Archive:Spleen Exam (OSCE)

Patient positioning

• knees flexed
• expose from nipples to pubis

Spleen location

• posterior to the midaxillary line (MAL), between 9 to 11th ribs, size of palm

General

Peripheral signs of hypersplenism

• pallor
• brusing
• oval ulcers
• skin infections
• petechiae

Stigmata of diseases associated with splenomegaly

• hepatomegaly
• lymphadenopathy (CLL, lymphoma, EBV)
• jaundice (hemolytic anemia)
• macroglossia (amyloidosis)

Inspection

*from the FOOT OF THE BED

Static

• Skin
  • surgical scars
  • discoloration
• Contour
  • distended
  • obese
  • umbilical herniation
  • bulging flanks

With Deep Inspiration

• Symmetry - during several deep inspirations
  • note that the spleen enlarges toward the RLQ

Percussion

Traube’s Space

• 6th ICS, lower costal margin, MAL
• tympanic due to the gastric bubble - in splenomegaly, stomach is displaced and region sounds dull (not a specific test)
• False Positives: full stomach, pleural effusion and pneumonia

Castell’s sign

• lowest intercostal space, L AAL
• ask the patient inhale and exhale slowly and deeply
• splenomegaly → resonant on expiration but dull on inspiration

Palpation

1. With right hand beginning in RLQ, pull the L ribcage forward (give slack for the R hand to feel under the costal margin), palpate superficially toward the LUQ

• assess effect of deep inspiration
  • describe: firm/soft, nodular/smooth, tenderness

2. Hooking Maneuver

• stand on patient’s left and try hooking hands under left costal margin

Auscultation

1. all 4 QUADRANTS for bowel sounds
   1. Friction rub (inflammation, tumor, infarction)
      1. systolic murmur over spleen - massive splenomegaly (dilated, tortuous splenic artery)

KIDNEY VS. SPLEEN

1. kidney is BLOTTABLE, spleen is NOT
   1. NOTCH ON ANTERIOR BORDER - palpable in spleen, not in kidney
      1. spleen enlarges diagonally towards RLQ, while the kidney enlarges inferiorly
         1. kidney can be resonant to percussion (d/t overlying bowel), spleen should be DULL
            1. UPPER EDGE of spleen NOT palpable, upper edge of kidney is
               1. SPLENIC RUB on auscultation (have patient breath in and out)

Observed structured clinical examination

Acute Confusion - Acute Coronary Syndrome Orders - Anemia - Arterial Blood Gasses - Asthma - Blood Pressure - Chest pain - Chest XRay - CHF - Coma - COPD - Cranial Nerves - Diabetic History - Diabetic Foot - Dysphagia - EKGs - Gallbladder and Liver - Liver Disease - Gait and Balance - Headache - Hematemesis - Hypertension - Jugular Venous Pulses - Knee Exam - Lymph Nodes - Community Acquired Pneumonia - Parkinson Disease - Peripheral Arterial Insufficiency - Pneumonia Examination - Precordial Exam - STD's - Spleen - Swollen Leg Exam - Thyroid Exam - Upper vs Lower Motor Neuron Lesions - Urinary Incontinence