Makindo Medical Notes

Related Subjects: |Cardiology Examination |Cardiology History Taking |Epstein-Barr Virus infection |Cytomegalovirus (CMV) infections

The commonest cause of splenomegaly in the western world will be a viral infections, such as mononucleosis

Overview of Spleen Examination

The spleen examination is performed to assess the size and consistency of the spleen. It is a critical part of the abdominal examination, especially in cases of suspected splenomegaly or other hematological conditions.

Preparation

• Ensure privacy and obtain consent from the patient.
• Explain the procedure to the patient and answer any questions they may have.
• Position the patient supine with their arms at their sides, ensuring comfort.

Inspection

• With the patient lying flat, observe the abdomen for visible masses or distention.
• Ask the patient to take a deep breath and observe for changes in the contour of the abdomen, especially in the left upper quadrant.

Palpation

• Stand on the right side of the patient:
  • Begin palpation in the right iliac fossa, moving diagonally toward the left costal margin.
  • Ask the patient to take a deep breath in, and with each breath, advance your hands toward the left upper quadrant.
  • Palpate gently but firmly, feeling for the spleen as it descends with inspiration.
• If the spleen is not palpable, repeat the process with the patient in the right lateral decubitus position:
  • Support the patient’s back with your left hand and palpate with your right hand.

Percussion

• Percuss from the left lower ribcage (Traube's space) toward the midline to detect dullness, which may indicate splenomegaly.
• Normal spleen size typically does not extend below the costal margin; dullness below this line may suggest splenomegaly.

Common Findings

• Normal:
  • The spleen is usually non-palpable in healthy individuals.
  • Percussion over Traube's space is typically resonant.
• Abnormal:
  • Splenomegaly: The spleen is palpable below the costal margin, indicating enlargement.
  • Consistency: A firm spleen may suggest conditions like chronic leukemia, while a soft, tender spleen may indicate acute infections or congestion.
  • Percussion: Dullness in Traube's space suggests splenomegaly.

Documentation

• Record the following in the patient's medical record:
  • Presence or absence of splenomegaly.
  • Consistency, tenderness, and size of the spleen, if palpable.
  • Any associated findings, such as liver enlargement or abdominal masses.

Patient Education

• Explain the significance of your findings to the patient in understandable terms.
• Discuss further investigations or referrals based on the findings.
• Advise the patient on symptoms to watch for and when to seek medical attention.

Summary

A thorough spleen examination involves careful inspection, palpation, and percussion to assess for splenomegaly or other abnormalities. Accurate documentation and patient education are essential for diagnosis and management.

Diagram Showing the Direction of Spleen Enlargement

Causes of Splenomegaly

• Hepatosplenomegaly:
  • Myeloproliferative disease
  • Myelofibrosis (often massive)
  • Polycythaemia vera
  • Lymphoproliferative disease
  • Infiltration (e.g., amyloid)
  • Liver disease (e.g., cirrhosis)
• Splenomegaly:
  • Haematological Malignancy:
    • Chronic Myeloid Leukaemia (Massive)
    • Myelofibrosis (Massive)
  • Infections:
    • Malaria (Massive)
    • Visceral leishmaniasis (Kala-azar) (Massive)
• Mild to Moderate Splenomegaly:
  • Portal hypertension
  • Abnormal hemoglobin:
    • Thalassemia
    • Hemolytic anaemias
  • Haematological Malignancy:
    • Lymphoma
    • Leukaemia (Acute and Chronic)
    • Polycythaemia Vera
  • Rheumatology:
    • Rheumatoid arthritis
    • Systemic lupus erythematosus (SLE)
    • Polyarteritis nodosa
  • Infiltrative Disorders:
    • Amyloidosis, Sarcoidosis
    • Storage diseases (Gaucher's and Niemann-Pick)
  • Infections:
    • Viral (e.g., infectious mononucleosis, EBV, CMV)
    • Bacterial infections (e.g., infective endocarditis)
    • Protozoal (e.g., malaria, kala-azar)

Investigations

• FBC: Shows hypersplenism with features such as:
  • Splenomegaly
  • Pancytopenia
  • Normal or hypercellular bone marrow
• Ultrasound or CT scan to confirm the size and consistency of the spleen.
• Biopsy of lymph nodes (if indicated).
• Chest X-ray (CXR) to assess associated conditions.
• Bone marrow examination (if necessary).
• Exclude infectious diseases through serology or cultures.

Management

• Splenectomy in selected cases, such as trauma or specific hematologic conditions.