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

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

Kidney vs. Spleen

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