Teaching Plan 2

Palpation of Viscera ----- liver

palpate liver at midclavicular and midsternal lines

      To

Method: The right hand may be held either parallel or perpendicular to the long axis of the patient. In the midclavicular starting at the anterior superior iliac crest, examiner presses down firmly and asks patient to inhale deeply. This allows the liver to move down to meet your fingertips.

√ If you feel nothing, press up a few centimeters toward the rib cage and repeat the maneuver. Do this continuously until you feel the liver or reach the coastal margin.

√ Normally the liver is not palpable, but sometimes the examiner may feel the edge of the normal liver at or slightly below the right costal margin.

√ When the liver is palpated, a firm edge will strike the fingers upon inspiration.

√ In the midsternal line, from the level of the umbilicus, repeat the above maneuvers to palpate the liver.

√ Most doctors like to use bimanual maneuvers to palpate the liver. To do this, place the left hand at right lower posterior chest wall parallel to, or supporting patient’s right 11-12th ribs or at lower sternal area to limit the chest respiration to make right hand palpation more effective.

Note: （ 1 ） When felt more than 2cm. below the costal margin, however, the organ should be considered abnormally large.

large right lobe of the liver, which occasionally extends quite far into the right flank. √ Another exception is seen in severe, chronic emphysema( 肺 气肿 ), in which the diaphragms are depressed by the overexpanded lung, displacing the liver below the costal margin. In both instances the total mass of the liver is within normal limits.

（ 2 ） If you feel the liver, detect the edge (sharp or round), tender or not, hard or soft and repeat the process laterally and medially to define the contour. For masses within the liver, describe the same characteristics as above and listen for a bruit over the mass.

        Size √ Ordinarily the liver is not palpable, or the liver can not be felt more than 2cm below the lower coastal margin, and can not be felt more than upper 1/3 distance of the line from xiphoid to umbilicus or more than 3cm under the xiphoid. √ Failure to feel the liver does not mean that the liver is normal. √ Measurement of the liver is done in the midclavicular line and midsternal line.

√ The quality of liver is classified into three grades: softness( 质软 ), toughness( 质韧 ), and hardness( 质 硬 ). √ Normally the quality of liver is soft and tender, just like the pouted( 撅嘴 ) lip. √ In acute hepatitis or fatty liver( 脂肪 肝 ), the quality of liver is slightly tough. In chronic hepatitis or blood stasis of liver, liver is more tough and usually as tough as apex nasi( 鼻尖 ). √ In liver cirrhosis, the quality of liver is hard. In liver carcinoma, the quality of

        Surface and edge √ To observe whether the surface of liver is smooth or not, whether there is any node( 结节 ) or not, and whether the edge is thin or thick and is regular or irregular. The character of the surface of the liver should be described. √ Sometimes large metastatic masses may be present and palpable in the liver. √ In some persons with cirrhosis, the anterior surface of the liver will have a granular feel. This is easily felt in the

        Tenderness Normally liver cannot be palpated as tenderness unless the liver is irritated by the liver chitonitis (that is, inflammation of the diolame 包膜 of the liver) or pulled by the enlargement of itself.

        Pulsation

搏动

√ Normally you cannot palpate any pulsation of the liver. √ If you palpate the pulsation of the liver, you should pay attention to its direction, that is, whether it is unidirectional( 单向性 ) or expansile( 扩张性 ). √ unidirectional pulsation is usually a conductive one( 传导性搏动 ), caused by the the conduction of the pulsation of aorta abdominalis( 腹主 动脉 ).

√ If you put your hand on the sufface of the liver, you will feel your hand is pushed upward.

√ expansile pulsation is the pulsation of the liver per se and usually found in tricuspid valve insufficiency( 三尖瓣关闭不全 ).

√ Because the contractive pulsation of right ventricle conducts to liver through right atrium and then inferior vena cava. If you put your hand on the sufface of the liver, you will have the opening-closing sensation.

The positive Hepatojugular reflux sign( 肝－颈静脉回流征 ): If you press the liver, you will find the dilated jugular vein becomes more bulged or distended, as from the enlargement of liver passive congestion resulted from right failure.         Liver friction sensation 肝区摩擦 感          Liver thrill 肝震颤

      To palpate spleen from umbilicus to left costal margin

√ In examining for splenic enlargement, the examiner should stand at the patient’s right side.

√

His left hand is placed over the patient’s left costovertebral angle, exerting pressure to move the spleen anteriorly. At the same time his right hand is worked gently under the left anterior costal margin.

√ With the examiner’s hands stationary in this position, the patient is instructed to take a deep breath.

√ If there is significant enlargement of the spleen, it will be palpated as a firm mass that slides out from under the ribs, bumping against the finger of the examiner’s right hand.

√ The spleen normally moves down with inspiration.

√ If splenic enlargement cannot be felt by the technique just described, the patient should then be rolled slightly toward the right so that the spleen may fall anteriorly

√The examining hands are again placed as described and the procedure is repeated. Occasionally a spleen that cannot be felt with the patient in the supine position may be palpated by this maneuver.

√ When the spleen can be felt, it must be considered abnormal, since the normal spleen is not palpable.

Notes:

（ 1 ）           Starting from the level of the umbilicus (or below the percussed dullness).

（ 2 ）  The maneuver is similar to that used to palpate the liver, but is more subtle because the spleen is more mobile and deeper than the liver.

（ 3 ）   If the spleen is not palpated, have the patient roll on his right side and repeat palpation.

（ 4 ） Measurement of the spleen is the same as that of the liver and is usually expressed as centimeters under the costal margin in the midclavicular and under the xiphoid process in the midsternal lines.

（ 5 ）  A moderately or greatly enlarged spleen is best described by a drawing, especially the three lines which are presented schematically in the following diagram . (NOTE: Severe splenomegaly may cause rupture when spleen is vigorously palpated, so palpate gently and carefully).

Line 1: The distance between left costal border and the lower edge of spleen along left midclavicular line

Line 2: The distance between the crossing point of left midclavicular line and left costal border and the most remote point of the spleen

Line 3: (when the spleen is extremely large and exceeds the anterior midline.) The distance between the right border of the spleen and the anterior midline. If the spleen indeed exceeds the anterior midline, The mark “+” is used to indicate “exceeding”, while “ – “ is used to indicate “not exceeding”.

In clinical practice, splenomegaly is classified into three levels:

level 1 (slight enlargement 轻 度肿大 ): During deep respiration, the lower edge of spleen is not more than 2cm below the costal border

level 2 (moderate enlargement 中度肿大 ): During deep respiration, the lower edge of spleen is more than 2cm below the costal border but above the umbilical horizontal line

level 3 (severe enlargement 高度肿大 ): During deep respiration, the lower edge of Spleen is below the umbilical horizontal line or over anterior midline

      To palpate gall bladder

Method: Put right hand below the costal margin or lower border of liver at midclavicular line (grossly equal to the lateral border of the right rectus muscles) and palpate deeply to check for tenderness or bulging.

√ Under normal circumstances, the gallbladder cannot be palpated.

patient, the right upper quadrant should always be carefully palpated for a soft, cystic mass, approximately 6 to 8 cm in diameter , which appears to be attached to the liver and moves with respiration. This is an exceedingly valuable sign in differentiating jaundice caused by cancer of the head of the pancreas or the common bile duct from that caused by

√ In the presence of tumor of the common bile duct or head of the pancreas, the wall of the gallbladder is normal, and consequently the organ is capable of distending to the point that it is palpable. Such sign is named Courvoisier sign.

√ If the obstruction is caused by gallstones, the gallbladder wall is inflamed, and this diseased organ is not capable of distention. Therefore, the gallbladder will not become palpable.

       To Murphy’s

check for sign..\..\教学相 关图片 \

腹部异 常体征 -Murphy氏征阳性 .rm

√ If pain is found in the gallbladder area but gallbladder is not palpated , the examiner should put his left hand on the lower lateral rib cage with the 4 fingers stretching superiorly and the thumb hooked under the costal margin.

√ Press down to the point of gallbladder tenderness and ask the patient to breathe deeply and check to see whether the patient stops breathing, changes facial expression, or complaints of pain.

√ The sign indicates the inflammation of gallbladder.

  abdominal

masses

Confused parts of body with masses The spine Posterior sacral prominence Stool Transverse colon Cecum Muscle belly of rectus abdominis

attention A complete description of the mass must be obtained during the examination Omission of any attrbute may lead to erroneous conclusion

Mass i n a bd ome n location size shape consistency Surface tenderness pulsatility mobility

location Suggests the organ to be considered For example: mass in LUQ : spleen? Left kidney? stomache? Colon?

size Pathologic process, extent and change over time

shape Some organs have a characteristic shape. Kidney-horsebean Spleen-fist liver-triangle

consistency Carcinoma-stony hard Lymphoma-rubbery Abcess-soft and fluctuant

Surface Smooth suface—diffuse homogeneous process Nodular surface--metastases

tenderness Inflammatory process:infectious or sterile Distention of the capsule of viscus ischemia

pulsatility Vascular: major arterial, aneurysmal dialation of the aorta or one of its major branches Simulating aneurysms Solid masses and tense cysts (transmit normal aortic pulsations

mobility Suspended by long mesenteries Movement with diaphragmatic respiration: association with the liver or spleen or mobile abdominal organ

Fluid wa ve th ril l

( 液波震颤 )

With patient lying on his back, the examiner’s left hand is placed   against the patient’s right flank. An assistant or the patient places the ulnar edge of one hand lightly against the middle of the abdomen to prevent the transmission of any wave through the tissues of the abdominal wall. The examiner’s right hand then lightly taps the left flank of the

Fluid wa ve th ril l In the presence of a siguificant amount of ascites, a wave will be transmitted through the fluid that will be felt against the examiner’s left hand as a sharp impulse. This finding is present only when there is a reasonably large amount of fluid, usually 3000-4000 ml. So the fluid wave thrill is not so

su ccussi on sp la sh 振 水音 ..\ ..\ 教学相关图片 \振水音 .rm Succession splash is the splash sound over the upper abdomen. It should be checked by rocking the upper abdomen to the left and right. In normal patients this is negative about 6-8 hours

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