Palpation

General guidelines for performing

The examination is performed with both hands with the patient in a comfortable position. The basic rule is that the physician's hands must be warm to avoid inducing reflex muscle tension. Palpation always begins away from the zone of maximum tenderness, gradually moving toward it. Movements progress from light, superficial touches to deeper presses.

According to V.F. Voyno-Yasenetsky's method, during abdominal palpation, the hand is placed flat, then slightly moved along the skin, and only afterward does gentle pressure begin with extended fingers. The purpose of such actions is to assess the resistance of the abdominal wall and the level of tenderness. Rough and abrupt movements are unacceptable, as they make further examination impossible.

Assessment of pathological formations

When palpating tumors or swellings, the physician determines their shape, size, position, and consistency. The latter may vary depending on the contents:

• Firm (comparable to wood or bone);
• Soft or doughy (the finger easily sinks in, leaving a pit);
• Elastic (resembling a rubber ball);
• Leathery.

An important parameter is mobility. Benign formations are usually mobile relative to surrounding tissues, whereas malignant ones are characterized by fixation due to infiltration. Vascular tumors (angiomas) may decrease in volume upon compression due to blood outflow, and hernia protrusions can be reduced into the cavity.

Specific symptoms during palpation

Fluctuation sign (wave sign) indicates the accumulation of fluid (pus, blood, serous exudate) in a closed cavity. To check this, the fingers of one hand are placed on one side of the swelling, and the other hand performs short taps from the opposite side. The first hand then feels the transmitted wave. It is important to distinguish true fluctuation from false fluctuation, which occurs with lipomas or relaxed muscles.

Crepitation is a crunch or crackling sound that occurs with light pressure. Possible causes:

• Subcutaneous emphysema or anaerobic infection (presence of gas in tissues);
• Accumulation of blood with clots ("snow crunch");
• Tenosynovitis (fibrin deposition in tendon sheaths);
• Fractures (friction of bone fragments against each other);
• "Parchment crunch" upon thinning of the bone plate.

Palpation of pulse and lymph nodes

Peripheral arteries are palpated at specific projection points. For example, the radial artery is sought on the forearm above the wrist joint, and the dorsalis pedis artery between the 1st and 2nd digits. In the presence of arterial aneurysms, a characteristic vibration resembling a buzzing sound can be felt. Pulsating hematomas contract synchronously with the pulse.

Lymph nodes are felt with the 2nd, 3rd, and 4th fingers, making careful circular movements. The physician assesses their size, consistency, mobility, adhesion to adjacent tissues or other nodes, as well as the degree of tenderness.

What else to study on this topic

• Abdominal palpation according to the Obraztsov-Strazhesko method
• Specific pain symptoms (Shchetkin-Blumberg, Rovsing)
• Determination of the `punctum maximum` in inflammatory processes and trauma
• Differential diagnosis of true and false fluctuation
• Topography of peripheral artery pulsation points

Other Topics in «CHAPTER 9. EXAMINATION OF THE SURGICAL PATIENT»

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