scarlet fever, otitis, acute respiratory diseases). This sequence is especially characteristic of acute glomerulonephritis. But it is sometimes difficult to establish the time of onset of the disease because some chronic affections of the kidneys and the urinary ducts can for a long time be latent. Moreover, when questioning the patient, it is necessary to find out if he had deranged hearing or vision in his childhood that might be suggestive of congenital renal pathology.
154