Thursday, February 11, 2010

Looking for a kidney? Check the pelvis

I was working with a family doctor who asked me to go in and do a cardiac and abdomenal physical exam on a patient who had "interesting findings". He told me to make sure I palpated the kidneys. I was also told that the history had already been taken so I didn't have to bother with that.

I began with a cardiac exam. The only significant finding was a grade 2/6 (very quiet) systolic murmur. I figured the doctor asked me to do a cardiac exam on this patient because he wanted me to find that murmur, so I was happy to find it so quickly. I then continued with the rest of the exam.

I began the abdomenal exam thinking this patient must have a kidney tumour or some kind of kidney inflammation because the doctor made a point of asking me to palpate the kidneys. Normally you cannot feel a kidney on an abdomenal exam because they are surrounded by fat and muscle. The only time you can feel a kidney is when it is pathologically enlarged, or so I thought...

I was trying to palpate the kidneys for five minutes but I couldn't feel anything. Not being able to palpate enlarged kidneys may be expected in a fatter patient, but this patient was relatively thin. Finally, the patient, clearly seeing that I was struggling, began laughing at me. He decided to put me out of my misery and pulled his shorts down past his groin revealing an abnormal bump in his pelvic region...his kidney.

Turns out this patient had bilateral pyelonephritis that ended up destroying his kidneys, so he had to have a transplant. Often with kidney transplants the old kidneys are not removed; instead, their ureters (tubes connecting them to the bladder) are cut and ligated to the new, transplanted kidney, which is placed in an empty space in the pelvis.

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