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Deep Palpation

Protocols

Left Kidney Palpation: 

Procedure of palpation: 

  • 1) The right hand is placed anteriorly in left lumber region .
  • 2. The left hand is placed posteriorly in the left loin .
  • 3. Ask the patient to breath in deeply 
  • 4. Press the left hand forwards and the right hand backwards, upwards and inwards. 
  • 5. The left kidney is not usually palpable unless either lower in position or enlarged 
  • 6. Its lower pole, when palpate, is felt as a rounded firm swelting - between both right and left hands (i.e. bimanually palpable) and it can be_ ushed from one hand to the other hand (ballotting)



Points Kidney palpation: 

  • 1) Site enlargement 
  • 2) Extent 
  • 3) Border- normally rounded 
  • 4) Bimanually palpable / Ballotable .
  • 5) Surface – smooth normally 
  • 6)Consistency : 
    • Firm – Normal 
    • Soft – perinephric abscess 
    • Hard – wilm’s tumor & renal carcinoma 
  • 7) Tenderness 
  • 8) Movement with respiration 
  • 9) Renal angle tenderness: Junction between lower border of 12th ribs & lateral border od erector spines muscle .


Different between kidney & Spleen : 

Kideney :

  • a. It is in the lumbar region or loin.
  • b. Moves downward and forward.
  • c. Round in shape.
  • d. Notch Absent.
  • e. Present and finger can be insinuated between the mass and left costal margin.
  • f. Ballotable.

Spleen: 

  • a. It is in the left hypochondrium.
  • b. Moves with respiration towards right iliac fossa.
  • c. Well defined medial border.
  • d. Notch is present.
  • e. Get above the swelling: Absent and finger cannot be insinuated between the mass and left costal margin.
  • f. Palpable.


Why it is spleen, not kidney?

A: It is spleen because:

  •  The mass is in left hypochondrium.
  •  Moves with respiration downward and towards the right iliac fossa.
  •  I could not get above the swelling and finger could not be insinuated between the mass and left lower rib.
  •  There is splenic notch (definitive sign).
  •  Percussion note is dull over the mass and continuous up to the left lower part of chest.



Right Palpation : 

Procedure of palpation —_ : 

  • 1. Place the right hand horizontally in the right lumber region anteriorly .
  • 2. Place the left hand posteriorly in the right loin 3. Ask the patient to breathe in deeply 
  • 4. Pushed towards with the left hand 
  • 5. Press the right hand inwards and upwards 


Points to be remember in right kidney palpation :

  • 1.Same as the left kidney 
  • 2. The lower pole of the normal right kidney is often palpable especially in thin subjects



Spleen palpation: 

Procedure of palpation: 

  • 1) place the flat of the left hand over the left lowermost rib cage postero-laterally 
  • 2)Place the right hand on the right illiac fossa with tip of the fingers directed towards the left costal margin 
  • 3. Right hand should always be in horizontal position 
  • 4. Ask the patient to breathe in deeply 
  • 5 Press the right hand inwards & upwards during inspiration 
  • 6. Move the right hand upward after each inspiration 
  • 7. If spleen is not palpable move the right hand until the finger tips are 
  • 8. Repeat this process along the entire rib margin ition 
  • 9. If still not palpable, position the patient in the right lateral pos with the left hip & knee flexed.



Points Spleen palpation : 

  • 1. Measurement: From costal margin along its long axis .
  • 2. Direction enlargement : Toward right iliac fossa .
  • 3) Edge 
  • 4) surface : smooth/ rough 
  • 5) Consistency : Firm / hard/soft 
  • 6)Tenderness; present/ not 
  • 7) splenic notch – present / not 
  • 8) movement with respiration
  • 9) Finger insinuation test : finger is introduced in between the enlarge mass & costal margin .
  • 10) Bimanually palpable or not 
  • 11) percussion : over enlarge spleen 
  • 12) Ausculation : splenic Rub 

Different between kidney & Spleen : 

Kideney :

  • a. It is in the lumbar region or loin.
  • b. Moves downward and forward.
  • c. Round in shape.
  • d. Notch Absent.
  • e. Present and finger can be insinuated between the
  • mass and left costal margin.
  • f. Ballotable.


Spleen: 

  • a. It is in the left hypochondrium.
  • b. Moves with respiration towards right iliac fossa.
  • c. Well defined medial border.
  • d. Notch is present.
  • e. Get above the swelling: Absent and finger cannot be insinuated between the mass and left costal margin.
  • f. Palpable.


Causes of huge splenomegaly (may cross the midline):

  • • Chronic kala-azar.
  • • Chronic malaria.
  • • CML.
  • • Myelofibrosis.
  • • Cirrhosis of liver with portal hypertension (occasionally, common in early age).
  • • Hairy cell leukaemia.
  • • Adult Gaucher’s disease.
  • • Rapidly progressive lymphoma.



Causes of just palpable spleen (spleen tip):

  • • Enteric fever.
  • • Subacute bacterial endocarditis (SBE).
  • • Viral infection (infectious mononucleosis and CMV infection).
  • • Collagen disease (SLE).
  • • Sarcoidosis.
  • • Polycythaemia rubra Vera.
  • • All causes of huge splenomegaly in the early stage.



Causes of lymphadenopathy with splenomegaly:

  • • Lymphoma.
  • • Leukaemia (acute lymphoblastic leukaemia, chronic lymphocytic leukaemia).
  • • Viral infection (infectious mononucleosis, CMV infection and HIV).
  • • Collagen disease (SLE).
  • • Kala-azar (African kala-azar, also Chinese kala-azar).
  • • Others (sarcoidosis, brucellosis, toxoplasmosis, disseminated TB).


Causes of fever with splenomegaly:

  • • Enteric fever.
  • • Malaria.
  • • Kala-azar.
  • • SBE.
  • • Viral infection (infectious mononucleosis and CMV infection).
  • • Lymphoma.
  • • Leukaemia.
  • • Collagen disease (SLE).
  • • Brucellosis.
  • • Toxoplasmosis.
  • • Disseminated TB.

Causes of splenomegaly with ascites:

  • • Cirrhosis of liver with portal hypertension.
  • • Collagen disease (SLE).
  • • Lymphoma.
  • • Leukaemia.
  • • Disseminated TB.


Liver Palpation: 

Procedure of palpation 

  • 1. Place the right hand in the right illiac fossa parallel o the right subcostal margins tie of the index finger is just lateral to right rectus abdominis muscle. 
  • 2. Ask the patient to breathe in deeply
  • 3. At the height of inspiration the liver edge will then be felt against the radial border of the index finger.



Liver palpation points needs to know: 

  • 1) Upper border of liver - must percuss.
  • 2) Measurement from costal margin in mid clavicular line 
  • 3) Margin- Regular /irregular 
  • 4) Consistency – soft /firm/hard 
  • 5) Tenderness 
  • 6)Surface 
  • 7) Movement with respiration 
  • 8) left lobe measurement 


Upper border of liver percussion 

  • Normally upper border of liver dullness lies in the sixth or fifth intercostal space .


Q: What are the causes of hepatosplenomegaly?


1. Infection:

• Kala-azar.

• Malaria.

• Schistosomiasis (in Middle East and Africa).

• Enteric fever.

• Viral infections such as infectious mononucleosis and cytomegalovirus infection.



2. Myeloproliferative diseases:

• CML.

• Polycythaemia rubra vera.

• Myelofibrosis.

• Essential thrombocythaemia.



3. Lymphoproliferative diseases:

• Chronic lymphatic leukaemia (CLL).

• Multiple myeloma.

• Waldenström macroglobulinaemia.

• Lymphoma.



4. Cirrhosis of liver with portal hypertension (In these 3 types, liver is enlarged. In other types of

cirrhosis, no hepatomegaly):

• Primary biliary cirrhosis,

• Haemochromatosis,

• Alcoholic cirrhosis


5. Collagen diseases (SLE, Sjögren’s syndrome, Felty’s syndrome).



6. Others:

• Sarcoidosis.

• Amyloidosis.

• Thyrotoxicosis (in Graves disease, rare).

• Acromegaly.

• Storage disease (Gaucher’s disease and glycogen-storage disease).

• Polycystic disease.




Q: What are the causes of fever with hepatosplenomegaly?

A: As follows:

• Malaria.

• Kala-azar.

• Enteric fever.

• Viral infection (infectious mononucleosis and CMV infection).

• Lymphoma.

• Leukaemia (CGL, CLL, ALL, AML).

• Collagen disease (SLE).

• Disseminated TB.

• Brucellosis.

• Toxoplasmosis.

• Sarcoidosis.