Palpation Budapest Semmelweis University

Transcription

1 Palpation Budapest Semmelweis University

2 The PosteriorChest General approach Undress to the waist Sitting position Inspect palpate percuss auscultate Compare one side with other apex and base

3 The Posterior/LateralChest

4 The PosteriorChest Identification of tender areas intercostal tenderness inflamed pleura Assessment of observed abnormalities shapeof thechest deformities asymmetry masses

5 The PosteriorChest

6 The PosteriorChest Assessment of respiratory expansion unilateral diminution pleural effusion lobar pneumonia

7 The PosteriorChest Tactile fremitus Patient says: 99 or (hungarian 66 =hatvanhat) palpable vibrations bronchopulmonary system chest wall comparison of symmetrical areas increased lobar pneumonia alveolifilledwithfluid, RBC,WBS transmission decreased fluid in the pleural cavity = pleural effusion air, ptx = pneumothorax

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10 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

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12 The Arterial Pulse - radial pulse -heartrate -rhythm -regular -irregular atrial fibrillation premature contraction

13 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

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15 The Heart supine position use your fingerpads patient exhale fully and stop breathing

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17 The Heart Apical impulse undetectable obesity muscular chest wall located behind the rib cage displaced left ventricular enlargement deformities of the thorax mediasinal shift

18 The Heart Apical impulse incresed amplitude hyperkinetic states young persons hyperthyroidism severe anemia AS prolonged duration hypertrophy of the left ventricule Thrills loud heart murmurs AS VSD MS

19 The Abdomen Quadrants, sections General approach relaxed patient legsflexedet hipsand knees supine position patient s right side armsatthesidesof thetrunk warm hands, short fingernails watch patient s face for signs of discomfort Normal structures palpable sigmoid colon normal liver lowerpoleof theright kidney pulsation of the abdominal aorta distended bladder tipof thenormalspleen

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22 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

23 The Liver below 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

24 The Liver

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26 The Spleen below the left costal margin press in toward the spleen tip of the spleen tenderness enlargement = splenomegaly

27 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

28 The Aorta deep palpation upper abdomen aortic pulsations abdominal mass with pulsations aortic aneurysm

29 The Neck Lymph nodes fingerpads both sides occipital, preaurical, submandibular, cervical, supraclavicular size, shape, discreteorgrouped, together, mobility, consistency, tenderness Normal person small, mobile, discrete, nontender Enlarged lymph nodes elsewhere regional, generalized

30 The Thyroidgland 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

31 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 to theskinand underlying chest wall cancer hard, irregular, poorly circumscribed nodule, fixed to the skin discharge of the nipple milky, bloody

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34 The Axillae sitting position normal person small, nontender nodes enlarged lymph nodes hard breast cancer or tender infection

35 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 -bothlobes - size, shape, nodules, tenderness normal rubbery, nontender, rounded, 2.5 cm inlength -cancer hard - BPH (benign prostatic hyperplasia) 5th decade, -symmetric enlargement, smooth, obstruction of urinary flow

36 The Peripheral Vascular System supine position both legs swelling symmetry size venous enlargement ulcers femoral artery below the inguinal ligament popliteal artery in the tissues behind the knee dorsalispedisartery thedorsumof thefoot 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

37 Percussion

38 Technique thepleximeterfinger: hyperextension of the middle finger of the left hand its DIP joint press firmly avoidcontactbyotherpart of thehand decrease of vibrations the plexor finger right middle finger partially flexed tip of the plexor finger strikes the pleximeter finger

39 Technique

40 Technique transmissionof vibrations throughthebonesofdip joint to the underlying chest wall movement of the wrist thick chest wall heavier percussion strike2x in1 location percussion audiblesounds motionof thechestwall

41 Technique underlying tissues air-filled fluid-filled solid penetracon 5-7cm into the chest deep-seated lesions undetected

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43 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 in pneumothorax or emphysema Abdomen: dullness, whichmaybe producedbyintra-abdominaltumorsormasses; shifting dullness may indicate presence of ascites Heart: an expanded area of dullness may indicatecardiomegaly or pericardial effusion

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45 The Posterior Chest Percussion 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(lungsarehyperinflated) percussion diffuse hyperresonance intensity: very loud, pitch: lower, duration: longer

46 The Posterior Chest Abnormal dullness fluid in the pleural space = pleural effusion hemothorax(blood), empyema(pus) solidtissueinthelung lobarpneumonia alveoli filled with fluid, RBC, WBC Unilateral hyperresonance largeair-filledbulla inthelungorlargeamountof air inthe pleural space

47 The Posterior Chest Identification of the level of diaphagmatic dullnes percussion: apex base resonance dullness = diaphragm abnormally high level diaphragmatic paralysis Diaphragmatic excursion distance between levels of dullness on full exspiration on full inspiration 5-6 cm

48 Summary Normal case: percussion note resonant tactile fremitus normal Lobarpneumonia(bacterialinfection, alveoli filled) percussion note dull over the airless area tactile fremitus increased Pleural effusion(fluid accumulates and separates the ai-filled lung from the chest wall and blocks the transmission of the sound) percussion note dull over the fluid tactile fremitus decreased

49 The PosteriorChest Ptx air inthepleuralspace blocksthetransmissionof thesounds percussion note hyperresonant or tympanic over the pleural air tactile fremitus decreased or absent over the pleural air

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51 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

52 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

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55 The Abdomen relaxed patient supine position full exposure warm hands stand on patient s right side

56 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

57 Traube'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.

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59 The Liver liver dullness vertical span = height incm intheright midclavicularline 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 sign of perforation

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62 The Spleen posterior to the midaxillary line splenic dullness oval area surroundings pulmonary resonance abdominal tympany enlarged spleen = splenomegaly large dull area

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64 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

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