By palpation we refer to the use of the sense of touch for the determination of the physical character of the tissues. It is employed:
- To elicit tenderness, or rigidity.
- To determine the presence of car thrill and to feel the pulse (see Chap. XIII).
- To determine the character of the skin (temperature, moisture, texture, edema).
- To discover local swelling, induration, softening, ete., of the tissues, especially as regards the lymph node.
Chest Expansion.—The bilateral equality of chest expansion can often be satisfactorily determined by laying the hands lightly upon the patient's chest during the act of respiration. Some examiners prefer this method to simple inspection.
<Callout type="important" title="Important">Always ensure the patient is comfortable and in a position that allows for accurate assessment.</Callout>
ZONES OF CUTANEOUS HYPERESTHESIA (HEAD’S AREAS), AND REFLEX PAIN
The nerves supplying the skin and skeletal muscles have become so educated that any injury to them is accurately located. Such is not the case with nerves of the internal organs. A painful irritation of the viscera finds expression, not necessarily over the site of the organ, but in a painful area of the skin often remote from it.
<Callout type="warning" title="Warning">Be cautious when interpreting referred pain as it can be misleading and lead to incorrect diagnoses.</Callout>
Pleural Pain
The parietal pleura and outer part of diaphragm receive their nerve supply from the lower six intercostal nerves. Lesions in this region produce pain in the overlying skin, which may be regarded as the result of a peripheral neuritis.
<Callout type="risk" title="Risk">Failure to properly examine the lungs can lead to unnecessary surgeries and missed diagnoses.</Callout>
TACTILE OR VOCAL FREMITUS
Fremitus is the tactile perception of vibrations, which may be produced by (1) phonation (vocal fremitus), (2) coughing (tussive fremitus), (3) breathing (rhonchous fremitus) produced by exudation into or stenosis of the air passages.
<Callout type="tip" title="Tip">Use the ulnar surface of your hand to accurately determine the lower pulmonary border.</Callout>
These phenomena set up vibrations within the bronchi and lungs, which under favorable conditions are accompanied by objectively sensible vibrations of the chest wall, which can be felt when the hand is laid upon it, as a faint vibration or trembling of its surface. The sensation thus obtained has been likened to that derived from a purring cat, but in the case of human fremitus the vibrations are much finer and move rapidly.
Vocal fremitus, which only is of practical utility, is elicited by laying the ulnar surface of the hand or fingers upon the chest or intercostal spaces, while the patient slowly repeats the numerals, ‘one;’ or, ‘ninety-nine’ in a clear, low tone. Symmetric areas of the chest are then compared in regard to the intensity of the vibrations which are felt.
<Callout type="important" title="Important">Always compare both sides of the patient for any asymmetry.</Callout>
The Mechanism of Voice Production.—The larynx is a reed instrument, the pitch of which is determined by the length and tension of the vocal cords. When these are approximated and air is forced upward from the lungs by means of the diaphragm and other respiratory muscles, the cords are thrown into vibration and a sound is generated.
<Callout type="gear" title="Gear">A stethoscope can enhance the detection of fremitus during auscultation.</Callout>
Key Takeaways
- Palpation is crucial for determining chest expansion and identifying local swelling, induration, or softening.
- Referred pain can be misleading; always compare both sides of the patient.
- Vocal fremitus is a practical method to assess lung conditions.
Practical Tips
- Always ensure the patient is comfortable during palpation examinations.
- Use the ulnar surface of your hand for accurate determination of the lower pulmonary border.
- Compare both sides of the patient for any asymmetry in fremitus intensity.
Warnings & Risks
- Failure to properly examine the lungs can lead to unnecessary surgeries and missed diagnoses.
- Be cautious when interpreting referred pain as it can be misleading.
- Incorrect assessment of chest expansion may result in misdiagnosis or delayed treatment.
Modern Application
While many of the techniques described in this chapter are still applicable, modern technology such as imaging and advanced diagnostic tools have improved accuracy. However, understanding palpation remains crucial for initial assessments and can be a valuable skill in resource-limited settings.
Frequently Asked Questions
Q: How does vocal fremitus help in diagnosing respiratory diseases?
Vocal fremitus helps in assessing the presence of exudate or stenosis in air passages, which can indicate conditions like pneumonia. It is elicited by placing your hand on the patient's chest and having them repeat a phrase in a clear, low tone.
Q: What are some common causes of referred pain during a chest examination?
Referred pain may occur due to irritation of internal organs like the liver or heart. For example, biliary colic can cause pain at the angle of the scapula, and renal colic can be felt in the testicles.
Q: Why is it important to compare both sides of the patient during a chest examination?
Comparing both sides helps identify any asymmetry or abnormalities that might indicate a specific condition. This comparison is crucial for accurate diagnosis and treatment planning.