PalpationPalpationDr. Laszlo JakabDr. Laszlo JakabDr. Laszlo JakabDr. Laszlo Jakab
The Posterior ChestThe Posterior ChestGeneral approachGeneral approach
Undress to the waistUndress to the waist
Sitting positionSitting position
Inspect Inspect –– palpate palpate ––percuss percuss –– auscultateauscultateInspect Inspect –– palpate palpate ––percuss percuss –– auscultateauscultate
Compare one side with otherCompare one side with other
apex and baseapex and base
The Posterior ChestThe Posterior ChestIdentification of tender areasIdentification of tender areas
intercostal tenderness intercostal tenderness →→ inflamed inflamed
pleurapleura
The Posterior ChestThe Posterior ChestAssessment of observed Assessment of observed abnormalitiesabnormalities
shape of the chestshape of the chest
deformitiesdeformitiesdeformitiesdeformities
asymmetryasymmetry
massesmasses
The Posterior ChestThe Posterior ChestAssessment of respiratory expansionAssessment of respiratory expansion
unilateral diminutionunilateral diminution
pleural effusionpleural effusion
lobar pneumonialobar pneumonialobar pneumonialobar pneumonia
The Posterior ChestThe Posterior ChestTactile fremitusTactile fremitus
999911--11--11palpable vibrationspalpable vibrationsbronchopulmonary systembronchopulmonary system→→chest wallchest wallcomparison of symmetrical areascomparison of symmetrical areasincreasedincreased lobar pneumonialobar pneumoniaincreasedincreased→→lobar pneumonialobar pneumonia
alveoli filled with fluid, alveoli filled with fluid, RBC,WBSRBC,WBS→→transmission transmission ↑↑
decreaseddecreased→→ fluid in the pleural cavityfluid in the pleural cavity= pleural effusion= pleural effusion
airairptx = pneumothoraxptx = pneumothorax
The Anterior ChestThe Anterior ChestSupine positionSupine position
Identification of tender areasIdentification of tender areas
Assessment of observed abnormalitiesAssessment of observed abnormalities
respiratory expansionrespiratory expansion
tactile fremitustactile fremitustactile fremitustactile fremitus
both sides of the chestboth sides of the chest
Identification of a fractured ribIdentification of a fractured rib
local pain, tendernesslocal pain, tenderness
aa--p compression sternum p compression sternum –– thoracic spinethoracic spine
increase in local painincrease in local pain
The Arterial PulseThe Arterial Pulseradial pulseradial pulse
heart rateheart rate
rhythmrhythm
regularregularregularregular
irregularirregular
atrial fibrillationatrial fibrillation
premature contractionpremature contraction
The Arterial PulseThe Arterial Pulseamplitude and contouramplitude and contour
carotid arterycarotid arterydecreased pulsationdecreased pulsationatherosclerotic occlusionatherosclerotic occlusiondo not press on both carotidsdo not press on both carotids
carotid sinuscarotid sinuscarotid sinuscarotid sinusamplitude ≈ pulse pressureamplitude ≈ pulse pressure
small, weaksmall, weaklarge, boudinglarge, bouding
thrills thrills vibrations of the carotid arteryvibrations of the carotid arteryarterial narrowingarterial narrowing
The HeartThe Heartsupine positionsupine position
use your fingerpadsuse your fingerpads
patientpatient→→ exhale fully and stop exhale fully and stop
breathingbreathingbreathingbreathing
The HeartThe Heart
Apical impulseApical impulsebrief early systolic pulsation of the left brief early systolic pulsation of the left ventricleventricleleft ventricular area = cardiac apexleft ventricular area = cardiac apexlocation: 5th interspacelocation: 5th interspacelocation: 5th interspacelocation: 5th interspace
medial to the midclavic. Linemedial to the midclavic. Linediameter: diameter: >> 2.5 cm in adults and 2.5 cm in adults and
occupies occupies only one interspaceonly one interspaceamplitude: small, gentleamplitude: small, gentleduration: duration: << 2/3 of systole2/3 of systole
The HeartThe HeartApical impulseApical impulse
undetectableundetectable
obesityobesity
muscular chest wallmuscular chest wallmuscular chest wallmuscular chest wall
located behind the rib cagelocated behind the rib cage
displaceddisplaced
left ventricular enlargementleft ventricular enlargement
deformities of the thoraxdeformities of the thorax
mediasinal shiftmediasinal shift
The HeartThe HeartApical impulseApical impulse
incresed amplitudeincresed amplitudehyperkinetic stateshyperkinetic states
young personsyoung personshyperthyroidismhyperthyroidismsevere anemiasevere anemiaASASASAS
prolonged durationprolonged durationhypertrophy of the left ventriculehypertrophy of the left ventricule
ThrillsThrillsloud heart murmursloud heart murmurs
ASASVSDVSDMSMS
The AbdomenThe AbdomenQuadrants, sectionsQuadrants, sectionsGeneral approachGeneral approach
relaxed patientrelaxed patientlegs flexed et hips and kneeslegs flexed et hips and kneessupine positionsupine positionpatientpatient´́s right sides right side
arms t the sides of the trunkarms t the sides of the trunkarms t the sides of the trunkarms t the sides of the trunkwarm hands, short fingernailswarm hands, short fingernailswatch patientwatch patient´́s face for signs of discomforts face for signs of discomfort
Normal structures palpableNormal structures palpablesigmoid colonsigmoid colonnormal livernormal liverlower pole of the right kidneylower pole of the right kidneypulsation of the abdominal aortapulsation of the abdominal aortadistended bladderdistended bladdertip of the normal spleentip of the normal spleen
The AbdomenThe AbdomenLight palpationLight palpation
abdominal tendernessabdominal tendernessmuscular resistancemuscular resistance
voluntaryvoluntaryinvolunntary muscula pasminvolunntary muscula pasm
superficial organssuperficial organsmassesmassesmassesmasses
Deep palpationDeep palpationmassesmasses→→ location, size, shape, consistency, tenderness, location, size, shape, consistency, tenderness,
pulsations, pulsations, mobilitymobilityAssessment of peritoneal irritationAssessment of peritoneal irritation
muscular spasmmuscular spasmabdominal pain on coughing and on ligh percussionabdominal pain on coughing and on ligh percussiontendernesstendernessinflammation of the parietal peritoneuminflammation of the parietal peritoneum
The LiverThe Liverbelow the right costal marginbelow the right costal marginuse your fingertips of the right handuse your fingertips of the right handpress gently in and uppress gently in and uppatient takes a deep breathpatient takes a deep breathpalpabilitypalpabilitythe edge of the liverthe edge of the liver
normalnormalnormalnormalsharpsharproundedroundedregularregular
the surface of the liverthe surface of the livernormalnormalsmoothsmooth
The LiverThe LiverAbnormalitiesAbnormalities
hardnesshardness
irregularity of its surfaceirregularity of its surface
tendeness tendeness hepatitishepatitistendeness tendeness →→ hepatitishepatitis
enlargement = hepatomegalyenlargement = hepatomegaly
The SpleenThe Spleenbelow the left costal marginbelow the left costal margin
press in toward the spleenpress in toward the spleen
tip of the spleentip of the spleen
tendernesstendernesstendernesstenderness
enlargement = splenomegalyenlargement = splenomegaly
The KidneysThe KidneysRight kidneyRight kidney
left hand left hand →→ costovertebral anglecostovertebral angle
right hand right hand →→ right upper quadrantright upper quadrant
patient takes a deep breathpatient takes a deep breath
maybe palpable the lower polemaybe palpable the lower polemaybe palpable the lower polemaybe palpable the lower pole
enlargementenlargement→→ tumor, hydronephrosis tumor, hydronephrosis
(pelvis of the kidney)(pelvis of the kidney)
left kidney left kidney →→ rarely palpablerarely palpable
kidney tendenesskidney tendeness
fist percussion at the costovertebral fist percussion at the costovertebral
angle angle →→ kidney infectionkidney infection
The AortaThe Aortadeep palpationdeep palpation
upper abdomenupper abdomen
aortic pulsationsaortic pulsations
abdominal mass with pulsations abdominal mass with pulsations abdominal mass with pulsations abdominal mass with pulsations →→
→→ aortic aneurysmaortic aneurysm
The NeckThe NeckLymph nodesLymph nodes
fingerpadsfingerpadsboth sidesboth sidesoccipital, preaurical, submandibular,occipital, preaurical, submandibular,cervical, supraclavicularcervical, supraclavicularcervical, supraclavicularcervical, supraclavicularsize, shape, discrete or grouped size, shape, discrete or grouped together, mobility, consistency, together, mobility, consistency, tendernesstenderness
Normal person Normal person →→ small, mobile, discrete, small, mobile, discrete, nontendernontender
Enlarged Enlarged →→ lymph nodes elsewhere lymph nodes elsewhere →→regional, regional, generalizedgeneralized
The Thyroid glandThe Thyroid glandpalpate behind the patientpalpate behind the patient
just below the cricoid cartilagejust below the cricoid cartilage
patient swallowspatient swallows
thyroid isthmus risesthyroid isthmus risesthyroid isthmus risesthyroid isthmus rises
feel the isthmus and the lateral feel the isthmus and the lateral lobeslobes
size, shape, consistency, nodules, size, shape, consistency, nodules, tendernesstenderness
goiter = diffusely enlarged thyroidgoiter = diffusely enlarged thyroid
The BreastsThe BreastsQuadrants Quadrants →→ upper inner, lower inner, upper inner, lower inner,
upper outer, lower outerupper outer, lower outer
tendernesstenderness
nodules = lumps = massesnodules = lumps = masses
location, size in cm, shape, consistency location, size in cm, shape, consistency location, size in cm, shape, consistency location, size in cm, shape, consistency (soft or hard), mobility to the skin and(soft or hard), mobility to the skin and
underlying chest wallunderlying chest wall
cancer cancer →→ hard, irregular, poorly hard, irregular, poorly circumscribed nodule, fixed to the skincircumscribed nodule, fixed to the skin
discharge of the nipple discharge of the nipple →→ milky, bloodymilky, bloody
The AxillaeThe Axillaesitting positionsitting position
normal person normal person →→ small, nontender small, nontender
nodesnodes
enlarged lymph nodes enlarged lymph nodes →→ hardhard→→enlarged lymph nodes enlarged lymph nodes →→ hardhard→→breast breast cancer or tender cancer or tender →→ infectioninfection
The Anus, Rectum, and ProstateThe Anus, Rectum, and ProstateRectal examinationRectal examination
sideside--lying positionlying positionglove, lubricantglove, lubricantperianal area perianal area →→ hemorrhoids, perianal hemorrhoids, perianal
abscessabscessrectum rectum →→ carcinomacarcinomaanterior surface of the prostate glandanterior surface of the prostate glandanterior surface of the prostate glandanterior surface of the prostate gland
both lobesboth lobessize, shape, nodules, tendernesssize, shape, nodules, tendernessnormal normal →→ rubbery, nontender, rounded, rubbery, nontender, rounded,
2.5 cm in length2.5 cm in lengthcancer cancer →→ hardhardBPH (benign prostatic hyperplasia) BPH (benign prostatic hyperplasia) →→ 5th 5th
decade,decade,symmetric enlargement, smooth, obstruction of symmetric enlargement, smooth, obstruction of
urinary urinary flowflow
The Peripheral Vascular SystemThe Peripheral Vascular Systemsupine positionsupine positionboth legsboth legs
swellingswellingsymmetrysymmetrysizesizevenous enlargementvenous enlargementulcersulcers
femoral artery femoral artery →→ below the inguinal ligamentbelow the inguinal ligamentfemoral artery femoral artery →→ below the inguinal ligamentbelow the inguinal ligamentpopliteal artery popliteal artery →→ in the tissues behind the kneein the tissues behind the kneedorsalis pedis artery dorsalis pedis artery →→ the dorsum of the footthe dorsum of the footposterior tibial artery posterior tibial artery →→ behind the medial malleolus of anklebehind the medial malleolus of ankle
arterial pulsationarterial pulsationlook for edemalook for edema
ankle, dorsum of the footankle, dorsum of the footpitting pitting →→ depression by pressuredepression by pressureseverity severity →→ light, very markedlight, very markedswelling swelling →→ unilateral, bilateralunilateral, bilateral