To perform palpation of the liver, place your left hand posteriorly between the patient's right 12th rib and the iliac crest, lateral to the paraspinal muscles. Place your right hand in the patient's right upper quadrant parallel and lateral to the rectus muscles and below the area of liver dullness. The patient is instructed to take a deep breath as you press inward and upward with your right hand and pull upward with your left hand. You may feel the liver edge slipping over the fingertips of your right hand as the patient breathes. Start as low as the pelvic brim and gradually work upward. If the examination does not start low, a markedly enlarged liver edge may be missed. The technique of liver palpation is demonstrated in Figure 17-23.
The normal liver edge has a firm, regular ridge, with a smooth surface. If the liver edge is not felt, repeat the maneuver after readjusting your right hand closer to the costal margin. Enlargement of the liver results from vascular congestion, hepatitis, neoplasm, or cirrhosis.
Another technique for liver palpation is the ''hooking'' method. The examiner stands near the patient's head and places both hands together below the right costal margin and the area of dullness. The examiner presses inward and upward and ''hooks'' around the liver edge while the patient inhales deeply. The technique of hooking the liver is shown in Figure 17-24.
On occasion, the liver appears to be enlarged, but the actual border is difficult to determine. The scratch test may be helpful in ascertaining the liver's edge. The examiner holds the diaphragm of the stethoscope with the left hand and places it below the patient's right costal margin over the liver. While the examiner listens through the stethoscope, his or her right index finger ''scratches'' the abdominal wall at points in a semicircle equidistant from the stethoscope. As the finger scratches over the liver's edge, there is a marked increase in the intensity of the sound. This technique is illustrated in Figure 17-25.
A palpable liver is not necessarily enlarged or diseased; however, its being palpable does increase the possibility of hepatomegaly. Being nonpalpable does not rule out hepatomegaly, but it does reduce the likelihood that the liver is enlarged. The LR+ for hepatomegaly, if the liver is palpable, is 2.5; if the liver is not palpable or if enlargement of the liver is detected by scintigraphic scanning, the LR— is 0.45.
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