Which of the following is the most appropriate position for the patient to be in to wait for general physical examination?

Q: Which of the following is the most appropriate position for examination of a patient with dyspnea?

With numerous applications, Fowlers position is used for patients who have difficulty breathing because, in this position, gravity pulls the diaphragm downward allowing greater chest and lung expansion.

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.

Inhaltsverzeichnis Show

Dr. Saul Rosenberg
Clinical Pearl
Techniques: Liver & Ascites
When preparing the patient for a vaginal examination you would position them in the position?
Which of the following would be an appropriate position for examination of the abdomen while the patient is undergoing a physical exam?
Which of the following positions is the most appropriate for examination of the patients breasts?
Which of the following is the most appropriate position for examination of a patient with dyspnea?

Technique

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.

Technique

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 patient 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.

Dr. Saul Rosenberg

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.

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.

[Skill Modules >> Liver & Ascites >> Techniques ]

Techniques: Liver & Ascites

Technique: Liver

Approach the examination of the liver from the right side of the patient. Have the patient lying supine. Preserve the patient�s privacy by draping the top of their body with the gown and below the waist with a sheet. For the best exam, make sure the patient is warm and comfortable. Additionally make sure your hands are warm so as to not startle the patient.

Inspection

Look for gross asymmetries across the abdomen. Look at the skin for signs of liver disease, such as caput medusa, or spider angiomata.

Auscultation

Follow the inspection of the liver, as with the rest of the abdominal exam, with auscultation. Listen over the area of the liver for bruits or venous hums.

Percussion

Percuss for the upper and lower margins of the liver. Place your non-dominant hand palm down flat on the abdomen with the fingers parallel to the lower costal margin pointed toward the midline. Percuss with the middle finger of your dominant hand on the middle finger of your non-dominant one.

Begin percussion over the lungs and move from the area of resonant lung sounds to the areas of dullness. Mark the area of change. Repeat the same process from below, moving again from resonance over the bowel to dullness and again mark the area of change. Start in the lower right quadrant so as to not miss a greatly enlarged liver. Measure the vertical distance from the top to the bottom. You can also use palpation to determine the lower border.

Palpation

Begin palpation over the right lower quadrant, near the anterior iliac spine. Palpate for the liver with one or two hands palm down moving upward 2-3 cm at a time towards the lower costal margin. Have the patient take a deep breath. The liver will move downward due to the downward movement of the diaphragm. Feel for the liver to hit the caudal aspect of your palpating hand. Palpate the bottom margin of the liver for the texture of the liver, i.e. soft/ firm/hard/nodular.

Scratch Test

Several different techniques have been described for this exam. One is to place the diaphragm over the area of the liver and then scratch parallel to the costal margin until the sound intensity drops off marking the edge of the liver. Other techniques involve different patterns of the scratching, for example as in spokes of a wheel and other places for placing the stethoscope such as over the abdomen.

Technique: Ascites

There are several physical examination maneuvers described for detection of ascites described below that are at least moderately sensitive and specific. No single maneuver is both highly sensitive and specific; therefore at least two maneuvers are necessary to increase the accuracy of physical exam for ascites.

Bulging Flanks

With the patient supine, the examiner visually observes whether the flanks are pushed outward (presumably by large amounts of ascitic fluid)
Positive test: simply the presence of bulging flanks

Note: A patient with an obese abdomen may also have flanks that bulge, although the fat of obesity extends further posterior than fluid in the peritoneum.

Flank Dullness

The patient is examined in the supine position.
Direct percussion is done over the abdomen, from the umbilicus to the flanks.
The location of the transition from tympany to dullness is noted.
Positive test: Percussion note is tympanitic over the umbilicus and dull over the lateral abdomen and flank areas

Note: The tympany over the umbilicus occurs in ascites because bowel floats to the top of the abdominal fluid at the level of the fluid meniscus.

Shifting Dullness

This maneuver is performed with the patient supine.
Percuss across the abdomen as for flank dullness, with the point of transition from tympany to dullness noted.
The patient then is rolled on his/her side away from the examiner, and percussion from the umbilicus to flank area is repeated.
Positive test: When ascites is present, the area of dullness will shift to the dependent site. The area of tympany will shift toward the top.

Note: The shift in zone of tympany with position change will usually be at least 3 cm when ascites is present.

Fluid Wave

Have the patient lying supine.
The patient or an assistant places one or both hands (ulnar surface of hand downward) in a wedge-like position into the patient's mid abdomen, applying with slight pressure.
The examiner places the fingertips of one hand along one flank, and with the other hand firmly gives a sharp tap along the opposite flank.
Positive test: The examiner is able to detect "a shock wave" of fluid moving against the fingertips pressed along the flank, as the fluid is pushed from one side of the abdomen to the other by the force of the tap along the opposite flank.

When preparing the patient for a vaginal examination you would position them in the position?

Knee-Chest Position. Used for rectal and vaginal examinations and as treatment to bring uterus into normal position. Patient is on knees with chest resting on bed and elbows resting on bed or arms above head. Head is turned to one side.

Which of the following would be an appropriate position for examination of the abdomen while the patient is undergoing a physical exam?

The patient is initially positioned at 45 degrees for comfort, but a supine position is necessary to palpate the abdomen. Keeping a pillow under the patient's head or knees can be considered. The ideal exposure is from the nipples to the knees, but this is sometimes not practically possible.

Which of the following positions is the most appropriate for examination of the patients breasts?

The breasts are best examined while lying down because it spreads the breast tissue evenly over the chest. Lie flat on your back, with one arm over your head and a pillow or folded towel under the shoulder. This position flattens the breast and makes it easier to check.

Which of the following is the most appropriate position for examination of a patient with dyspnea?

With numerous applications, Fowler's position is used for patients who have difficulty breathing because, in this position, gravity pulls the diaphragm downward allowing greater chest and lung expansion.