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