#3 Examination of the Spleen
Key Learning Points
- Learn how to palpate the spleen
- Learn how to percuss the spleen
Introduction: The purpose of both palpation and percussion of the spleen is to look for splenic enlargement. Evaluation of splenomegaly is notoriously difficult and embarrassingly easy to miss when present. In part this is because the spleen enlarges in the inferior anteromedial direction, sometimes as far as the RLQ.
- Start in RLQ (so you don’t miss a giant spleen).
- Get your fingers set then ask patient to take a deep breath. Don’t dip your fingers or do anything but wait.
- When patient expires, take up new position.
- Note lowest point of spleen below costal margin, texture of splenic contour, and tenderness
- If spleen is not felt, repeat with pt lying on right side. Gravity may bring spleen within reach.
- “LET THE SPLEEN PALPATE YOUR FINGERS AND NOT THE OTHER WAY AROUND. THERE IS NO GOLD, SO DON’T DIG!”
- Remember that the spleen can become very enlarged and fragile (e.g. in mononucleosis); overly aggressive palpation may cause injury.
Dr. Saul Rosenberg is a Stanford University Emeritus Professor and a luminary in the research and treatment of Hodgkin's Disease and other lymphomas. He is also a skilled bedside examiner and has wonderful tips for examining the spleen and lymph nodes. Click here to watch his lymph node exam.
Clinical Pearl: To better appreciate the spleen, have your patient lay on their right side and flex their legs towards their body. In adults, a normal spleen cannot be palpated unless they are very thin.
NOTE: Percussion may indicate but does NOT confirm splenomegaly.
- With patient supine, percuss inferior to lung resonance to map out gastric tympany (i.e. Traube’s Space).
- This area is variable; however, tympanic extending laterally makes splenomegaly less likely.
- Dullness may indicate splenomegaly, solid gastric content, or colon content.
- Splenic Percussion Sign (Castell’s Sign): Percuss the most inferior interspace on the left anterior axillary line (Castell’s Point). This is usually tympanic. Ask pt to breath deeply.
- Remains tympanic on inspiration: Splenic Percussion Sign negative: splenomegaly less likely.
- Shift from tympanic to dullness: Splenic Percussion Sign positive: splenomegaly more likely.