Although kidneys are not usually palpable, you should learn and practice the techniques. Detecting an enlarged kidney may prove to be very important.

Palpation of the Left Kidney. Move to the patient's left side. Place your right hand behind the patient just below and parallel to the 12th rib, with your fingertips just reaching the costovertebral angle. Lift, trying to displace the kidney anteriorly. Place your left hand gently in the left upper quadrant, lateral and parallel to the rectus muscle. Ask the patient to take a deep breath. At the peak of inspiration, press your left hand firmly and deeply into the left upper quadrant, just below the costal margin, and try to "capture" the kidney between your two hands. Ask the patient to breathe out and then to stop breathing briefly. Slowly release the pressure of your left hand, feeling at the same time for the kidney to slide back into its expiratory position. If the kidney is palpable, describe its size, contour, and any tenderness.

Alternatively, try to feel for the left kidney by a method similar to feeling for the spleen. With your left hand, reach over and around the patient to lift the left loin, and with your right hand feel deep in the left upper quadrant. Ask the patient to take a deep breath, and feel for a mass. A normal left kidney is rarely palpable.

Palpation of the Right Kidney. To capture the right kidney, return to the patient's right side. Use your left hand to lift from in back, and your right hand to feel deep in the left upper quadrant. Proceed as before.

A left flank mass (see the solid line on photo on previous page) may represent marked splenomegaly or an enlarged left kidney. Suspect splenomegaly if notch palpated on medial border, edge extends beyond the midline, percussion is dull, and your fingers can probe deep to the medial and lateral borders but not between the mass and the costal margin. Confirm findings with further evaluation.

Attributes favoring an enlarged kidney over an enlarged spleen include preservation of normal tympany in the left upper quadrant and the ability to probe with your fingers between the mass and the costal margin but not deep to its medial and lower borders.

A normal right kidney may be palpable, especially in thin, well-relaxed women. It may or may not be slightly tender. The patient is usually aware of a capture and release. Occasionally, a right kidney is located more anteriorly than usual and then must be distinguished from the liver. The edge of the liver, if palpable, tends to be sharper and to extend farther medially and laterally. It cannot be captured. The lower pole of the kidney is rounded.

Causes of kidney enlargement include hydronephrosis, cysts, and tumors. Bilateral enlargement suggests polycystic disease.

Assessing Kidney Tenderness. You may note tenderness when examining the abdomen, but also search for it at each costovertebral angle. Pressure from your fingertips may be enough to elicit tenderness, but if not, use fist percussion. Place the ball of one hand in the cos-tovertebral angle and strike it with the ulnar surface of your fist. Use enough force to cause a perceptible but painless jar or thud in a normal person.

To save the patient needless exertion, integrate this assessment with your examination of the back (see p. 10).

Pain with pressure or fist percussion suggests pyelonephritis, but may also have a musculoskeletal cause.

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