Spleen Exam (OSCE)

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Contents 1 Patient positioning 2 Spleen location 3 General 3.1 Peripheral signs of hypersplenism 3.2 Stigmata of diseases associated with splenomegaly 4 Inspection 4.1 Static 4.2 With Deep Inspiration 5 Percussion 5.1 Traube’s Space 5.2 Castell’s sign 6 Palpation 7 Auscultation 8 Kidney vs. Spleen 9 Other OSCE modules

[edit] Patient positioning

• knees flexed
• expose from nipples to pubis

[edit] Spleen location

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

[edit] General

[edit] Peripheral signs of hypersplenism

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

[edit] Stigmata of diseases associated with splenomegaly

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

[edit] Inspection

*from the FOOT OF THE BED

[edit] Static

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

[edit] With Deep Inspiration

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

[edit] Percussion

[edit] 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

[edit] 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

[edit] 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

[edit] 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)

[edit] Kidney vs. Spleen

1. kidney is BLOTTABLE, 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 breath in and out)

[edit] Other OSCE modules