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8 Part I: Clinical Evaluation of the Patient Chapter 1: Initial Approach to the Patient: History and Physical Examination 9

right hand while exerting pressure forward with the palm of the left and motor neuropathies. Polyneuropathy is a feature of POEMS, a
hand placed over the lower ribs posterolaterally. This action permits the syndrome marked by polyneuropathy, organomegaly, endocrinopathy,
spleen to descend and be felt by the examiner’s fingers. If nothing is monoclonal gammopathy, and skin changes.
felt, the palpation should be performed repeatedly, moving the examin-
ing hand approximately 2 cm toward the inguinal ligament each time. Joints
It is often advantageous to carry out the examination initially with the Deformities of the knees, elbows, ankles, shoulders, wrists, or hips may
patient lying on the right side with left knee flexed and to repeat it with be the result of repeated hemorrhage in patients with hemophilia A,
the patient supine. hemophilia B, or severe factor VII deficiency. Often, a target joint is
It is not always possible to be sure that a left upper quadrant mass prominently affected.
is spleen; masses in the stomach, colon, kidney, or pancreas may mimic
splenomegaly on physical examination. When there is uncertainty
regarding the nature of a mass in the left upper quadrant, imaging pro- REFERENCES
cedures will usually permit accurate diagnosis. 13–15
1. Bickley LS: Bates Guide to Physical Examination and History Taking, 11th ed. Lippincott
Williams & Wilkins, Philadelphia, 2012.
Liver 2. Sackett DL: A primer on the precision and accuracy of the clinical examination. JAMA
Palpation of the edge of the liver in the right upper quadrant of the 267:2638, 1992.
abdomen is commonly used to detect hepatic enlargement, although 3. Williams ME: Geriatric Physical Diagnosis: A Guide to Observation and Assessment.
the inaccuracies of this method have been demonstrated. It is necessary McFarland & Company, Jefferson, NC, 2008.
to determine both the upper and lower borders of the liver by percus- 4. Mor V, Laliberte L, Morris JN, Wiemann M: The Karnofsky performance status scale:
An examination of its reliability and validity in a research setting. Cancer 53:2002, 1984.
sion in order to properly assess liver size. 16,17 The normal liver may be 5. Oken MM, Creech RH, Tormey DC, et al: Toxicity and response criteria of the Eastern
palpable as much as 4 to 5 cm below the right costal margin but is usu- Cooperative Oncology Group. Am J Clin Oncol 5:649, 1982.
ally not palpable in the epigastrium. The height of liver dullness is best 6. Janssen CAH, Scholten PC, Heintz APM: A simple visual assessment technique to
discriminate between menorrhagia and normal menstrual blood loss. Obstet Gynecol
measured in a specific line 8, 10, or 12 cm to the right of the midline. 85:977, 1995.
Techniques should be standardized so that serial measurements can be 7. Black C, Kaye JA, Jick H: MMR vaccine and idiopathic thrombocytopaenic purpura. Br
made. The vertical span of the normal liver determined in this manner J Clin Pharmacol 55:107, 2003.
will range approximately 10 cm in an average-size man and approxi- 8. O’Leary ST, Glanz JM, McClure DL, et al: The risk of immune thrombocytopenic pur-
pura after vaccination in children and adolescents. Pediatrics 129:248, 2012.
mately 2 cm smaller in a woman. Because of variations introduced by 9. Grubnic S, Vinnicombe SJ, Norman AR, Husband JE: MR evaluation of normal retro-
technique, each physician should determine the normal area of liver peritoneal and pelvic lymph nodes. Clin Radiol 57:193, 2002.
dullness by the physician’s own procedure. Correlation of radioisotope 10. Atula TS, Varpula MJ, Kurki TJI, et al: Assessment of cervical lymph node status in head
and neck cancer patients: Palpation, computed tomography and low-field magnetic
imaging data with results from routine physical examinations indicates resonance imaging compared with ultrasound-guided fine needle aspiration cytology.
that often a liver of normal size is considered enlarged on physical Eur J Radiol 25:152, 1997.
examination and an enlarged liver is considered normal. Ultrasonogra- 11. Arkles LB, Gill GD, Nolan MP: A palpable spleen is not necessarily enlarged or patho-
logical. Med J Aust 145:15, 1986.
phy and computed tomography measurements are useful in determin- 12. Barkun AN, Camus M, Green L, et al: The bedside assessment of splenic enlargement.
ing size and demonstrating localized infiltrative lesions. 18–20 Am J Med 91:512, 1991.
13. Benter T, Klühs L, Teichgräber U. Sonography of the spleen. J Ultrasound Med 30:1281,
2011.
Nervous System 14. Lamb PM, Lund A, Kanagasbay RR, et al: Spleen size: How well do linear ultrasound
A thorough evaluation of neurologic function is necessary in many measurements correlate with three-dimensional CT volume assessments? Br J Radiol
patients with hematologic disease. Vitamin B deficiency impairs cere- 75:573, 2002.
12
bral, olfactory, spinal cord, and peripheral nerve function, and severe 15. Palas J, Matos AP, Ramalho M. The spleen revisited: An overview on magnetic reso-
nance imaging. Radiol Res Pract 2013:219297, 2013.
chronic deficiency may lead to irreversible neurologic degeneration. 16. Castell DO, O’Brien KD, Muench H, Chalmers TC: Estimation of liver size by percus-
Leukemic meningitis is often manifested by headache, visual impair- sion in normal individuals. Ann Intern Med 70:1183, 1969.
ment, or cranial nerve dysfunction. Tumor growth in the brain or spinal 17. Tucker WN, Saab S, Rickman LS, Mathews WC: The scratch test is unreliable for detect-
ing the liver edge. J Clin Gastroenterol 25:410, 1997.
cord compression may be caused by malignant lymphoma or plasma cell 18. Bennett WF, Dova JG: Review of hepatic imaging and a problem-oriented approach to
myeloma. A variety of neurologic abnormalities may develop in patients liver masses. Hepatology 12:761, 1990.
with leukemias, lymphomas, and myeloma as a consequence of tumor 19. Barloon TJ, Brown BP, Abu-Yousef MM, et al: Teaching physical examination of the
adult liver with the use of real-time sonography. Acad Radiol 5:101, 1998.
infiltration, bleeding, infection, or a paraneoplastic syndrome. Essen- 20. Elstein D, Hadas-Halpern I, Azuri Y, et al: Accuracy of ultrasonography in assessing
tial monoclonal gammopathy is associated with several types of sensory spleen and liver. J Ultrasound Med 16:209, 1997.

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