Anatomy and Clinical Examination

Clinical Examination
 Kidney
The kidneys are retroperitoneal, lying on the posterior abdominal wall either side of the vertebral column between T12 and L3
vertebrae. They move slightly inferiorly with inspiration. The right kidney lies a little lower than the left (displaced by the liver).
Palpation is bimanual (both hands). You may be able to feel the lower pole of the right kidney in normal, thin people.
• Place your left hand behind the patient at the right loin.
• Place your right hand below the right costal margin at the lateral border of the rectus abdominis.
• Keeping the fi ngers of your right hand together, flex them at the metcarpophalangeal joints, pushing deep into the abdomen.
• Ask the patient to take a deep breath—you may be able to feel the rounded lower pole of the kidney between your hands,
slipping away when the patient exhales.
• This technique of using one hand to move the kidney toward the other is called renal ballottement.
• Repeat the procedure for the left kidney, leaning over and placing your left hand behind the patient’s left side
Findings
• Unilateral palpable kidney:hydronephrosis, polycystic kidney disease, renal cell carcinoma, acute renal vein thrombosis, renal
abscess, acute pyelonephritis
• Bilateral palpable kidneys:bilateral hydronephrosis, bilateral renal cell carcinoma, polycystic kidney disease, nephrotic
syndrome, amyloidosis, lymphoma, acromegaly
 Rectal Examination
This is an important part of the examination and should not be avoided simply because it is considered unpleasant. It is
particularly important in patients with symptoms of rectal bleeding, tenesmus, change in bowel habit, and pruritus ani.
Remember: If you don’t put your finger in it, you may put your foot in it.
Before you begin
Explain to the patient what is involved and obtain verbal consent. Choose your words carefully, adjusting your wording to
suit the patient. Favorite phrases include “hindend,” “backside,” and “bottom.” Tell the patient that you need to examine
their bottom with a fi nger. Warn that it ‘probably won’t hurt’ but may feel cold and a little unusual. Ask for another staff
member to chaperone, to protect yourself against future claims of inappropriate treatment and to reassure the patient.*
As you proceed, explain each stage to the patient.
Equipment : • Chaperone ; • Nonsterile gloves ; • Tissues ; • Lubricating jelly
Technique
• With informed verbal consent obtained, ensure adequate privacy. Uncover the patient from the waist to the knees.
• Ask the patient to lie in the left lateral position with their legs bent such that their knees are drawn up to their chest and their buttocks facing
toward you—preferably projecting slightly over the edge of the bed or exam table.
• Ensure that there is a good light source, preferably a mobile lamp.
• Put on a pair of gloves. ; • Separate the buttocks carefully by lifting the right buttock with your left hand.
• Inspect the perianal area and anus. ; • Look for rashes, excoriations, skin tags, ulcers, anal warts, fistulous openings, fi ssures, external
hemorrhoids, abscesses, fecal soiling, blood, and mucus.
• Ask the patient to strain or bear down and watch for the projection of pink mucosa of a rectal prolapse.
• Lubricate the tip of your right index fi nger with the jelly.
• Begin by placing the pulp of your right index fi nger against the anus in the midline and press in firmly but slowly.
• Most anal sphincters will refl exively tighten when touched but will quickly relax with continued pressure.
• When the sphincter relaxes, gently advance the fi nger into the anal canal.
• Assess anal sphincter tone by asking the patient to tighten around your finger.
• Rotate the fi nger backward and forward, covering the full 360*, feeling for any thickening or irregularities.
• Push the fi nger further into the rectum.
• Examine all 360˚ by moving the fi nger in sweeping motions. Note: Presence of thickening or irregularities of the rectal wall
• Presence of palpable feces, and its consistency ; • Any points of tenderness
• Next, in the male, identify the prostate gland, which can be felt through the anterior rectal wall.
• The normal prostate is smooth-surfaced, fi rm with a slightly rubbery texture, measuring 2–3cm diameter. It has two lobes with a palpable
central sulcus.
• Gently withdraw your fi nger and inspect the glove for feces, blood, or mucus and note the color of the stool, if present. Test the stool for
occult blood if a testing card is available.
• Tell the patient that the examination is over and wipe any feces or jelly from the gluteal cleft with the tissues. Some patients may prefer to do
this themselves.
• Thank the patient and ask them to get dressed. You may need to help.