Physical Exam

Physical (1 of 2 slides)

Physical (2 of 2 slides)

The following describes this patient’s physical exam:

Vital signs: Heart rate 81/min, respiratory rate 20/min, BP 120/60, T 98.9oF

General: Calm in no acute distress

Head and neck: No conjunctival pallor or icterus; moist mucous membranes; no lymphadenopathy; retina, no obvious lesions DID THE RETINA SHOW ANY CHANGES?

Chest: Clear breath sounds bilaterally

CVS: Regular rate and rhythm; no murmurs

Abdomen: Soft, distended, with tenderness to palpation in the right lower quadrant; palpable splenomegaly in the right lower quadrant

CNS: Alert oriented x 3; no focal deficits

Skin: Petechiae on lower limbs

Skin: A few healing ecchymosis noted in the legs bilaterally; no petechiae or rashes

Does this patient have massive splenomegaly?

a
Yes
Massive splenomegaly is usually defined as clinically palpable > 8 cm below left costal margin, which will the case if the spleen is felt in the right lower quadrant.
b
No

Physical examination of the spleen includes:

Inspection

  • Look for bulging mass emerging from under the left costal margin and descending on inspiration.
  • Low sensitivity since only massive spleens will distort the abdominal wall sufficiently to be seen.

Percussion

  • Loss of tympany as the enlarging spleen impinges on the adjacent air-filled lung, stomach, and colon.
  • Three percussion methods
    • Percussion by Nixon’s method
      • patient is placed in the right lateral decubitus position.
      • percussion is initiated midway along the left costal margin and continued upward along a line perpendicular to the costal margin.
      • normally dullness extends no further than 8 cm above the costal margin.
      • splenomegaly is diagnosed when the upper limit of dullness extends more than 8 cm above the costal margin.
    • Percussion by Castell’s Method (see quiz, next slide)
    • Percussion of Traube’s Space
      • The patient is supine with the left arm slightly abducted for access to the entire Traube’s space.
      • Traube’s space defined by the sixth rib superiorly, the midaxillary line laterally, and the left costal margin inferiorly.
      • With the patient breathing normally, this triangle is percussed across one or more levels from its medial to lateral margins.
      • Normal percussion yields a resonant or tympanitic note.
      • Splenomegaly is diagnosed when the percussion note is dull.

Palpation

  • Three palpation methods
    • Two-handed palpation, with patient in right lateral decubitus
      • With patent in right lateral decubitus position, examiners left had is slipped from front to back around the left lower thorax, gently lifting the left lowermost rib cage anteriorly and medially.
      • The tips of the fingers of the examiner’s right hand are pressed gently just beneath the left costal margin, and the patient is asked to take a long, deep breath as the palpation of a descending spleen is sought.
      • If none is felt, the procedure is repeated, lowering the right hand 2 cm toward the umbilicus each cycle, until the examiner is confident that a massive spleen has not been missed (some authorities suggest starting palpation over the lower abdomen and moving up toward the costal margin.
      • The same procedure can be carried out with the patient supine.
    • One handed palpation with patient supine
      • This method is identical to the former one, except that no counter pressure is applied by the left hand to the rib cage.
    • Hooking maneuver of Middleton with patient supine
      • The patient is asked to lie flat with his or her left fist under the left costovertebral angle.
      • The examiner is positioned to the patient’s left, facing the patient’s feet. The fingers of both the examiner’s hands are curled under the left costal margin, and the patient is asked to take a long, deep breath as the palpation of a descending spleen is sought.

From: Grover et al.

What is Castell’s method for detecting splenomegaly?

a
Percussing over the lowest intercostal space in the anterior axillary line
The Castell’s method result is considered positive if the percussion note was noted to be dull or became dull with full inspiration
b
Percussing over Traube’s space
c
Palpation over Traube’s space
d
Auscultation at edge of spleen while scratching the skin

You have detected splenomegaly on physical examination. Which of the following are causes of splenomegaly?

a
Cirrhosis
b
Chronic pancreatitis
c
Chronic myelogenous leukemia
Splenomegaly reported in 55-70% of patients with CML. Median spleen size adults 3 cm. Almost universally attributed to the expansion of myelopoiesis in the spleen
d
Malaria
e
Chronic obstructive airway disease

This patient appears to have massive splenomegaly, though we will want to confirm with imaging. Massive splenomegaly is generally defined as a spleen that is palpated > 8 cm below the costal margin, and its presence helps to narrow down the differential diagnosis for an enlarged spleen. The most common causes include:

  • Hematological disorders
    • Chronic myeloid leukemia
    • Agnogenic myeloid metaplasia
    • Polycythemia vera
    • Essential thrombocythemia
    • Indolent lymphomas
    • Hairy cell leukemia
  • Infectious diseases
    • Kala-azar (visceral leishmaniasis)
    • Malaria
  • Infiltrative conditions
    • Gaucher disease
    • Primary angiosarcoma of the spleen
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