CHAPTER II PALPATION
By palpation we refer to the use of the sense of touch for the determination of the character of the tissues. It is employed:
- To elicit tenderness, or rigidity; to ascertain the position and pulsations or thrills, and to feel the pulse.
- To determine the character of the texture, moisture, edema).
- To discover local swelling, induration, softening, etc., of the tissues, especially as regards the lymph nodes.
- To elicit vocal fremitus; to determine the presence of hepatic or splenic enlargement, etc.
Chest Expansion. —The bilateral equality of chest expansion can often be determined by laying the hand lightly upon the patient’s chest during the act of respiration. Some examiners prefer this method to simple inspection.
<Callout type="important" title="Important">Palpation is crucial for detecting subtle changes in tissue texture and swelling, which may indicate underlying diseases.</Callout>
ZONES OF CUTANEOUS HYPERESTHESIA (HEAD’S AREAS), AND REFLEX PAIN
The nerves supplying the skin have become so educated that any injury to them is perceived as pain. Such is not the case with nerves of the internal organs; a painful irritation of the viscera finds its expression, not necessarily over the site of the organ, but in a painful area of the skin often remote from it. Head has shown that the painful stimulus in the organ travels in a centripetal direction to the posterior part of the cord and there sets up excitation of the nerves which supply the same and in the adjoining segments with pain. The pain is referred to the skin because therein the pain sense reaches its highest development.
<Callout type="warning" title="Warning">Referred pain can be misleading, as it may not accurately indicate the location of the underlying issue.</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 referred pain—by way of the seventh to the twelfth dorsal segments.
<Callout type="tip" title="Tip">Always consider the possibility of referred pain when examining pleural regions.</Callout>
The visceral pleura is devoid of the pain sense. Irritation of the diaphragm posteriorly produces pain in lower chest, abdomen or lumbar region. This is a referred pain—by way of the seventh to the twelfth dorsal segments. The pericardial pleura when irritated may produce similar pain, because its nerve supply is mainly if not entirely phrenic in origin.
<Callout type="risk" title="Risk">Failure to recognize referred pain can lead to incorrect diagnosis and treatment.</Callout>
Pleural pain may be referred to the abdominal wall and lack of a careful examination of the lungs has led to unwarranted celiotomies in patients who a day or two later have developed well-marked signs of the pneumonia which was the cause of the original abdominal pain and rigidity. Vice versa, although less frequently, abdominal lesions may occasionally produce thoracic pain.
TACTILE OR VOCAL FREMITUS Fremitus is produced by (1) phonation (vocal fremitus), (2) coughing (tactile fremitus), or (3) breathing (rhonchous fremitus) produced by exudation into or stenosis of the air passages. These actions 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 surface.
<Callout type="important" title="Important">Vocal fremitus is essential for diagnosing respiratory issues, especially in cases where auscultation alone may not provide sufficient information.</Callout>
The lower pulmonary border can be accurately determined by laying the ulna and little finger against the chest wall while the patient counts one—one-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="gear" title="Gear">A sensitive flame can be used as an auxiliary tool for detecting fremitus, especially in cases where the vibration is faint.</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. The sounds thus produced by the vocal cords and glottis pass upward through a variable resonator—mouth and nares—and are there modified as regards their overtones by the lips, tongue, ete., and thus the vowel sounds originate. A further modification of the overtones by means of the lips, teeth, tongue, ete., results in the consonants of articulate speech. The laryngeal sounds are further reinforced by means of a large resonator—the thorax—which under favorable conditions vibrates in unison with the larynx and, therefore, amplifies the sonorous waves and intensifies the sound, as does a sound box those of the tuning fork. Vocal fremitus is, therefore, not an accidental vibration of the thorax but is a rhythmic vibration due to, and in unison with, the vocal cords.
Pleural pain may be referred to the abdominal wall and lack of a careful examination of the lungs has led to unwarranted celiotomies in patients who a day or two later have developed well-marked signs of the pneumonia which was the cause of the original abdominal pain and rigidity. Vice versa, although less frequently, abdominal lesions may occasionally produce thoracic pain.
<Callout type="risk" title="Risk">Failure to recognize referred pain can lead to incorrect diagnosis and treatment.</Callout>
Key Takeaways
- Palpation is essential for detecting subtle changes in tissue texture and swelling, which may indicate underlying diseases.
- Referred pain can be misleading and must be considered when examining pleural regions.
- Vocal fremitus is a crucial diagnostic tool for identifying respiratory issues.
Practical Tips
- Always consider the possibility of referred pain when examining pleural regions to avoid misdiagnosis.
- Use vocal fremitus in conjunction with auscultation for more accurate diagnosis of respiratory conditions.
- Be aware that referred pain can be a significant diagnostic challenge and may require further investigation.
Warnings & Risks
- Failure to recognize referred pain can lead to incorrect diagnosis and treatment, potentially resulting in unnecessary surgery or delayed care.
- Incorrectly interpreting tactile fremitus without considering the patient's full clinical picture can result in misdiagnosis.
- Overreliance on palpation alone may miss critical findings that require further diagnostic testing.
Modern Application
While the techniques described in this chapter are foundational for understanding chest examinations, modern medical practices have advanced with more precise imaging and diagnostic tools. However, the principles of palpation remain crucial for initial assessments and can complement other diagnostic methods to ensure a comprehensive evaluation.
Frequently Asked Questions
Q: What is vocal fremitus and how is it used in diagnosing respiratory issues?
Vocal fremitus refers to the tactile perception of vibrations produced by phonation, coughing, or breathing. It is used to determine the presence of exudate or stenosis in air passages, which can indicate conditions like pneumonia.
Q: How does referred pain occur and why is it important during chest examinations?
Referred pain occurs when a painful stimulus in an internal organ travels via nerve pathways to the skin, causing pain at a distant site. It is crucial because it can mislead diagnosis if not considered, leading to incorrect treatment.
Q: What are some practical applications of palpation techniques described in this chapter?
Palpation can be used to detect swelling, induration, and local changes in tissue texture, which may indicate underlying diseases. It is also useful for determining chest expansion and identifying areas of pain or tenderness.