Special attention should be given to the presence in the patient's past history of diseases of the kidneys and the urinary ducts (acute nephritis, pyelitis, cystitis) or symptoms that might suggest them (dysuria, hematuria, edema, arterial hypertension, attacks of pain in the abdomen or loin resembling renal colics), since these symptoms can be connected with the present renal pathology. In certain cases the cause and the time of onset of grave kidney affections (necronephrosis) can be established by revealing industrial or domestic poisoning, intentional (or by mistake) taking of some poisons (corrosive sublimate, preparations of bismuth, phosphorus, silver, large doses of sulpha preparations, or of some antibiotics, e.g. aminoglycosides, expired tetracyclines, phosphorus compounds), transfusion of incompatible blood, etc. Amidopyrin, phenacetin, barbiturates, camphor, and some other medicines can cause allergic changes in the kidneys.
The patient must be asked about the character of the disease course: it may be gradual (arteriolosclerosis, chronic diffuse glomerulonephritis, amyloidosis of the kidneys), or with periodical exacerbations (chronic pyelonephritis, chronic diffuse glomerulonephritis). It is necessary to establish the cause of exacerbations, their frequency, clinical signs, the character of therapy given and its efficacy, the causes inducing the patient to seek medical help.
Anamnesis (Past history)
Special attention should be given to the factors that might provoke the present disease or have effect on its further course. For example, a common factor promoting development of acute and chronic nephritis and pyelonephritis is chilling and cooling (poor housing or working conditions, draughts, work in the open, acute cooling of the body before the disease). Spreading of genital infection onto the urinary system can be the cause of pyelonephritis. It is necessary to establish the presence or absence in the past of tuberculosis of the lungs or other organs. This helps establish the tuberculous nature of the present disease of the kidneys.
It is necessary to establish if the patient has some other diseases that might cause affections of the kidneys (collagenosis, diabetes mellitus, certain diseases of the blood, etc.). Various chronic purulent diseases (osteomyelitis, bronchiectasis) can be the cause of amyloidosis of the kidneys. Occupations associated with walking, riding, weight lifting, etc., can have their effect on the course of nephrolithiasis and provoke attacks of renal colic. Some abnormalities of the kidneys, nephrolithiasis, amyloidosis, etc., can be inherited. It is also necessary to record thoroughly the information on past operations on the kidneys or the urinary ducts.
When examining women, it is important to remember that pregnancy can aggravate some chronic diseases of the kidneys and be the cause of the so-called nephropathy of pregnancy (toxemia of late pregnancy).
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Physical Examination
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 uremic 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 uremic 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 uremic coma, renal eclampsia, and nephropathy of pregnancy (toxemia of late pregnancy with involvement of the kidneys).
Edema is characteristic of acute and chronic glomerulonephritis, nephrotic syndrome, and amyloidosis of the kidneys. The appearance of the patient with edema of the renal origin is quite specific. The face is pallid, swollen, with edematous eyelids and narrowed eye-slits (facies nephritica). In patients with more pronounced signs of pathology, edema affects the upper and lower extremities and the trunk (anasarca).
The colour of the patient's skin is also important. Edematous skin in chronic nephritis is pallid due to the spasm of skin arterioles, and anemia which attends this disease. The skin is wax-pallid in amyloidosis and lipoid nephrosis. It should be remembered that in cardiac edema (as distinct from renal edema) 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 (uremia).
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.
Percussion of kidneys
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.
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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. 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.
Percussion of urinary bladder
The finger-pleximeter is placed horizontally, i.e. collaterally to a pubis, on anterior abdominal wall at a level of umbilicus or slightly below it, and a quiet percussion is performed from top to down on anterior midline in the direction of pubis. If urinary bladder is full of urine, there is dullness on percussion above a pubis at percussion. If it is empty the tympanic note down to a pubis in a vertical and horizontal position of the patient is determined.
Palpation of kidneys
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 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.
Palpation of kidneys becomes possible in enlarged volume of kidneys or at their ptosis. Palpation of kidneys should be effected in vertical (according to S.P. Botkin) and horizontal (according to V.P. Obraztsov) positions of patient. Palpation of kidney in vertical position of the patient is especially valuable for revealing nephroptosis, it is especial in case of its small shift. In a lying position a kidney is reverted, and any deep respiratory motions of a diaphragm are not capable to shift it downwards to be available for palpation.
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.
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When the patient is in the horizontal position, his kidneys are 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, 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 first moment of palpation is the position of arms. Palpation of kidneys in a horizontal position of researched patient, as well as in a vertical position, is performed by two arms, i.e. bimanually. The physician should hold a position by the right side of the patient with his left hand under the patient's loin, slightly below the 12-th rib so that the finger tips are placed near the spinal column. During palpation of the left kidney, the physician's 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. It is connected with a little bit slanting position of kidneys which inferior poles are located far from a vertebrae column, rather than superior poles.
The second moment is the formation of artificial skin bunch by superficial movement of a palpating arm upward.
The third moment is the gradual dipping the tips of fingers of the right arm into an abdomen on an expiration when a maximal abdominal wall muscles relaxation. It is possible routinely to reach a posterior abdominal wall for 2-3 expirations. 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 of expirations to reach the posterior abdominal wall, while the left hand presses the lumbar region to meet the fingers of the right hand.
The fourth moment is the palpation of the kidney. 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
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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 beanshaped body with a smooth surface, slipping upwards from under the palpating fingers and returning to normal position, tossed up by ballottement and giving tympany during percussion over the kidney (by overlying intestinal loops). Protein and erythrocytes sometimes appear in the urine after palpation of the kidney. 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.P. 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 (A.A. Shelagurov, 1964):
I degree – a palpated kidney (ren palpabilis), its inferior pole can be palpated only. Mobility of kidneys is small;
II degree – a movable kidney (ren mobilis), the entire kidney can be palpated in the second degree; it is easily displaced, not translocated for a white line of an abdomen.
III degree - a wandering (vage) kidney (ren migrans), the kidney freely moves about in all directions to pass beyond the vertebral column in the side of the other kidney, and to sink downwards at a considerable distance.
Palpation of urinary bladder
Palpation of the urinary bladder in absence of its pathology and its overflow yields a negative result. Palpation of urinary bladder is performed from top to bottom on midline under all rules of deep sliding methodical palpation according to V.P. Obraztsov. If it contains much urine, especially
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