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

Peripheral signs of hypersplenism

 * pallor
 * bruising
 * oral 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

Traube’s Space

 * 6th rib, 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 have patient lie on right lateral position
 * stand on patient’s left and try hooking hands under left costal margin

Auscultation

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


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