Palpation2018.09.18.

Budapest

Semmelweis University

The Posterior Chest

• General approach

Undress to the waist

Sitting position

Inspect – palpate –percuss – auscultate

Compare one side with other

apex and base

The Posterior/Lateral Chest

The Posterior Chest

• Identification of tender areas

intercostal tenderness → inflamed pleura

• Assessment of observed abnormalities

shape of the chest

deformities

asymmetry

masses

The Posterior Chest

The Posterior Chest

• Assessment of respiratory expansion

unilateral diminution

pleural effusion

lobar pneumonia

The Posterior Chest

• Tactile fremitus

Patient says: 99 or 1-1-1 (hungarian 66 =hatvanhat)

palpable vibrations

bronchopulmonary system→chest wall

comparison of symmetrical areas

increased→lobar pneumonia

alveoli filled with fluid,

RBC,WBS→transmission ↑

decreased→ fluid in the pleural cavity = pleural effusion

air, ptx = pneumothorax

The Anterior Chest

• Supine position

• Identification of tender areas

• Assessment of observed abnormalities

respiratory expansion

tactile fremitus

both sides of the chest

Identification of a fractured rib

local pain, tenderness

a-p compression sternum – thoracic spine

increase in local pain

The Arterial Pulse

- radial pulse

- heart rate

- rhythm

- regular

- irregular

atrial fibrillation

premature contraction

The Arterial Pulse

amplitude and contour

carotid artery

decreased pulsation

atherosclerotic occlusion

do not press on both carotids

carotid sinus

amplitude ≈ pulse pressure

small, weak

large, bouding

thrills

vibrations of the carotid artery

arterial narrowing

The Heart

supine position

use your fingerpads

patient→ exhale fully and stop breathing

The Heart

• Apical impulse

undetectable

obesity

muscular chest wall

located behind the rib cage

displaced

left ventricular enlargement

deformities of the thorax

mediasinal shift

The Heart

• Apical impulseincresed amplitude

hyperkinetic states

young persons

hyperthyroidism

severe anemia

AS

prolonged duration

hypertrophy of the left ventricule

Thrills

loud heart murmurs

AS

VSD

MS

The Abdomen• Quadrants, sections

• General approach

relaxed patient

legs flexed et hips and knees

supine position

patient´s right side

arms at the sides of the trunk

warm hands, short fingernails

watch patient´s face for signs of discomfort

• Normal structures palpable

sigmoid colon

normal liver

lower pole of the right kidney

pulsation of the abdominal aorta

distended bladder

tip of the normal spleen

The Abdomen• Light palpation

abdominal tenderness

muscular resistance

voluntary

involunntary muscula pasm

superficial organs

masses

• Deep palpation

masses→ location, size, shape, consistency, tenderness, pulsations, mobility

• Assessment of peritoneal irritation

muscular spasm

abdominal pain on coughing and on ligh percussion

tenderness

inflammation of the parietal peritoneum

The Liverbelow the right costal margin

use your fingertips of the right hand

press gently in and up

patient takes a deep breath

palpability

the edge of the liver

normal

sharp

rounded

regular

the surface of the liver

normal

smooth

The Liver

The Spleen

below the left costal margin

press in toward the spleen

tip of the spleen

tenderness

enlargement = splenomegaly

The Kidneys

• Right kidney

left hand → costovertebral angle

right hand → right upper quadrant

patient takes a deep breath

maybe palpable the lower pole

enlargement→ tumor, hydronephrosis

(pelvis of the kidney)

left kidney → rarely palpable

kidney tendeness

fist percussion at the costovertebral

angle → kidney infection

The Aorta

deep palpation

upper abdomen

aortic pulsations

abdominal mass with pulsations →

→ aortic aneurysm

The Neck• Lymph nodes

fingerpads

both sides

occipital, preaurical, submandibular,

cervical, supraclavicular

size, shape, discrete or grouped, together, mobility, consistency, tenderness

Normal person → small, mobile, discrete, nontender

Enlarged → lymph nodes elsewhere → regional, generalized

The Thyroid gland

palpate behind the patient

just below the cricoid cartilage

patient swallows

thyroid isthmus rises

feel the isthmus and the lateral lobes

size, shape, consistency, nodules, tenderness

goiter = diffusely enlarged thyroid

The Breasts

Quadrants → upper inner, lower inner, upper outer, lower outer

tenderness

nodules = lumps = masses

location, size in cm, shape, consistency (soft or hard), mobility tothe skin and

underlying chest wall

cancer → hard, irregular, poorly circumscribed nodule, fixed to theskin

discharge of the nipple → milky, bloody

The Axillae

sitting position

normal person → small, nontender nodes

enlarged lymph nodes → hard→ breast cancer or tender � infection

The Anus, Rectum, and Prostate

• Rectal examination

side-lying position

glove, lubricant

perianal area → hemorrhoids, perianal abscess

rectum → carcinoma

anterior surface of the prostate gland

- both lobes

- size, shape, nodules, tenderness

normal → rubbery, nontender, rounded,

2.5 cm in length

- cancer → hard

- BPH (benign prostatic hyperplasia) → 5th decade,

-symmetric enlargement, smooth, obstruction of urinary flow

The Peripheral Vascular Systemsupine position

both legs

swelling

symmetry

size

venous enlargement

ulcers

femoral artery → below the inguinal ligament

popliteal artery → in the tissues behind the knee

dorsalis pedis artery → the dorsum of the foot

posterior tibial artery → behind the medial malleolus of ankle

arterial pulsation

look for edema

ankle, dorsum of the foot

pitting → depression by pressure

severity → light, very marked

swelling → unilateral, bilateral

Percussion

Technique

the pleximeter finger:

hyperextension of the middle finger of the left hand

its DIP joint press firmly

avoid contact by other part of the hand →

→ decrease of vibrations

the plexor finger

right middle finger→ partially flexed

tip of the plexor finger strikes the pleximeter finger

Technique

Technique

transmission of vibrations → through the bones of DIP joint → tothe underlying chest wall

movement of the wrist

thick chest wall → heavier percussion

strike 2x in 1 location

percussion → audible sounds ← motion of the chest wall

Technique

underlying tissues

air-filled

fluid-filled

solid

penetraCon → 5-7cm into the chest

deep-seated lesions → undetected

Medical percussion sounds

• NORMAL PERCUSSION SOUNDS

• Resonance: heard over lung tissue

• Tympany: heard over most portions of the abdominal cavity

• Dullness: heard over solid organs (eg, liver) and muscles

• ABNORMAL PERCUSSION SOUNDS

• Lung: dullness, which may be produced by pneumonia,

• tumor, infarction, or fluid collection;

• hyperresonance or even tympany, which may result from confluent air collection, as seen inpneumothorax or emphysema

• Abdomen: dullness, which may be produced by intra-abdominal tumors or masses; shifting dullness may indicate presence of ascites

• Heart: an expanded area of dullness may indicatecardiomegaly or pericardial effusion

The Posterior ChestPercussion → compare one side with other

symmetrical areas

sitting position

undress to the waist

apex → base

omit the scapular areas ← thick musculosceletal structures

normal lung percussion → resonance →

→ intensity: loud, pitch: low, duration: long

emphysema (lungs are hyperinflated) percussion →

→diffuse hyperresonance

→ intensity: very loud, pitch: lower, duration: longer

The Posterior Chest

Abnormal dullness

fluid in the pleural space = pleural effusion

hemothorax (blood), empyema (pus)

solid tissue in the lung → lobar pneumonia

alveoli filled with fluid, RBC, WBC

Unilateral hyperresonance

large air-filled bulla in the lung or large amount of air in thepleural space

The Posterior Chest

• Identification of the level of diaphagmaticdullnes

percussion: apex → base

resonance→ dullness = diaphragm

abnormally high level→ diaphragmaticparalysis

• Diaphragmatic excursion

distance between levels of dullness

on full exspiration

on full inspiration

5-6 cm

Summary• Normal case:

percussion note → resonant

tactile fremitus → normal

• Lobar pneumonia (bacterial infection, alveoli filled)

percussion note → dull over the airless area

tactile fremitus → increased

• Pleural effusion (fluid accumulates and separates the ai-filled lung from the chestwall and blocks the transmission of the sound)

percussion note → dull over the fluid

tactile fremitus → decreased

The Posterior Chest

• Ptx

air in the pleural space → blocks the transmission of the sounds

percussion note → hyperresonant or tympanic over the pleural air

tactile fremitus → decreased or absent over the pleural air

The Anterior Chest

supine position

compare both sides

dullness behind the right breast → right middle lobe pneumonia

identification of the upper border of liver dullness

The Heart

supine position

estimation of cardiac size

percussion: lung resonance → cardiac dullness

percuss for the right, left and upper border

leF border → LV

right border → RA

The Abdomen

relaxed patient

supine position

full exposure

warm hands

stand on patient´s right side

The Abdomen

• Orientation

4 quadrants

tympany predominates → gastric air bubble, gas in the GI tract

dullnes → each side solid structures(liver, spleen)

suprapubic area → distended bladder, enlarged uterus

Traube's spaceTraube's spaceTraube's spaceTraube's space

• Anatomical boundaries are:

1. Right : Lateral margin of left lobe of liver.2. Left : Spleen.3. Superior : Resonance of lung.4. Inferior : Costal margin.

Contents

1. Fundus of stomach (Hence percussion of Traubes area normally gives Tympanitic resonance).2. Costo-phrenic recess of left pleura devoid of lungs.

Causes of obliteration of Traubes space:1. Full stomach.2. Left sided Pleural effusion.3.Splenomegaly.4. Enlargment ofleft lobe of liver due to any etiology.5. Dextrocardia.6. Proloiferative growth in fundus of stomach.

The Liver

liver dullness

vertical span = height

in cm

in the right midclavicular line

lung resonance → upper border of liver dullness

tympany → lower border of liver dullness

increased span → enlarged liver=hepatomegaly

decreased span → small liver

liver dullness disappears → free air present below the diaphragm → signof perforation

The Spleen

posterior to the midaxillary line

splenic dullness → oval area

surroundings

pulmonary resonance

abdominal tympany

enlarged spleen = splenomegaly

→ large dull area

Ascites

protuberant abdomen

ascites fluid → sinks with the gravity

percussion → dullness outward → central tympanic area

shifting dullnes

paCent turns onto one side → dullness shifts

fluid wave

impulse transmitted through the fluid