Percussion method for diagnosing the spleen. Percussion of the spleen in children. Examination of the anal area in a child Why does pain appear

Superficial palpation in liver diseases can reveal a zone of pain in the right hypochondrium and epigastric region. Particularly strong local pain, even with a light touch to the anterior abdominal wall in the area of the projection of the gallbladder, is observed in acute cholecystitis and biliary colic. In chronic cholecystitis, only mild or moderate pain is usually determined at the so-called point of the gallbladder: it corresponds to the projection of its bottom onto the anterior abdominal wall and is normally localized in most cases directly under the right costal arch along the outer edge of the right rectus abdominis muscle.

Palpation of the liver is carried out according to the Obraztsov-Strazhesko method. The principle of the method is that with a deep breath, the lower edge of the liver descends towards the palpating fingers and then, bumping into them and sliding off them, becomes palpable. It is known that the liver, due to its close proximity to the diaphragm, has the highest respiratory mobility among the abdominal organs. Consequently, during palpation of the liver, an active role belongs to its own respiratory mobility, and not to palpating fingers, as during palpation of the intestine.

Palpation of the liver and gallbladder is performed with the patient standing or lying on his back (however, in some cases, palpation of the liver is facilitated when the patient is positioned on the left side; in this case, the liver, under the influence of gravity, comes out of the hypochondrium and then it is easier to probe its lower front edge). Palpation of the liver and gallbladder is carried out according to the general rules of palpation, and most of all they pay attention to the anteroinferior edge of the liver, by the properties of which (contours, shape, soreness, consistency) the physical state of the liver itself, its position and shape are judged. In many cases (especially when the organ is lowered or enlarged), in addition to the edge of the liver, which can often be traced by palpation from the left hypochondrium to the right, it is also possible to palpate the upper anterior surface of the liver.

The examiner sits on the right next to the bed on a chair or on a stool facing the subject, puts the palm and four fingers of the left hand on the right lumbar region, and with the thumb of the left hand presses on the side and front of the costal arch, which contributes to the approach of the liver to the palpating right hand and, making it difficult to expand the chest during inspiration, it helps to increase the excursions of the right dome of the diaphragm. The palm of the right hand is placed flat, with fingers slightly bent, on the patient's stomach directly under the costal arch along the mid-clavicular line and slightly pressed with fingertips on the abdominal wall. After such an installation of the hands, the subject is offered to take a deep breath; the liver, descending, first approaches the fingers, then bypasses them and slips out from under the fingers, that is, it is palpable. The hand of the researcher remains motionless all the time, the technique is repeated several times.

The position of the edge of the liver can be different depending on various circumstances, therefore, in order to know where to place the fingers of the right hand, it is useful to first determine the position of the lower edge of the liver by percussion.

According to V.P. Obraztsov, a normal liver is palpable in 88% of cases. Palpation sensations obtained from the lower edge of the liver, allow you to determine its physical properties (soft, dense, uneven, sharp, rounded, sensitive, etc.). The edge of the unchanged liver, palpable at the end of a deep breath 1-2 cm below the costal arch, is soft, sharp, easily folded and insensitive.

The lower edge of the normal liver is usually palpable along the right mid-clavicular line; to the right of it, the liver cannot be palpated, since it is hidden by the hypochondrium, and on the left, palpation is often difficult due to the severity of the abdominal muscles. With an increase and compaction of the liver, it can be felt along all lines. Patients with bloating should be examined on an empty stomach to facilitate palpation. With the accumulation of fluid in the abdominal cavity (ascites), it is not always possible to palpate the liver in the horizontal position of the patient. In these cases, the indicated technique is used, but palpation is performed in an upright position or in the position of the patient on the left side. With the accumulation of a very large amount of fluid, it is first released using paracentesis. If there is a large accumulation of fluid in the abdominal cavity, the liver is also palpated with jerky ballot palpation. To do this, the right hand with slightly bent II IV fingers is placed at the bottom of the right half of the abdomen, perpendicular to the supposed lower edge of the liver. With closed fingers of the right hand, jerky blows are applied to the abdominal wall and moved in the direction from the bottom up until the dense body of the liver is felt, which, when the fingers are struck, first goes into the depths of the abdominal cavity, and then hits them and becomes palpable (a symptom of a floating ice floe).

Soreness is characteristic of inflammatory liver damage with the transition of the inflammatory process to the liver capsule or to stretch it (for example, with stagnation of blood in the liver due to heart failure).

The liver of a healthy person, if it is accessible to palpation, has a soft texture, with hepatitis, hepatosis, cardiac decompensation, it is more dense. The liver is especially dense with its cirrhosis (at the same time, its edge is sharp, and the surface is even or finely tuberous), tumor lesions of multiple cancer metastases (in these cases, sometimes the surface of the liver is rough-hilly, corresponding to superficially located metastases, and the lower edge is uneven), with amyloidosis. Sometimes it is possible to palpate a relatively small tumor or echinococcal cyst.

The protrusion of the lower edge of the enlarged liver is determined in relation to the costal arch along the right anterior axillary, right near the sternal and left parasternal lines. Palpation data clarify the idea of the size of the liver, obtained by percussion.

The gallbladder is normally not palpable, as it is soft and practically does not protrude from under the edge of the liver. But with an increase in the gallbladder (dropsy, filling with stones, cancer, etc.), it becomes accessible to palpation. Palpation of the bladder is carried out in the same position of the patient as palpation of the liver. The edge of the liver is found and directly below it, at the outer edge of the right rectus muscle, the gallbladder is palpated according to the rules of palpation of the liver itself. It can be most easily detected when moving the fingers transversely to the axis of the gallbladder The gallbladder is palpated as a pear-shaped body of various sizes, density and pain, depending on the nature of the pathological process in itself or in the organs surrounding it (for example, an enlarged soft-elastic bladder when the common bile duct is blocked by a tumor - a sign of Courvoisier - Terrier; dense - tuberous bladder with neoplasms in its wall, with overflowing with stones, with inflammation of the wall, etc.). ness and reflex tension of the muscles of the anterior abdominal wall in the region of the right hypochondrium make palpation difficult.

This technique of palpation of the liver and gallbladder is the simplest, most convenient and gives the best results. The difficulty of palpation and, at the same time, the consciousness that only it allows obtaining valuable data for diagnosis, forced us to look for the best method of palpation. Various techniques have been proposed, which mainly boil down to a variety of positions of the examiner's hands or a change in the position of the examiner in relation to the patient. However, these methods do not have any advantages in the study of the liver and gallbladder. The point is not in the variety of techniques, but in the experience of the researcher and his systematic implementation of the study plan for the abdominal cavity as a whole.

The spleen is an unpaired organ located on the left side of the abdominal cavity. The anterior part of the organ is adjacent to the stomach, and the posterior part to the kidney, adrenal gland and intestines.

The structure of the spleen

The composition of the spleen is determined by the serous cover and its own capsule, the latter is formed by a combination of connective tissue, muscle and elastic fibers.

The capsule passes into the skeleton of the organ, dividing the pulp (parenchyma) into separate "islands" with the help of trabeculae. In the pulp (on the walls of the arterioles) there are round or oval nodules of the follicle). The pulp is based on what is filled with a variety of cells: erythrocytes (mostly decaying), leukocytes and lymphocytes.

Organ functions

The spleen is involved in lymphopoiesis (that is, it is a source of lymphocytes).
Participates in the hematopoietic and immune functions of the body.
Destruction of used platelets and red blood cells.
Deposition of blood.
In the early stages of embryogenesis, it works as a hematopoietic organ.

That is, the organ performs many important functions, and therefore, in order to determine pathologies at the initial stages of the examination, it is necessary, first of all, to perform palpation and percussion of the spleen.

The sequence of palpation of internal organs

After collecting complaints, anamnesis and a general examination, the doctor, as a rule, proceeds to physical research methods, which include palpation and percussion.

Distinguish:

Superficial palpation, which reveals pain in a particular area, tension in the abdominal muscles, swelling, various seals and formations (hernias, tumors, nodes). It is carried out by light pressure with half-bent fingers, starting from the left iliac region counterclockwise.
Deep palpation, carried out in the following sequence: blind (its final part), colon (ascending and descending sections), transverse colon, stomach, liver, pancreas, spleen, kidneys, is carried out using deep penetration of the doctor's fingers into the abdominal cavity .

In case of suspicion of the presence of diseases of the spleen (or its increase due to liver disease), percussion, palpation of the liver and spleen are mandatory.

General rules for palpation

The spleen is one of the most informative physical research methods conducted by a doctor. In the case of a slight increase in the organ, when the spleen is not easy to feel, the doctor will definitely recommend an ultrasound scan to confirm / refute the alleged pathology in a child or an adult.

Patient position:

Lying on your back (in this position, palpation of the liver and spleen is performed).
Lying on the right side. The right hand is located under the head, and the left should be bent at the elbow and laid on the chest (this technique is called Sali palpation of the spleen). Moreover, the patient's head should be slightly tilted to the chest, the right leg is straight, and the left leg should be bent at the hip and knee joints.

Palpation of the spleen: algorithm

The doctor should place his left hand so that it is on the left side of the subject's chest, between the 7th and 10th ribs in accordance with the axillary lines, and apply slight pressure. In this case, the fingers of the right hand should be half-bent and located on the left costal arch so that the middle finger is adjacent to the 10th rib.
When the patient inhales, the skin is pulled down to form a skin fold.
After exhalation, the doctor's hand penetrates deep into the abdomen (abdominal cavity).
The patient, at the request of the doctor, inhales deeply, while under the influence of the diaphragm, the spleen moves down. In the case of its increase, the doctor's fingers will come across its lower pole. This action must be repeated several times.

Interpretation of results

Under normal conditions (in healthy people), the spleen is not palpable. An exception is asthenics (usually women). In other cases, it is possible to feel the spleen when the diaphragm is lowered (pneumothorax, pleurisy) and splenomegaly, that is, an increase in the size of the organ. This condition is more often observed in the following conditions:

Blood diseases.
Chronic pathologies of the liver (here splenomegaly is a sign of portal hypertension or
Chronic and acute infectious processes (infectious endocarditis, malaria, typhoid, sepsis).
Connective tissue diseases.
heart attacks or

Most often, palpation of even an enlarged spleen is painless. The exceptions are organ infarcts, rapid expansion of the capsule, perisplenitis. In these cases, the spleen becomes extremely sensitive (that is, painful on palpation).

With cirrhosis of the liver and other chronic pathologies, the edge of the spleen is dense, while in acute processes it is soft.

The consistency is usually soft in acute infections, becoming firm in chronic infections and cirrhosis of the liver.

According to the degree of enlargement of the organ, the palpable part may be smaller or larger, and the extent to which the spleen has come out from under the ribs may indicate the true degree of enlargement of the organ. So, a relatively small increase is indicated by the exit of the edge of the organ from under the costal arch by 2-7 centimeters, which is observed in acute infections (typhus, meningitis, sepsis, lobar pneumonia, and so on) or chronic pathologies (heart disease, cirrhosis, erythremia, leukemia, anemia) and unknown etiology, which occurs more often in young people (possibly with hereditary syphilis, rickets)

Accordingly, the density of the palpable edge of the spleen (with its increase), it is possible to draw conclusions about the age of the process. That is, the longer inflammation is present in the organ, the denser and harder its parenchyma, from which it follows that in acute processes the edge of the spleen is softer and more elastic than in chronic ones.

If the organ is too large, when the lower edge is determined in the pelvic cavity, it is very easy to palpate the spleen, and no special skills are required.

In the case of splenomegaly, as a result of a neoplasm, palpation of the spleen (more precisely, its margo crenatus) determines notches (from 1 to 4). A similar diagnostic sign indicates the presence of amyloidosis, leukemia (chronic myelogenous or pseudoleukemia), malaria, cysts and endothelioma.

That is, when performing palpation of the spleen, the doctor has the opportunity to assess the condition of its surface, detect fibrin deposits (as, for example, with perisplenitis), various protrusions (which happens, for example, with abscesses, hemorrhagic and serous cysts, echinococcosis) and determine the density of tissues. With abscesses, swell is often found. All information determined by palpation is extremely valuable both for diagnosing the disease of the spleen itself, and for determining diseases that could lead to splenomegaly.

Normally, the spleen is located in the region of the left hypochondrium, its long axis is located along the tenth rib. The organ has an oval (bean-shaped) shape.

The spleen in childhood

The size of the spleen is normal depending on age:

Newborns: width - up to 38 millimeters, length - up to 40 millimeters.
1-3 years: length - up to 68 millimeters, width - up to 50 millimeters.
7 years: length - up to 80 millimeters, width - up to 55 millimeters.
8-12 years: width - up to 60 millimeters, length - up to 90 millimeters.
15 years: width - up to 60 millimeters, and length - 100-120 millimeters.

It should be remembered that palpation of the spleen in children, as well as in adults, should be painless, in addition, normally the spleen in a child is not determined. The sizes described above are not absolute, that is, small deviations towards a decrease / increase in the size of an organ should not be regarded as a pathology.

Percussion of the spleen

This method is used to estimate the size (boundaries) of the body.

The patient is placed in the right semi-lateral position with the arms located above the head, while the legs are slightly bent at the hip and knee joints. Percussion should be done by moving from a clear to a dull sound, using quiet percussion strokes.

Conducting percussion

The plessimeter finger must be placed on the edge of the costal arch on the left side of the body, perpendicular to the 10th rib.
A weak percussion is performed along the 10th rib, first from the costal arch (left) until a dull sound (dullness) appears. A mark is made on the skin at the point of sound transition. Then they percuss from the axillary line (back) anteriorly until the sound becomes dull and also put a mark on the skin.
The length of the segment between the marks is the length of the spleen (corresponding to the 10th rib). Normally, this indicator is 6-8 centimeters.
From the middle of the length, perpendiculars are drawn to the tenth rib and further percussion is performed along them to determine the diameter of the spleen, which normally ranges from 4 to 6 centimeters.
Normally, the anterior part of the spleen (that is, its edge) should not go medial to the line that connects the free end of the 11th rib and the sternoclavicular joint. It is worth noting that the calculation of the size of the spleen using percussion is a very approximate indicator. The size of the organ is written as a fraction, where the numerator is the length, and the denominator is the diameter of the spleen.

When diagnosing patients with suspected diseases of the digestive system, palpation of the spleen is performed. This organ is located in the hypochondrium on the left side. If the spleen is slightly enlarged and not easily palpable, doctors prescribe an ultrasound to confirm or refute the preliminary diagnosis in children and adults.

There are many methods of tactile examination that do not cause obvious harm to the patient.

External examination of the abdomen

If suspicious symptoms appear, the patient should consult a doctor. Before the examination, the specialist asks the patient and finds out the frequency, intensity and nature of pain. It is important to take into account whether the patient has had injuries and surgeries. After that, they begin to examine the abdomen. Such an examination will determine whether there is pallor of the skin, whether sweating is increased.

Superficial palpation

If the boundaries of the organ do not correspond to the norm and it has increased, then this is easily determined during superficial palpation. This type of palpation is also called indicative. Using this technique, you can check the muscle tone of the abdominal wall in adults and children, the resistance of the muscles to probing, painful places, the divergence of the muscles located around the navel with the rectus muscles. Before the examination, the patient should lie on his back, put his hands along the body and straighten his legs. It is also possible to determine the length, the diameter of the organ using palpation. To find out about the condition of the length and diameter, a person is examined when he lies on his back or on his side.

It is important that the bed is not very soft and with a low headboard. The specialist should sit next to the patient and turn to him with his right side (left-handers should sit on the left side of the recumbent). At the same time, it is necessary that the chair on which the doctor sits is approximately at the same level as the patient's hip joint. In turn, the height of the seat should be the same as the height of the bunk. It is necessary that the hands of a specialist during palpation of the spleen or liver be warm, the nails short cut. To warm up the brushes, the doctor may rub them or wash them with warm water.

As a rule, the abdominal cavity and liver are palpated on an empty stomach. In this case, the intestines must be emptied. During the procedure, the patient should breathe through the mouth, take deep breaths, but at the same time, do not overstrain the abdominal wall. Just before examining the liver or spleen, the doctor may place a hand on the patient's abdomen to help reduce muscle tension. At the same time, you need to pay attention to how evenly different parts of the abdominal cavity participate in the process of breathing. In addition, it should be checked whether the patient is able to breathe by using the diaphragm: when inhaling, the specialist’s palm, located on the front wall of the abdomen, rises, and when exhaled, it falls.

Deep methodical palpation according to Obraztsov-Strazhesko

Palpation is used in the diagnosis of diseases of the gastrointestinal tract

This technique is used to determine diseases of the gastrointestinal tract. During the study, the pancreas and spleen are not palpated. One of the intestines (sigmoid) should be palpated in the iliac region on the left side, the blind is checked on the right side, and the transverse colon is examined a couple of centimeters below the navel. The intestines have a dense texture, they are painless, they should not rumble. The appendix is not palpable during the procedure. The curvature of the abdominal cavity is examined during the procedure. It has the shape of a fold, its thickness is 1 centimeter near the navel. Mesenteric lymph nodes are not examined during the examination.

Percussion of the spleen

During the examination of the hematopoietic system, percussion of the spleen (tapping) does not play an important role: it is used only to determine the approximate size of the liver and spleen in children and adults. Since the spleen is surrounded by hollow organs of the gastrointestinal tract, which contain air, they give out loud sounds when percussion. Therefore, it is impossible to accurately establish the size and percussion borders of the spleen through the use of this method. The definition of ailments with the help of percussion is carried out when the patient is standing or lying on his side. To achieve the best result, it is better to use the method of V. P. Obraztsov.

Tapping the spleen according to M. G. Kurlov

The patient should lie on the right side. The specialist percusses down the intercostal space and ribs (starting from V). With the help of percussion, the upper limit is set (in the area of dullness). After that, the doctor places a finger on a similar line and percusses up, thereby fixing the lower boundaries. Then measure the gap between both boundaries. To determine whether the boundaries of the organ are normal, it is necessary to find the X edge. To do this, it is necessary to percute perpendicular to the line of the navel towards the rib and above. After that, the back and front boundaries are found. In turn, the examination of the liver should begin with the designation of the upper border of the organ.

The principle of palpation of the spleen is similar to palpation of the liver. The study begins to be carried out in the position of the patient on the back, and then it is necessarily carried out in the position on the right side.

The patient should lie on the right side with the left leg slightly bent at the knee and hip joints and the left arm bent at the elbow joint. The doctor sits on a chair to the right of the patient's bed, facing him. Palpation of the spleen is bimanual: the left hand is laid flat on the lower part of the chest on the left costal arch and slightly squeezes this area to limit the movement of the chest to the sides during inspiration and increase the downward movement of the diaphragm and spleen. The terminal phalanges of 2-5 fingers of the right hand are placed parallel to the anterior edge of the spleen 3 cm below its location found during percussion. The second and third moments of palpation are the formation of a skin fold and “pockets”: during exhalation, when the anterior abdominal wall relaxes, the fingertips of the palpating hand pull the skin towards the navel (formation of a skin fold), and then they are immersed deep into the abdomen towards the left hypochondrium (pocket formation). The fourth point is the palpation of the spleen: upon completion of the formation of a "pocket", which is carried out at the end of exhalation, the patient is asked to take a deep breath. The left hand at this time slightly presses on the lower part of the chest and the left costal arch, and the fingers of the palpating hand somewhat straighten out and make a slight oncoming movement towards the spleen. If the spleen is enlarged, then it falls into the pocket and gives a certain tactile sensation (Fig. 77). In the case of palpation of the spleen, its localization (in centimeters from the edge of the costal arch), consistency, shape and soreness are noted.

In a healthy person, the spleen is inaccessible to palpation, since its anterior edge is 3-4 cm above the costal arch, but if the spleen is palpated even at the edge of the costal arch, it is already 1.5 times enlarged.

Enlargement of the spleen (splenomegaly) is observed in hepatitis, cirrhosis of the liver, cholangitis, typhoid fever, malaria, leukemia, hemolytic anemia, thrombosis of the splenic vein, etc. In acute infectious diseases, such as typhoid fever, or acute stagnation of blood in the spleen, it retains its soft texture , and in chronic diseases with its involvement in the pathological process, it becomes dense.

The edge of the spleen, with its enlargement, most often retains a slightly rounded shape and, in the vast majority of cases, is painless on palpation. Pain sensations appear during the acute development of the pathological process in the form of a traumatic injury to the spleen or a thromboembolic process.

Palpation examination of the surface of the enlarged spleen is performed with light sliding rotational or flexion-extensor movements over its surface. Usually the surface of the spleen is smooth, but sometimes it is uneven due to scarring from former heart attacks or traumatic injuries.

Palpation of the spleen

Palpation of the spleen is performed to assess its shape, consistency, surface condition, mobility and tenderness. The study is carried out in the position of the patient on the back and right side. Slightly bent fingers of the right hand are placed 3-4 cm below the left costal arch parallel to it. On inhalation of the patient, the spleen, if it is enlarged, comes out from under the edge of the costal arch, encounters palpating fingers and “slips” from them. Normally, the spleen is not palpable, since its front edge does not reach 3-4 cm to the edge of the costal arch. With its increase, at least 1.5-2 times, palpation succeeds.

Splenomegaly (enlargement of the spleen) is observed in many infectious diseases, blood diseases, tumor processes, thrombosis of the splenic vein, splenic infarction, storage disease, autoimmune diseases, etc.

The gas outlet tube is used for flatulence (accumulation of gases in the intestines), constipation.

Most often, gas removal is carried out in newborns, infants and young children.

To install a gas outlet tube, you must prepare:

- a sterile gas outlet tube;

vaseline or sterile vegetable oil;

- a robe with markings.

Before the procedure, put a cleansing enema.

1. Lay an oilcloth, covering it with a diaper.

2. Wash and dry your hands, put on a gown, gloves, mask.

3. Lay the child on the left side with legs bent and brought to the stomach.

4. Lubricate the end of the gas outlet pipe with oil by watering.

5. Spread the child's buttocks with 2 fingers of the left hand and fix the child in this position.

6. Insert the gas outlet tube into the anus, pinching its free end.

7. Move the tube into the rectum by 10-12 cm, directing first to the navel, and then, having overcome the sphincters, parallel to the coccyx.

8. Open the free end of the tube and place it in a tray of water.

9. Remove the tube through the min, passing it through a napkin.

10. Treat the perianal area with a swab dipped in oil.

11. Place the vent tube in a container with a disinfectant solution.

12. Remove gloves, gown, mask, wash hands.

13. Place gloves in a container with a disinfectant solution, and a gown in a waterproof bag.

It is impossible to keep the gas tube in the rectum for a long time, as it can irritate the intestines and even contribute to the formation of pressure sores. In a child, the gas outlet tube is held for no more than a minute. If necessary, this procedure can be repeated after a few hours (after 3-4 hours).

After use, the gas outlet tube should be washed in running water with soap and boiled for 30 minutes, and then, dried in air, put into a jar.

Indications. Suspicion of kidney disease.

Execution technique. Palpation of the kidneys is carried out in two positions - lying and standing.

Standing probing is carried out according to the method of the so-called flank palpation. The doctor sits on a chair facing the patient standing in front of him. The left hand is located transversely to the body behind the XII rib, the right arm is in front and to the side below the XII rib vertically, i.e. parallel to the axis of the body. On exhalation, taking advantage of the relaxation of the abdominal muscles, the doctor seeks to bring the fingers of both hands together until they touch. Thus, first the left, then the right flanks are examined.

Methods of palpation of the kidneys in the supine position are the same as for the liver, spleen. When probing the right kidney, the doctor's right hand with slightly bent fingers is located on the abdomen outside the rectus muscle so that the ends of the fingers are 2-3 cm below the edge of the costal arch; the left hand is brought under the lumbar region. On exhalation, the ends of the fingers of the right hand advance until they come into contact with the back wall of the abdominal cavity and through it - with the left hand. Then, with the movement of the left hand, the kidney lying on them is lifted through the thickness of the lumbar muscles and brought under the fingers of the right. At this time, the patient should take a shallow breath. Then, without relieving the pressure and without reducing the convergence of both hands, the fingers of the right begin to slide down until the kidney “slips out”. At this moment, an idea is formed about the size, shape, consistency and degree of mobility of the kidney.

Simultaneously, palpation is performed on the side. When examining the right kidney, the patient lies on the left side, on palpation of the left - on the right.

During palpation, manipulations with a change of hands are also performed.

. The child normally should not show anxiety, palpation should be painless.

. Increased pain in the lumbar region, the appearance or increase in the number of red blood cells in the urine (for example, with urolithiasis).

Evaluation of the results. Normally, the kidneys are located between the 11th thoracic and 4-5th lumbar vertebrae. At the age of up to 3 years, the kidneys are located somewhat lower, and their size in relation to the body is larger. The lower pole of the right kidney is palpable next to the spine, somewhat lower than the left.

With an enlarged or displaced kidney, you can feel most of it or all of it between the fingers of two oppositely directed palms.

On palpation of the kidneys, its size, shape, consistency, the nature of its anterior surface, pain when pressed with a finger, and mobility are determined.

During the palpation of the kidney, it is examined for its ability to ballot. To do this, with half-bent fingers of the hand lying on the lower back, make quick jerky tapping. In response to this, the kidney, with each push, undulates against the palm immersed in the stomach of the right hand. Feeling the balloting of the kidney, the doctor receives additional information about its sensitivity, size, shape, surface.

Indications. Due to the peculiar location of the kidneys, it has no particular practical value. Usually, in practice, the method of tapping in the kidney area, proposed by Pasternatsky, is used.

Execution technique. In older children, tapping is performed as follows: the doctor applies the palm of the left hand to one side of the lumbar region and then with the right hand inflicts light blows on the back of the left hand. In young children, tapping can be done in the position of the child on the stomach.

It is possible to apply light short blows on one, and then on the other side of the lumbar region, with half-bent fingers of the right hand.

Natural reaction to the procedure. No pain when tapping.

Possible undesirable consequences. Increased pain after tapping.

Evaluation of the obtained results. Pasternatsky's symptom is considered positive if the older child indicates the appearance of unpleasant painful sensations during tapping, and the small child will shudder or cry.

Soreness can be not only with kidney pathology (the presence of stones in the pelvis, inflammation of the parenchyma, paranephritis and other diseases), but also with myositis of the vertebral muscles, changes in the lumbar column, a stretched liver capsule due to hepatitis and in other cases.

Palpation of the spleen

On palpation of the spleen (Fig. 63), the patient should lie on his right side or on his back. His arms should be along the body, legs extended. The examiner sits to the right of the patient, facing him and puts his left hand on the lower part of the left half of his chest (along the axillary lines), slightly squeezing it (it is necessary to limit the mobility of the chest during breathing in order to increase the movement of the diaphragm and spleen down). He places his right hand with slightly bent fingers on the anterior abdominal wall, opposite the X rib, parallel to the costal arch, 3-5 cm below it (if the spleen is not changed percussion) or the pole of the enlarged spleen. Then, on exhalation, the patient, with a superficial movement of this hand, pulls the skin towards the navel and immerses the fingertips deep into the abdominal cavity, moving them towards the left hypochondrium. Further, without releasing his right hand, the doctor asks the patient to take a deep breath. At the same time, the edge of the spleen enters the pocket and, with further downward movement of the diaphragm, leaves it, bending around the fingers. If it was not possible to feel the spleen, palpation is repeated, slightly shifting the fingers of the right hand upwards from their original position.

Rice. 63. Palpation of the spleen.

The spleen is not palpable unless it is enlarged. If the spleen is palpated at the edge of the costal arch, then this indicates its increase by approximately one and a half times. To distinguish an enlarged spleen from tumors originating from other organs of the abdominal cavity (left kidney, intestines, etc.), allows the presence of cuts characteristic of it (1-3) on the front edge.

How is palpation of the spleen

Why is palpation performed?

Palpation is primarily carried out to assess the general shape of the spleen, the condition of its surface tissues, consistency, as well as possible mobility, pain symptoms and other signs of abnormality. Before the parenchymal organ is palpated, the doctor may ask the patient to collect data for anamnesis. This will determine the possible cause of the malfunction of the spleen.

With the help of the palpation technique, the doctor can guess the diagnosis by touch. A qualified specialist is able to distinguish an enlarged spleen from a heart attack and from an organ rupture. Also, you can immediately detect the presence of abrasions near the left hypochondrium or bruising. If the patient has suffered a blunt trauma in the abdomen, then bleeding may first affect the parenchyma of the organ, while it will be whole. During a palpation examination, the doctor may notice the accumulation of fluid in the organ and suggest internal bleeding, and then send the patient for additional diagnostics.

When the spleen is palpated, a painful sensation can be found in the left side of the abdominal cavity. When turning the body, the doctor is able to fix a seal in the left channel, which could be caused by blood clots accumulated in it. The channel does not change its position when moving.

Also, palpation allows you to detect at an early stage diseases associated with damage to the organs of the gastrointestinal tract. Patients with gastroenterology will be able to immediately begin treatment after the diagnosis is made. The specialist strongly recommends that you immediately consult a doctor if prolonged pain in the abdominal cavity has been detected.

Video "Rules for palpation"

Demonstrative video with detailed instructions and rules for palpation of the spleen.

Description of methods

When the spleen is palpated, several methods of examination may be used. Percussion of the spleen is carried out by palpation of the upper and lower borders of the parenchymal organ, as well as the anterior and posterior parts. Quiet percussion is usually used to determine the size of the organ itself. The patient at this time can be in a standing position, stretching his arms forward or to the side.

If the doctor asks to acquire a horizontal position, then it will be necessary to lie on the right side, and at the same time bend the left arm at the elbows. You will need to lie with the front of the sternum, the right hand should be kept under the head. The right leg should be extended along the body, and the left leg should be bent at the knee.

During percussion, to determine the size of the spleen, the doctor will place the plessimeter finger in the midaxillary line, between the sixth and seventh ribs and continue to percuss along the intercostal space until a distinct sound becomes dull. The boundary is defined at the place where a clear sound is heard. The lower border is usually set along the midaxillary line in parallel, then percussed from the bottom up. The lower border is marked in the place where the tympanic sound is heard. Normally, the distance between the lower and upper border is about 5-7 centimeters. This distance may also be referred to as the blunt width.

For bimanual palpation of the spleen, the patient should lie on his back. Palpation of the left intercostal space is carried out with the palms. The patient will have to take a deep breath when the doctor presses his palm on the left costal arch, limiting its movement. At the same time, the fingers of the right hand must resist the abdominal wall, which protrudes during inhalation, in order to keep it in the stomach.

Palpation according to the Sali method is performed when the patient is in a horizontal position on the right side. Inspection is also carried out in two hands, feeling the peritoneum from the front and side. If the parenchymal organ is normal, then it is practically not subjected to palpation. When the doctor manages to feel it, this means that there has been some increase in its walls.

With a pronounced enlargement of the spleen, a suspicion of splenomegaly may arise, since a significant part of the wall can protrude from under the costal arch. It can be examined by surface palpation without using the above methods.

If the dimensions of the diseased organ are normal, and the patient is concerned about certain symptoms in the region of the left hypochondrium, then the doctor should prescribe additional diagnostic methods. More accurate data can be provided by computed tomography, ultrasound radiation, as well as a study of biological material taken from a patient. In the event that at the first stage of the examination it was found that the spleen is larger than normal, then the doctor must immediately make some appointments before conducting an additional examination. In some cases, bleeding may not be immediately recorded, so certain behavioral measures should be followed until the final results of the analysis and diagnosis are received.

What can you find out

After palpation of the spleen, the condition of the organ can be established. First of all, you can find out whether its walls are normal, and whether they correspond to the size of a healthy person. It is also very important to determine if there is a displacement of the parenchymal organ to the other side of the abdominal cavity. The doctor is able to find out about possible bleeding only with a very thorough examination.

This diagnostic technique is considered to be very common, although it does not have high efficiency, therefore, in this way it is possible to determine what additional examination procedures the patient should take. A palpation examination will allow you to highlight the search area for a possible problem, identifying a segment of the abdominal cavity for a more detailed study, as well as to determine the necessary tests. When feeling the parenchyma, you can find out whether adjacent organs are normal. This is important, since if a pathology of the spleen is detected, suspicions of other developing pathologies may arise. With the timely detection of the disturbed position of the internal organs, you can immediately begin to treat the patient.

Video instruction with a detailed algorithm of actions and practical advice from a specialist.

In fact, this is exactly what happens. When I came to the doctor with complaints of abdominal pain, the doctor first felt me in the place where the symptoms bothered me the most. So, if I suspected an enlarged spleen, the doctor found I had gastritis. Of course, confirmation of the results had to wait, but precautionary measures could already be taken.

When I took my father to the doctor, palpation did not give any results at all. Only because of severe pain in the left side, the doctor ordered additional diagnostics. After tomography and ultrasound, internal bleeding in the spleen was recorded. I had to have an operation. So this method still does not give you anything.

I wonder why to use several different methods for palpation of the spleen ... Hasn't the most optimal way been determined for this?! And from three, and perhaps even more.

Percussion and palpation of the spleen

External examination of the abdomen

Superficial palpation

If the boundaries of the organ do not correspond to the norm and it has increased, then this is easily determined during superficial palpation. This type of palpation is also called indicative. Using this technique, you can check the muscle tone of the abdominal wall in adults and children, the resistance of the muscles to probing, painful places, the divergence of the muscles located around the navel, with the rectus muscles. Before the examination, the patient should lie on his back, put his hands along the body and straighten his legs. It is also possible to determine the length, the diameter of the organ using palpation. To find out about the condition of the length and diameter, a person is examined when he lies on his back or on his side.

Deep methodical palpation according to Obraztsov-Strazhesko

Percussion of the spleen

Tapping the spleen according to M. G. Kurlov

Palpation of the spleen

Palpation of the upper and lower boundaries of the organ must be carried out when the patient lies on his back or on his side (on the right side). If the patient is lying on his back, he should extend his arms and legs. In this case, the head of the bed should be low. If the patient is examined on the right side, then he should slightly tilt his head forward and bend his left arm. At the same time, the left leg should be bent and the right leg extended. This position of the body will allow you to achieve maximum relaxation of the press, slightly move the spleen forward. Thus, it is easier for the doctor to determine the boundaries of the organ by palpation, even if it is slightly enlarged. The specialist sits on the right side of the patient. The doctor puts the left hand on the chest on the left side between the two ribs (X and VII) and slightly squeezes the chest, limiting movement during breathing.

Norms and pathologies

The norm implies the impossibility of probing the spleen. The organ becomes perceptible on palpation only with a noticeable omission and with a clear increase. In the case of the development of infectious diseases, the density of the organ decreases. It becomes soft if a person is ill with sepsis. In chronic forms of infectious diseases, cirrhosis of the liver, leukemia, the density of the spleen increases. With the development of most ailments, palpation does not cause pain. Pain appears in cases of infarction and perisplenitis.

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/ Palpation and percussion of the liver and spleen / Palpation and percussion of the liver and spleen

The gallbladder is normally not palpable, as it is soft and practically does not protrude from under the edge of the liver. But with an increase in the gallbladder (dropsy, filling with stones, cancer, etc.), it becomes accessible to palpation. Palpation of the bladder is carried out in the same position of the patient as palpation of the liver. The edge of the liver is found and directly below it, at the outer edge of the right rectus muscle, the gallbladder is palpated according to the rules of probing the liver itself. It can be most easily detected by moving the fingers transversely to the axis of the gallbladder. The gallbladder is palpated in the form of a pear-shaped body of various sizes, density and soreness, depending on the nature of the pathological process in itself or in the organs surrounding it (for example, an enlarged soft-elastic bladder when the common bile duct is blocked by a tumor - a sign of Courvoisier - Terrier; dense - tuberous bladder with neoplasms in its wall, with overflowing with stones, with inflammation of the wall, etc.). The enlarged bubble is mobile during breathing and makes pendulum movements. The mobility of the gallbladder is lost with inflammation of the peritoneum covering it, pericholecystitis. With cholecystitis and cholelithiasis, sharp pain and reflex tension of the muscles of the anterior abdominal wall in the right hypochondrium make palpation difficult.

The percussion method allows you to determine the boundaries, size and configuration of the liver. Percussion determine the upper and lower boundaries of the liver. There are upper limits of two types of hepatic dullness: relative dullness, which gives an idea of the true upper limit of the liver, and absolute dullness, i.e. the upper border of the area of the anterior surface of the liver, which is directly adjacent to the chest and is not covered by the lungs. In practice, they limit themselves to determining only the boundaries of the absolute dullness of the liver, since the position of the upper limit of the relative dullness of the liver is not constant and depends on the size and shape of the chest, the height of the right dome of the diaphragm. In addition, the upper edge of the liver is very deeply hidden under the lungs, and the upper limit of the relative dullness of the liver is difficult to determine. Finally, in almost all cases, the enlargement of the liver occurs predominantly downward, as judged by the position of its lower edge.

Percussion of the liver is carried out in compliance with the general rules of topographic percussion. Quiet percussion is used to determine the upper limit of absolute dullness of the liver. Percussion from top to bottom along vertical lines, as in determining the lower boundaries of the right lung. Borders are found by the contrast between a clear pulmonary sound and a dull one from the liver. The found border is marked with dots on the skin along the upper edge of the plessimeter finger along each vertical line. Normally, the upper limit of the absolute dullness of the liver is located along the right parasternal line at the upper edge of the VI rib, along the right mid-clavicular line on the VI rib and along the right anterior axillary line on the VII rib, i.e., the upper limit of the absolute dullness of the liver corresponds to the position of the lower edge right lung. In the same way, it is possible to establish the position of the upper border of the liver and behind, however, they are usually limited to determining only along the indicated three lines.

Determining the lower limit of the absolute dullness of the liver presents some difficulty due to the proximity of hollow organs (stomach, intestines), which give high tympanitis during percussion, hiding the hepatic sound. With this in mind, you should use the quietest percussion, or even better, use direct percussion with one finger according to the Obraztsov method. Percussion of the lower limit of absolute dullness of the liver according to Obraztsov Strazhesko begins in the region of the right half of the abdomen along the right anterior axillary line in the horizontal position of the patient. The finger-plessimeter is placed parallel to the intended position of the lower edge of the liver and at such a distance from it that a tympanic sound is heard when a blow is applied (for example, at the level of the navel or below). Gradually moving the plessimeter finger up, they reach the border of the transition of tympanic sound to absolutely dull. In this place, along each vertical line (right mid-clavicular line, right parasternal line, anterior midline), and with a significant increase in the liver and along the left parasternal line, a mark is made on the skin but the lower edge of the plessimeter finger

When determining the left border of the absolute dullness of the liver, the finger-plessimeter is set perpendicular to the edge of the left costal arch at the level of VIII IX ribs and percussed to the right directly under the edge of the costal arch to the point of transition of tympanic sound (in the region of Traube's space) into a dull one.

Normally, the lower limit of the absolute dullness of the liver in the horizontal position of a patient with a normosthenic form of the chest passes in the right anterior axillary line on the X rib, along the mid-clavicular line along the lower edge of the right costal arch, along the right parasternal line 2 cm below the lower edge of the right costal arc, along the anterior median line, 3-6 cm from the lower edge of the xiphoid process (on the border of the upper third of the distance from the base of the xiphoid process to the navel), does not go to the posterior median line on the left. The position of the lower edge of the liver and normally can be different depending on the shape of the chest, the human constitution, but this is mainly reflected only at the level of its position along the anterior midline. So, with a hypersthenic chest, the lower edge of the liver is located slightly above the indicated level, and with an asthenic chest, it is lower, approximately halfway from the base of the xiphoid process to the navel. The displacement of the lower edge of the liver down by 1 - 1.5 cm is noted in the vertical position of the patient. With an increase in the liver, the border of the location of its lower edge is measured from the edge of the costal arch and the xiphoid process; the border of the left lobe of the liver is determined along the right parasternal line down from the edge of the costal arch and to the left of this line (along the costal arch).

The obtained data of percussion of the liver allow to determine the height and dimensions of hepatic dullness. To do this, vertical lines measure the distance between the two corresponding points of the upper and lower limits of the absolute dullness of the liver. This height is normal along the right anterior axillary line equal to cm. along the right mid-clavicular line 9-11 cm, and along the right parasternal line, cm. Behind, it is difficult to determine the percussion zone of dullness of the liver (it merges with the zone of dull sound formed by a thick layer of muscles of the lower back, kidneys and pancreas), but sometimes it is possible in the form of a strip 4-6 cm wide. This avoids the erroneous conclusion that the liver is enlarged in cases where it is lowered and comes out from under the right costal arch, and also slightly rotated around its axis anteriorly, then the band of dull sound behind becomes narrower.

Percussion of the liver according to Kurlov. During percussion of the liver according to Kurlov, the following three sizes are determined: the first size along the right mid-clavicular line from the upper to the lower border of the absolute dullness of the liver (normally 9-11 cm), the second size along the anterior midline from the upper border of the liver to the bottom (normally 7 9 cm), the third size along the edge of the costal arch (normally 6-8 cm).

Determination of the percussion borders of the liver and its size is of diagnostic value. However, the displacement of the upper border (up or down) is more often associated with extrahepatic changes (high or low standing of the diaphragm, the presence of a subdiaphragmatic abscess, pneumothorax, exudative pleurisy). Only with echinococcosis and liver cancer, its upper border can shift upwards. The displacement of the lower border of the liver upward indicates a decrease in its size, but can also be observed with flatulence and ascites, pushing the liver upward. The downward displacement of the lower border of the liver is observed, as a rule, with an increase in the organ as a result of various pathological processes (hepatitis, cirrhosis, cancer, echinococcus, blood stasis in heart failure, etc.), but sometimes due to the low standing of the diaphragm. Systematic monitoring of the percussion borders of the liver and changes in the height of hepatic dullness makes it possible to judge the increase or decrease in this organ during the course of the disease.

The gallbladder is usually not detected percussion, but with a significant increase it can be determined using very quiet percussion.

Percussion is used not only to determine the size of the liver and gallbladder (topographic percussion), but also to assess their condition: percussion (careful) on the surface of the enlarged liver or over the area of the gallbladder causes pain during inflammatory processes (hepatitis, cholecystitis, pericholecystitis and etc.). Tapping (succusio) on the right costal arch also causes pain in diseases of the liver and biliary tract, especially in cholelithiasis (Ortner's symptom).

Palpation of the spleen is carried out in the position of the patient lying on his back or on his right side. In the first case, the patient lies on a bed with a low headboard, his arms are extended along the body, his legs are also extended. In the second case, the patient is laid on the right side, his head is slightly tilted forward to the chest, the left arm, bent at the elbow joint, lies freely on the front surface of the chest, the right leg is extended, the left is bent at the knee and hip joints. In this position, maximum relaxation of the abdominals is achieved and the spleen is moved closer anteriorly. All this facilitates its determination by palpation, even with a slight increase. The doctor sits to the right of the patient facing him. The doctor places his left hand on the left half of the patient's chest between the 7th and 10th ribs along the axillary lines and squeezes it somewhat, limiting its movement during breathing. The doctor places the right hand with slightly bent fingers on the anterolateral surface of the patient's abdominal wall at the edge of the costal arch, at the junction of the end of the X rib with it, or, if the examination and preliminary percussion data suggest an enlarged spleen, at the supposed location of its anteroinferior edge. Then, as the patient exhales with his right hand, the doctor slightly presses the abdominal wall, forming a pocket; then the doctor asks the patient to take a deep breath. At the moment of inhalation, if the spleen is accessible to palpation and it is carried out correctly, the spleen, moving downward by the descending diaphragm, approaches the fingers of the doctor’s right hand with its anteroinferior edge, rests against them and, with its further movement, slips under them. This technique is repeated several times, trying to explore the entire edge of the spleen accessible to palpation. At the same time, attention is paid to the size, soreness, density (consistency), shape, mobility of the spleen, and the presence of cuts on the front edge is determined. Characteristic for the spleen, one or more cuts on the front edge are determined with a large increase in it. They allow you to distinguish the spleen from other enlarged abdominal organs, such as the left kidney. With a significant increase in the spleen, it is also possible to examine its anterior surface, emerging from under the edge of the costal arch.

Normally, the spleen is not palpable. It becomes accessible to palpation only with a significant omission (rarely with an extreme degree of enteroptosis), most often with an increase. Enlargement of the spleen is observed in some acute and chronic infectious diseases (typhoid and relapsing fever, Botkin's disease, sepsis, malaria, etc.), liver cirrhosis, thrombosis or compression of the splenic vein, as well as in many diseases of the hematopoietic system (hemolytic anemia, thrombocytopenic purpura, acute and chronic leukemias). A significant increase in the spleen is called splenomegaly (from the Greek. Splen - spleen, megas - large). The greatest increase in the spleen is observed in the final stage of chronic myeloid leukemia, in which it often occupies the entire left half of the abdomen, and goes into the small pelvis with its lower pole.

In acute infectious diseases, the density of the spleen is low; especially soft, doughy consistency of the spleen in sepsis. In chronic infectious diseases, cirrhosis of the liver and leukemia, the spleen becomes dense; it is very dense in amyloidosis.

In most diseases, palpation of the spleen is painless. It becomes painful with splenic infarction, perisplenitis, and also in case of a rapid increase due to stretching of the capsule, for example, when venous blood stagnates in it during thrombosis of the splenic vein. The surface of the spleen is usually smooth, the roughness of its edge and surface is determined with perisplenitis and old heart attacks (there are retractions), the tuberosity of its surface is observed with syphilitic gums, echinococcal and other cysts and extremely rare tumors of the spleen.

The mobility of the spleen is usually quite significant; it is limited to the perispleen. The sharply enlarged spleen remains motionless during breathing, but it usually still manages to be displaced by hand during palpation. Often, with leukemia, not only the spleen increases, but also the liver (due to metaplasia), which is also examined by palpation.

In the study of the system of hematopoietic organs, percussion is of limited importance: it is used only for an approximate determination of the size of the spleen. Due to the fact that the spleen is surrounded by hollow organs (stomach, intestines), containing air and giving a loud tympanic sound during percussion, it is impossible to accurately determine its size and boundaries by this method.

Percussion is carried out in the position of the patient standing or lying on the right side. You need to percuss very quietly from a clear sound to a dull one; It is best to use the Obraztsov method. To determine the diameter of splenic dullness, percussion is carried out along a line located 4 cm lateral to the left costoarticular line (this line connects the sternoclavicular joint with the free end of the XI rib). Normally, splenic dullness is determined between the IX and XI ribs: its size is 4 6 cm. The length of the spleen comes medially to the costoarticular line; the percussion size of the dullness of the length of the spleen is 6-8 cm

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First, a few general remarks about how to palpate the abdomen in general.

To achieve maximum relaxation of the abdominal muscles, it is necessary to lay the patient on a comfortable but hard bed with outstretched legs and arms along the body. Each of these seemingly simple rules is very important for the success of the business. To see this, let's see what happens if we do the opposite. For example, let's ask the patient to slightly bend his legs and raise his knees (by the way, a very common, but erroneous recommendation!). It would seem that this is beneficial: the pubic bones will approach the xiphoid process somewhat, and the tension of the abdominal muscles should decrease. However, in order to keep the legs in a half-bent position with raised knees, the patient must strain a number of muscles. There will no longer be complete rest in this position, while the tone of the abdominal muscles will also involuntarily increase. Palpation won't get any easier. Only if we place a pillow or bolster under the subject's knees will the legs be passively flexed, thus avoiding this unwanted muscle tension. But it is much easier than just to offer the patient to lie down comfortably and stretch his legs! In addition, when palpated flat with the whole palm, the doctor's forearm also touches or almost touches the abdominal wall, and the elbow will often rest against the patient's raised hips, interfering with freedom of movement. If the patient puts his hands behind his head, then the chest will move up to the head. But since the pelvis remains in the same place, the abdominal muscles will stretch. Again, palpation will become more difficult. Finally, if the patient finds himself on a bed that is too soft (a featherbed, a squeezed bed or a “cot”), then his back will bend, the distance between the costal arches and the pelvis will decrease significantly, the stomach will seem to fail, and it will become uncomfortable to palpate it.

As for the doctor, he should sit to the right of the patient (left-handed doctor - to the left) and also make himself comfortable so that his back and shoulder girdle muscles do not get tired. Hands must be warm so as not to cause a protective spasm of the abdominal muscles. If the hands are cold, then either wash them in warm water, or begin to palpate through a sheet or shirt. Sometimes children are ticklish and convulsively contract their abdominal muscles at every touch of someone else's hand. In these cases, a very simple trick helps. Put the patient's hand on the stomach, and yours on it, and begin to palpate through such a "pad". As a rule, the stomach immediately becomes supple.

Finally, it is extremely important to always palpate gently, without much physical effort. But the point here is not only and even not so much in the desire not to cause pain; as will be seen from the following, it is soft, delicate palpation that provides the greatest amount of information. One highly experienced American physician begins his recommendations for palpation with the following wise remark: “First, gently place your warm palm on the epigastric region and relax it. This will subconsciously convince the patient that he is being examined by an experienced and attentive doctor; the patient will calm down and relax.

Inexperienced Doctors often they feel the stomach the way all people do when looking for a switch or a keyhole in the dark: they just rummage around and poke their hand at random, at random. This has nothing to do with the methodical deep sliding palpation developed by V.P. Obraztsov, F.O. Gausman and N.D. Strazhesko. The techniques they describe very ingeniously use some facts from the physiology of the tactile sense and topographic anatomy. To successfully use these techniques, you need to clearly understand their meaning. To this end, we will make a preliminary simple experiment.

Let's put a piece of paper on the table and cover it with a thick soft cloth, for example, a blanket or at least a hollow jacket. Let's try to feel the leaf through this impressive barrier. It would seem that the task is impossible: no matter how much we fumble with our hands, the tactile sensation will be the same everywhere, and it will not be possible to find a sheet of paper. But let's not despair. Let's put the right palm flat on the cloth in such a way that the nail phalanges of the II-IV fingers are on the sheet, and the rest of the hand would be where there is no sheet under the cloth. Lightly press the cloth to the table with the tips of these fingers, and quickly pull out the sheet with the left, free hand, pulling it from under the fingers in the direction of the longitudinal axis of the right hand. At this moment, we will clearly feel not only how the edge of the sheet slips under the fingers, but we will also get a clear idea of \u200b\u200bthe outlines of this edge (whether it is even or jagged), as well as its thickness.

This simple experience, described by F.O. Gausman in his wonderful book “Fundamentals of methodical probing of the gastrointestinal tract” (Moscow, 1912), clearly illustrates the essence of Gliding palpation: in order to feel any object, you need to lightly press him and then make him move quickly so that he slips under the probing fingers.

How to do it? First, you can take advantage of the respiratory mobility inherent in some organs. So, the liver, spleen, kidneys, stomach and transverse colon descend when inhaling along with the diaphragm to the pelvis, and when exhaling they return up to the chest. If, in addition, at the moment of the respiratory displacement of the object under study, we also move the palpating fingers towards (opposite-directed movement), then the slipping speed will increase. As a result, our palpatory sensation will become even more distinct. So, the first condition for successful deep palpation of the abdomen is deep diaphragmatic breathing.

The second, even more important condition is the sliding movements of the palpating fingers. Don't point your fingers, but slide! This maneuver becomes especially necessary when palpating those organs that do not themselves move during breathing. For example, how to feel the sigmoid colon? No matter how much you blindly poke your fingers in the left iliac region, you will not find this intestine, unless it is filled with dense fecal masses. Let's do it differently. We put the tips of the half-bent II-IV fingers of the right hand deliberately inward from the intended projection of the sigmoid colon, gently press them to the posterior wall of the abdominal cavity and, with a sliding movement, begin to shift the depressed ends of the fingers outward perpendicular to the alleged length of the sigmoid colon. At some point in this movement, we will definitely hit the medial edge of the intestine, but at first we will not feel it. With further outward movement, the fingers will drag the intestine along, its mesentery will stretch, and then the intestine will inevitably slip out from under the fingers to return to its original place. It is at this moment that we will immediately get a surprisingly clear idea about the size (diameter) of the intestine, and about its tone, and about the density of its walls, and about its fullness with fecal masses.

That's why, on deep palpation, the hand doesn't just move and grope around the abdomen. It is necessary to constantly make sliding movements, and the direction of sliding should always be meaningful, determined by topographic anatomy: either towards the movements of the respiratory organ that is displaced, or perpendicular to the long axis of the displaced segment of the intestinal loop.

How to use the respiratory mobility of the abdominal organs to the maximum advantage? Sometimes, for this purpose, the patient is asked: “Breathe with your stomach!”. However, in response, the patient often does not at all what we need: when inhaling, he straightens his chest (“chest with a wheel”) and draws in his stomach, and when he exhales, he sticks out, inflates his stomach. Therefore, it is better not to fix the patient's attention on abdominal breathing, but simply tell him: "Breathe deeply, through your mouth, but take your time." With free deep breathing, the diaphragm will certainly move, and the amplitude of the displacement of the abdominal organs will be quite sufficient for our purpose. Often the patient obediently takes a few deep breaths, but soon returns to calm, that is, very shallow breathing. That is why it is necessary to constantly, throughout the entire study, control the patient's breathing and, if necessary, again encourage him to breathe deeper. Since we do not just need to move the object under the fingers, but rather quickly slip it, then the breath should not only be deep, but also quite fast. Therefore, the patient must necessarily breathe through the mouth, and not through the nose, and exhale a little faster than usual. At the same time, it is not necessary to force exhalation: otherwise, the abdominal muscles will inevitably tighten, and palpation will become difficult. Exhalation should be passive, but not deliberately slow. Very often it is necessary to repeatedly show the patient what type of breathing the doctor needs for research. As a rule, after several such shows, joint work becomes well-coordinated and convenient. Sometimes the patient pauses between inhalation and exhalation. This also interferes, for it is precisely the sudden change of motion through 180 degrees that makes the palpatory sensation especially clear. In this case, I say: "Breathe deeply, but continuously, do not linger!" and if necessary, I again show what I need. It is not necessary to spare time for the patient to understand his task, because as a result we can get really reliable and valuable information.

After these general preliminary, but absolutely necessary details, we turn to a description of the methods of palpation of various organs.

LIVER PALPATION.

Often I see how a doctor with many years of experience, poking the patient's stomach with his hand - a shovel, and, of course, not finding anything, passes from this fruitless (in his opinion), but for some reason mandatory stage to a more reliable one, as it seems to him , method - determination of the lower edge of the liver by percussion. Every time I think at the same time: “Poor thing, how unlucky you are! They didn't teach you how to palpate the liver, but it's so easy! As for the popular advice to determine the lower edge of the liver using percussion, let's recall some anatomical facts. The liver in the sagittal plane resembles a sharp wedge, with its apex facing anteriorly and downwards. Only at some distance from the edge, the thickness of the liver becomes sufficient to cause dullness of the percussion sound. If, moreover, we take into account that a change in the tone of the sound has to be sought against the background of loud intestinal tympanitis, then all doubtfulness becomes clear, one might even say - the hopelessness of this diagnostic technique. And indeed, if you are not too lazy and find the edge of the liver with the help of palpation, then it will certainly turn out to be at least one finger width lower than it seems according to percussion. That's why I personally never use percussion for this purpose. If the liver is enlarged by at least two centimeters, it can almost always be felt. How to do it?

For preliminary orientation, gently place the right palm flat on the stomach in the right hypochondrium so that the direction of the fingers coincides with the length of the body, and their ends lie just below the costal arch. Then we slightly immerse the slightly bent nail phalanges of the II-IV fingers several times into the stomach. If the liver protrudes from under the costal margin, then we will feel some resistance, resistance. Immediately, until this feeling is forgotten, let's move the palm to the symmetrical section of the left hypochondrium and repeat the same maneuver. You will immediately feel that this time the immersion is much easier, and this is not surprising - here only the loops of the intestines or the stomach resist the fingers. Let's return to the right hypochondrium again, but now we put our hand a little lower (closer to the pelvis) and again lightly press our fingers into the stomach. Such alternating light superficial palpation on both sides in the direction from the costal arches down to the pelvis allows you to quickly and completely painlessly determine the approximate position of the lower edge of the liver: this is the border between normal and increased resistance. It goes without saying that if the liver is not enlarged, then there will be no additional resistance in the right hypochondrium, and palpation sensations on the right and left will be the same.

You can do it a little differently. Let us try to plunge the fingers, as just described, directly under the right costal arch, and then immediately move the palpating hand as low as possible into the right iliac region and repeat this maneuver again. Here, below, the fingers will certainly meet no resistance. Taking this last sensation as a "standard", we will begin to gradually move the hand up, towards the desired edge of the liver, each time only slightly immersing the fingertips. As soon as the nail phalanges lie on the anterior surface of the liver, we immediately and clearly feel that the resistance has increased.

For the success of the case, the pressure of the fingers must be soft, delicate, because only then can one catch the difference in the resistance of two adjacent sections of the abdominal wall. Do not press your fingers very deeply; on the contrary, the immersion depth should not exceed one or two centimeters. If you press roughly, with all your urine, then the abdominal wall will definitely bend, go down, regardless of what lies under it - an intestinal loop filled with air, or a dense liver. Palpatory sensation in both cases will be the same. So, gentle, sparing palpation is preferable not only for humane reasons: it is also much more informative!

By the way, any pickpocket prefers to steal in a dense crowd, in a crush: he knows perfectly well that against the background of strong ambient pressure, an additional light touch is almost imperceptible. That is why, if the palpating hand presses strongly, then the fingers will not feel the additional light movement of the desired organ under them! ..

Now let's check ourselves. Let's put the palm on the stomach in such a way that the nail phalanges of the II-IV fingers are just below the border of the liver we found and again plunge them into the stomach, but this time a little deeper. Having fixed the submerged fingers, we will ask the patient to take a deep breath (all previous maneuvers are carried out with calm spontaneous breathing). As soon as the patient, on our command, inhales, we immediately feel how something dense slipped under our fingers. To make this feeling more distinct, let's make an oncoming movement: as soon as the inhalation begins, we quickly move our fingers up, to the ribs, along with the skin; while the fingers should still remain half-bent and slightly immersed in the stomach. And during the next exhalation, we will again move the half-bent nail phalanges, but now down to the pelvis. With this last maneuver, there is often a sensation as if the fingers were slipping off some step. The described techniques make it easy and completely painless to find the edge of the liver, even with a very thick abdominal wall.

If the edge found in this way protrudes from under the ribs much (3-5 cm or more), then the anterior (upper) surface of the liver should be immediately examined - whether it is smooth or bumpy. To this end, we put the nail phalanxes of the II-IV fingers of the right hand on the anterior surface of the liver, that is, between the found edge and the costal arch, and again make several sliding movements: when inhaling up (to the ribs), and when exhaling down (to the pelvis). At the same time, the pressure of the fingers should also be small so as not to dull the tactile sensations; fingers should move with the skin. Moving the fingers in this way, we can easily detect even small irregularities on the surface of the liver. On palpation in the region of the rectus abdominis muscles, it is sometimes possible to feel the depressions caused by the transverse tendon bridges characteristic of these muscles. To find out whether this irregularity belongs to the liver or the abdominal wall, it is enough to invite the lying patient to slightly raise his head. The abdominal muscles will tighten, and if the unevenness remains, then it is in the rectus muscle.

Having thus discovered the edge of the liver, that is, its lower border, we will then try to find out the properties of this edge - whether it is sharp or not, the degree of its density and sensitivity. To do this, use slightly different palpation techniques. We put the nail phalanxes of the II-IV fingers of the right hand just below the supposed edge of the liver. During a calm exhalation, we smoothly immerse the half-bent fingers deeper and fix them in this position: in the first moments of the subsequent deep breath, our fingers should remain motionless, that is, provide some (however, moderate!) Resistance to the abdominal wall already beginning to heave. During this time, the edge of the liver will drop and rest against the fingertips; if the abdominal wall is flabby, and the fingers are sunk deep enough, then moving down to the pelvis, the edge of the liver will lie on the nail surface of the terminal phalanges. Usually this touch is palpable, although not very distinct. Even if we felt it, after a few moments from the beginning of inhalation, we must make a quick extensor movement with the fingers and the whole hand (but without taking the fingers off the skin of the abdomen!) And then immediately move the still half-bent fingers up towards the costal arch. The result will be a trajectory reminiscent of a "knight's move" in chess. With this maneuver, which, by the way, is very simple and easy, despite the cumbersome description, the edge of the liver, continuing its movement down to the pelvis, slips around the fingertips, so that at the end of inspiration, the palmar surfaces (pads) of the nail phalanges are on the front surface. liver, just above its edge.

I emphasize once again that throughout this maneuver the fingers do not leave the abdominal wall for a moment: they remain immersed in the stomach all the time. It's just that at the end they are not as deep as at the beginning. In addition, let me remind you again that without correct, that is, deeper than normal, but not forced breathing, palpation of the liver rarely gives the desired results. The slipping itself takes only a moment, but the sensation is so distinct that one can immediately give a detailed description of the edge of the liver: is it sharp or rounded, soft or hard, painful or not, even or jagged.

Regardless of whether we found the edge of the liver in this way or not, we must then make the opposite movement: as soon as the next exhalation begins, we should move our fingers together with the skin down (toward the pelvis) and inward. In this case, there is a feeling that the fingers seem to be slipping off some kind of step. Often only at this second stage, that is, already during exhalation, it is possible to feel the edge of the liver.

Naturally, it is easiest to master these techniques under the guidance of an experienced doctor. Alas, not always a young doctor is lucky in this regard, but you should not despair. In this case, you yourself need to find a suitable object for the initial training. A combination of hepatomegaly with a sufficiently thin and soft abdominal wall is necessary. Of course, under such conditions, the liver and its edge can be felt without the above manipulations, simply by the “poke” method. But a doctor who wants to learn how to palpate for real in any conditions should learn the technique of sliding palpation in such an facilitated situation, since constant self-control is possible here.

We now turn to the diagnostic conclusions that palpation of the liver can give. In a healthy person, the edge of the liver is either not palpable at all, or, at most, slightly protrudes at the height of inspiration from under the right costal arch. In this case, it is painless, softly elastic and slightly rounded. If the edge of the liver protrudes one transverse finger or even lower, then this is a clear deviation from the norm. The first thing to find out in this case is whether the liver is actually enlarged, or whether it is simply lowered, pressed down. The latter often occurs with severe emphysema, since in this disease the diaphragm flattens and is very low. Percussion determination of the upper border of the liver helps here, which, by the way, is much more reliable than percussion of its lower border. The distance between the palpable lower edge of the liver and its upper (percussion) border along the right mid-clavicular line should not exceed 10-12 cm (approximately the width of the palm). If the liver is crushed by a right-sided massive hydrothorax, then, naturally, percussion will not help here. But when the liver is simply lowered, then its edge retains a normal soft-elastic consistency, it is painless, and it does not protrude much - a maximum of 3-4 cm.

If the edge of the liver protrudes significantly - by two or three transverse fingers or even more, then there is no doubt: the liver is enlarged, there is hepatomegaly. The causes of liver enlargement are many, but in the daily work of a general practitioner, the first diagnostic considerations should be as follows.

The general condition of the patient is quite satisfactory (no weight loss, abdominal pain, jaundice, dyspeptic complaints), the liver is moderately enlarged (by two to three centimeters), its edge is of normal consistency and painless. In this situation, you need to think about heart failure, alcoholism, diabetes. It is imperative to look for the spleen: its enlargement will immediately direct the diagnostic search towards cirrhosis of the liver or blood diseases. Quite often, however, none of the assumptions just mentioned are confirmed; liver function tests and ultrasound are normal. In this case, you can temporarily refrain from further, more time-consuming and complex studies and limit yourself to monitoring the patient.

The liver is significantly enlarged (by two or three transverse fingers or more). Most often this is the result of long-standing severe heart failure. With such congestive induration, the edge of the liver is pointed, dense, painless. The spleen is either not palpable (most often) or slightly protrudes from under the left costal arch.

Other, more rare causes are chronic hepatitis, fatty degeneration of the liver due to chronic alcoholism or diabetes, and, finally, metastases of a malignant tumor (by the way, the liver is not necessarily tuberous). In the cases just listed, the spleen is not palpated. On the contrary, if the spleen is also enlarged, then the diagnostic search is directed towards blood diseases (chronic myeloid leukemia, myelofibrosis) and liver cirrhosis. Of course, only the most common causes of hepatomegaly are listed here, which should be thought about in the first place, right there at the patient's bedside, even in the process of direct physical examination. The results of additional laboratory and instrumental methods may provide new food for diagnostic considerations.

In another way, you have to look for the liver with large ascites. Let's put the patient on his back. We bring our right hand to the right hypochondrium of the patient and slightly touch the abdominal wall with the ends of slightly bent II-IV fingers (while the palm remains on weight and does not touch the abdominal wall!). Then sharply, abruptly push the abdominal wall perpendicularly inward and leave the fingertips in contact with the skin. If there is a liver in this place under the fingers, then from our push it will first go into the depths - “drown”, and then pop up again. It is at the moment of its return to its original position that our fingers will feel a slight push. Where there is no liver behind the abdominal wall, and only intestinal loops float, the described jerky palpation does not give such a sensation. This technique was shown to me by my unforgettable teacher V.A. Kanevsky; he called it the "floating ice phenomenon". By gradually moving the hand down from the costal arch to the pelvis and repeating the pushes, one can get an approximate idea of the degree of liver enlargement, although the edge of the liver cannot be felt with ascites.

PALPATION OF THE GALL BLADDER.

If the outflow of bile from the gallbladder is disturbed, it swells, stretches and comes out from under the edge of the liver. Then it can often be felt. With a significant increase in the gallbladder is defined as a smooth elastic body with a clear rounded lower border (bottom of the bladder). His body is no longer palpable so clearly, although it seems that it goes somewhere deeper, under the right costal arch or, if the liver is enlarged, under its edge. Sometimes the bubble enlarges so much that it resembles a small eggplant to the touch. In this case, it shifts not only during breathing together with the liver (cranially and caudally), but it can even be moved with a palpating hand to the right and left. This body differs from an enlarged kidney in that, during bimanual palpation, it is felt only by the front hand lying on the stomach, while the other hand, located behind, in the lumbar region, does not feel it. However, such huge gallbladder sizes are rare.

More often you can only feel the bottom of the bladder, protruding from under the liver by one to three centimeters. If at the same time the liver itself is also enlarged, then often on palpation of its anterior surface, one can detect a slight swelling near its edge: it seems that directly under the lower edge of the liver there is some small body, like a plum, raising a rather thin tongue-shaped edge of the liver . The edge itself also forms a small rounded protrusion.

To find out whether we are simply dealing with an uneven hepatic margin, or whether this protrusion is formed by the fundus of the gallbladder, a technique taught to me by Dr. A.S. Wolfson. The initial position of the palpating hand is the same as during normal palpation of the edge of the liver (palm flat on the stomach, terminal phalanges of the II-IV fingers just below the edge of the liver). Now let's spread the third and fourth fingers in such a way that the "ledge" of interest to us is in the gap between them, and ask the patient to take a deep breath. If this protrusion is the bottom of the gallbladder, that is, a spherical formation, then when we inhale, when the bubble descends, this “ball” will further push our fingers apart. If there is only an unevenness of the liver edge, then all the fingers will simply be pushed down to the pelvis, but we will not feel the additional spreading of the third and fourth fingers.

By the way, it should be noted that during palpation the gallbladder very often is not in the traditional "point of the gallbladder", but much more lateral, to the right of the right midclavicular line. Of course, the gallbladder is not palpated as often as the edge of the liver, but still much more often than it seems to doctors who do not know the technique of sliding palpation. Therefore, I strongly advise not to spare a few tens of seconds and look for the gallbladder in every case when we suspect the possibility of its disease.

The gallbladder is palpable in several situations. If the bladder is painful, and if, in addition, the disease is acute (recent pain in the right hypochondrium, fever), then the diagnosis of acute cholecystitis becomes very likely.

If the bladder is painless, then you need to think about chronic dropsy of the gallbladder, and here there are two completely different options. An enlarged, painless gallbladder without jaundice indicates long-standing blockage (by a stone) in the bladder neck or cystic duct (ductus cysticus). In this case, the bile from the liver continues to flow into the duodenum, as expected, through the common bile duct (ductus choledochus) bypassing the gallbladder, and jaundice does not occur. If we find a painless enlarged gallbladder against the background of jaundice, this means that the common bile duct is closed. This situation is most often caused by a tumor of the head of the pancreas (Courvoisier symptom).

By the way, if pancreatic cancer is suspected, it is useful to attach a phonendoscope to the abdominal wall in the epigastrium along the midline, approximately at the level of the pancreas. The fact is that sometimes a cancerous tumor compresses a large artery that passes inside the pancreas along its length, and then you can hear a systolic vascular murmur. If such a noise is detected, then the question arises, where does it form - in the sclerotically altered abdominal aorta or is it really in the pancreatic artery? To find out, let's shift the head of the phonendoscope to the left of the midline. If the noise is caused by stenosis of the pancreatic artery, then it will spread along its course, that is, to the left. If the noise occurs in the aorta, then it will only spread down the midline, that is, along the aorta, and we will not hear it to the right and left of the aorta. I encountered this phenomenon several times in my own practice.

SPLEEN PALPATION.

The spleen enlarges, and is palpable much less frequently than the liver, but its enlargement usually indicates some serious disease. The most common causes of splenomegaly are: infections, in particular sepsis; diseases of the blood system; cirrhosis of the liver; autoimmune diseases. That is why, in the case of an unclear clinical picture, it is so important to find out whether the spleen is enlarged or not.

First, we proceed to palpation of the spleen in the position of the patient lying on his back. We place the right hand flat in the left hypochondrium so that the ends of the II-IV fingers are located along the costal arch, just below it, approximately along the anterior axillary line. Then, in the same way as during the approximate, superficial palpation of the liver (see above), we gently immerse the half-bent nail phalanges of these fingers deep into the abdomen by one or two centimeters. After that, we will begin to gradually move the palpating hand more and more outward - to the middle, and then to the posterior axillary line. By repeating each time a slight pressure with the fingertips, one can thus examine the compliance of the abdominal wall in the entire left hypochondrium.

The fact is that the location of the spleen is not strictly defined, because it is held mainly by a rather mobile vascular pedicle, in contrast, for example, to a firmly fixed liver. Therefore, when looking for the edge of the spleen, it is necessary to examine a fairly large area of the left hypochondrium, starting slightly anterior to the anterior axillary line and down to the back.

If the spleen protrudes beyond the costal margin, then in this place we will feel a slightly increased resistance. Having discovered this, it is then necessary, with the help of the same light superficial palpation, to find out its approximate outlines. If, as most often happens, there is no such area of resistance (that is, the spleen is not enlarged or only slightly enlarged), then we proceed to deep palpation, again along the entire left costal arch, and not only in the so-called "projection of the spleen" . The technique here is exactly the same as for palpation of the liver. We immerse the end phalanges of the half-bent fingers of the right hand two to four centimeters deep into the abdomen and slightly upwards, to the supposed edge of the spleen, and then invite the patient to take a deep breath. At the very beginning of this inhalation, our fingers must remain motionless, fixed, so that the lower edge of the spleen, which begins to descend, rests on the fingertips (or even lies on their nail surface). Only then, after a few moments from the beginning of inhalation, you need to make a quick extensor movement with your fingers. If the spleen is enlarged, then at this point its edge will slip under the fingertips and continue its movement down to the pelvis. This touch is fleeting, but very well felt. Do not forget also at the very beginning of the next exhalation to make a reverse movement with your fingers from top to bottom and deep into; sometimes only with this last maneuver, when the fingers seem to slide off the step, it is possible to find the edge of the spleen.

If palpation with the patient lying on his back is inconclusive, and the question of whether the spleen is enlarged or not is very important, then you should turn the patient halfway to the right side (by 45 degrees) and again examine the entire left hypochondrium using the techniques just described . The subject's left hand should at this time lie on his left half of the chest in order to increase the respiratory excursions of the diaphragm. It is usually recommended to palpate the spleen only in this position - lying half-turned on the right side. In fact, a slightly enlarged spleen can sometimes be found only in the supine position, and in other cases only in the position on the right side. In my practice, the position on the back more often turned out to be effective; perhaps this is due to the fact that the position on the back is most convenient for the patient and therefore provides maximum relaxation of the abdominal muscles. Be that as it may, if necessary, you should look for the spleen in both positions. Sometimes it is advised to use two hands at once when palpating the spleen: the left palm should be placed on the ribs just above the left costal arch in order to limit the mobility of the chest during breathing and, thereby, supposedly, increase diaphragm excursions, and palpate with the right hand. I find this way cumbersome and inconvenient. Excellent results can be obtained by palpating with only one hand, but for the success of the case, you must constantly control the patient's breathing!

Finding the edge of the spleen suggests that it is enlarged, because the normal spleen is never palpable. In the case of an acute infectious process, the edge of the spleen is usually rounded and softly elastic, it resembles in consistency the tip of the tongue when it is probed through the cheek. In chronic processes, the edge of the spleen is usually pointed, dense, cartilaginous - like the cartilage of the auricle. Sometimes it is not clear what we have probed - the spleen or the left kidney. The spleen is located very superficially, just below the costal margin, while the kidney is located much deeper, behind the peritoneum of the posterior abdominal wall (retroperitoneally). Further, the edge of the spleen is rather sharp, while the lower pole of the kidney is rounded. Finally, the retroperitoneal location of the kidney makes it possible to palpate it, unlike the spleen, simultaneously with both hands (bimanual palpation).

It happens that the length of the spleen has not yet increased, but the organ itself has become more massive, thicker. This will be manifested by a more distinct dullness of the percussion sound, whereas normally the percussion of the spleen is greatly hampered by tympanitis due to the large air bubble in the stomach, not to mention the gas in the intestinal loops. The best method of percussion of the spleen is, in my opinion, percussion according to V.P. Obraztsov. It consists in the following.

Let's bring the right hand close to the area under study and place it parallel to the chest, but we will not touch the skin with our fingers (the hand remains hanging). Let's start the terminal phalanx of the index finger on the back (nail) surface of the third finger and then sharply move it down. A blow on the skin of the nail phalanx of the index finger sliding down creates a soft percussion sound (click). Since the impact falls on a very small area, the differentiation of different shades of percussion sound becomes much easier. For percussion of the spleen, the patient lies half-turned on his right side, he puts his left hand on his head. They are percussed from top to bottom along the anterior, middle and posterior axillary lines, and they start obviously above the expected location of the upper edge of the spleen - for example, from the level of the nipple or the lower edge of the scapula. Such percussion often makes it possible to detect an area of dullness, which in its contour is very similar to the outline of the spleen.

That this dullness really belongs to the spleen is confirmed by the following maneuver. Even if the lower edge of the spleen cannot be felt, we will immerse the fingers of the left hand under the left costal arch in the place where, according to percussion, the spleen should be located, and with the right hand we will again begin to percuss according to V. P. Obraztsov from top to bottom, gradually approaching the upper limit of dullness . At the moment when the clicks begin to fall on this border, we will feel that they are transmitted through the spleen to the fingertips of the left hand, located deep in the left hypochondrium.

KIDNEY PALPATION.

The kidneys are located in the retroperitoneal space, but it is not possible to probe them from the lumbar side. For palpation of the kidneys use both hands at once. The principle of this bimanual palpation is to try to catch and hold the kidney between the palms, and then let it slip out of them. In textbooks, it is usually recommended to lay the patient half-turned on the right side if they are looking for the left kidney, and half-turned on the left side if they are looking for the right kidney. Personally, I have more often achieved positive results with the patient simply lying on his back - perhaps because this position is more comfortable and creates the best relaxation of all muscles.

The doctor is located to the right of the patient. When examining the right kidney, we put the right palm flat on the stomach in the right hypochondrium, and slip the palm of the left hand from the right side of the patient into the right half of the lower back. The length of each palm coincides with the length of the body, and the fingertips slightly do not reach the costal arch both in front and behind. Then we try to bring the front palm closer to the back (I remind you again, this compression should be smooth and soft!). Since the kidneys are displaced during breathing, it is extremely important to control the patient's breathing during this study. The patient is offered to take a deep, but not very fast breath through the mouth. The fingers of both hands remain all the time slightly pressed into the patient's body both in front (from the side of the abdomen) and behind (from the side of the waist). As soon as the inhalation begins, it is necessary to slightly weaken the pressure of the fingers (only!), But do not spread the palms themselves. Thus, we, as it were, let the kidney into the “trap” between the palms. At the moment the next exhalation begins, we again slightly increase the compression of the fingers and at the same time slightly move both hands, together with the skin, down to the pelvis. As a result of this maneuver, the caught kidney slips out of the hands like a fish. The moment of slipping is very clearly felt by both palms at once. This creates an idea about the size of the kidney, and the nature of its surface, and its sensitivity.

If there is uncomplicated nephroptosis, that is, if the kidney tissue itself is not affected by the disease, then the fingers feel a smooth-elastic body with rounded edges, like a somewhat flattened cylinder with a characteristic rounded lower edge. The upper pole of the kidney is available for palpation very rarely, with extreme degrees of nephroptosis; usually it is possible to probe only the lower part of the kidney. A normal kidney is painless on palpation. The left kidney is palpated in the same way, only this time the left palm is located in front, on the stomach, and the right palm is slipped through the left side into the left half of the lower back. In healthy people, the kidneys are not palpable. Therefore, the detection of at least the lower pole of the kidney, especially its body, requires further clarification with the help of more complex instrumental research methods (ultrasound, x-ray).

Sometimes the kidney is enlarged (or lowered) so much that it is palpable even with quiet breathing in the form of a dense formation in the hypochondrium. Then naturally the question arises whether this body is a kidney or something else (spleen? liver? tumor?). The following signs help here: A) good respiratory mobility; B) rounded lower and lateral edges of the palpated body (the spleen is much flatter, and therefore its edges are perceived as somewhat pointed, and the edges of the kidney are rounded, like the lateral surface of a slightly flattened cylinder); C) the ability to feel this body with the help of bimanual palpation (the spleen and liver are located much closer anteriorly and therefore cannot be palpated with the back hand); D) Finally, the kidney ballot maneuver helps.

In this maneuver, both hands are positioned in exactly the same way as in conventional bimanual palpation. When the body under study is between both palms, it is necessary to slightly push it several times with the fingers of the back hand; if it is a kidney, then it will transmit these shocks to the fingers of the front hand.

Palpation of the abdomen will be incomplete if the space above the pubis is not examined. Here you can find an overflowing bladder or an enlarged uterus, not to mention various tumors. Here the palpating fingers should slide from top to bottom, from the navel to the pubic bones. Prostate adenoma, so common after the age of 40-50, always makes it somewhat difficult for urine to drain from the bladder. Constantly overcoming this obstacle, the bladder muscle gradually weakens, emptying becomes incomplete, and residual urine accumulates in the bladder. Therefore, often the bottom of the bladder begins to protrude above the pubis. Then we palpate the upper pole of the smooth elastic body, the main part of which is hidden behind the pubic joint.

To make sure that this is really the bladder, and not, say, a loop of the sigmoid colon, we press lightly on this body deep into (towards the back) and downwards (towards the small pelvis) and ask the patient if he wants to urinate. In the case of an affirmative answer, we will check ourselves additionally: move our fingers a little higher, to the navel, so as not to touch this body, press again and ask again: “Do you want to urinate now?”. A negative response during the second maneuver will finally certify that the detected formation is indeed the bladder. However, the research should not end there. If we find a bladder protruding at least slightly above the pubis, we must offer the patient to urinate, and then immediately again probe the suprapubic space. If the bottom of the bladder is still palpable, this indicates a serious disorder of emptying and a significant amount of residual urine. Several times during the usual, routine examination of the abdomen, to my amazement, I found the bottom of the bladder in the middle of the distance between the pubis and the navel and even higher, although the patient did not present absolutely any dysuric complaints!

In the same way, one should get into the habit of palpating the suprapubic space in every woman: at a young age, one should always be aware of a possible pregnancy, which can be a surprise not only for the doctor, but also for the woman; at an older age, tumors of the uterus and appendages, both benign and malignant, are not so rare.

I will end with the words of the famous French surgeon A. Mondor: “How painful is the sight of an inexperienced, rude and not reaching its goal hand, so pleasant and instructive is the sight of two gentle, dexterous and skillful palpating hands that successfully collect the necessary data, inspiring confidence in the patient. I had to observe palpation techniques, amazing in their completeness and subtlety. The doctor's movements are at this time the most beautiful of all his movements. At the sight of ten fingers striving to discover such an important and serious truth through patient research and tactile talent, the whole greatness of our profession stands out before us. The palpation lesson should be one of the first and longest. The well-being of the patient depends on him to a greater extent than on the most lengthy theoretical reasoning "...

From my book "Diagnostics without tests and healing without drugs", M., 2014, QUORUM publishing house. You can get the e-book version from me at [email protected]

Norbert Alexandrovich Magazanik