Place your left hand behind the patient, parallel to and supporting the right 11th and 12th ribs and adjacent soft tissues below. Remind the patient to relax on your hand if necessary. By pressing your left hand forward, the patient's liver may be felt more easily by your other hand.
Place your right hand on the patient's right abdomen lateral to the rectus muscle, with your fingertips well below the lower border of liver dullness. Some examiners like to point their fingers up toward the patient's head, while others prefer a somewhat more oblique position, as shown on the next page. In either case, press gently in and up.
Ask the patient to take a deep breath. Try to feel the liver edge as it comes down to meet your fingertips. If you feel it, lighten the pressure of your palpating hand slightly so that the liver can slip under your finger pads and you can feel its anterior surface. Note any tenderness. If palpable at all, the edge of a normal liver is soft, sharp, and regular, its surface smooth. The normal liver may be slightly tender.
Firmness or hardness of the liver, bluntness or rounding of its edge, and irregularity of its contour suggest an abnormality of the liver.
An obstructed, distended gallbladder may form an oval mass below the edge of the liver and merging with it. It is dull to percussion.
Some people breathe more with their chests than with their diaphragms. It may be helpful to train such a patient to "breathe with the abdomen," thus bringing the liver, as well as the spleen and kidneys, into a palpable position during inspiration.
Try to trace the liver edge both laterally and medially. Palpation through the rectus muscles, however, is especially difficult. Describe or sketch the liver edge, and measure its distance from the right costal margin in the midclavicular line.
See Table 9-12, Liver Enlargement: Apparent and Real (pp. 365-366).
In order to feel the liver, you may have to alter your pressure according to the thickness and resistance of the abdominal wall. If you cannot feel it, move your palpating hand closer to the costal margin and try again.
The edge of an enlarged liver may be missed by starting palpation too high in the abdomen, as shown below.
The "hooking technique" may be helpful, especially when the patient is obese. Stand to the right of the patient's chest. Place both hands, side by side, on the right abdomen below the border of liver dullness. Press in with your fingers and up toward the costal margin. Ask the patient to take a deep breath. The liver edge shown below is palpable with the fingerpads of both hands.
Assessing Tenderness of a Nonpalpable Liver. Place your left Tenderness over the liver suggests hand flat on the lower right rib cage and then gently strike your hand with inflammation, as in hepatitis, or the ulnar surface of your right fist. Ask the patient to compare the sensation congestion, as in heart failure. with that produced by a similar strike on the left side.
M The Spleen_
When a spleen enlarges, it expands anteriorly, downward, and medially, often replacing the tympany of stomach and colon with the dullness of a solid organ. It then becomes palpable below the costal margin. Percussion cannot confirm splenic enlargement but can raise your suspicions of it. Palpation can confirm the enlargement, but often misses large spleens that do not descend below the costal margin.
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