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Palpation of Arterial Pulses
- Carotid: In the neck just below thyroid cartilage
- Subclavian: base of neck; midclavicular
- Brachial: Just medial to biceps tendon
- Radial: Lateral and ventral side of wrist
- Ulnar: Medial and ventral side of wrist
- Abdominal Aorta: 1" supeior and 1" lateral to patient's left of umbilicus
- Femoral: Inferior and medial to the inguinal ligament
- Popliteal: Press firmly in popliteal fossa
- Dorsalis Pedis: Medial dorsum of the foot.
- Posterior Tibialis: Behind medial malleolus
- INDICATION: An irregular heart pattern which continues in a regular pattern may indicate sinus arrythmia.
- Patternless rhythm may indicate heart disease
- Arterial insufficiency may be indicated by diminished or absent pulse.
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Palpate Lymph Nodes of Head and Neck
- I'll be checking for size, consistency, mobility, and condition:
- Occipital
- Postauricular
- Preauricular
- Tonsilar
- Submandibular
- Submental
- Facial
- Anterior Cervical Chain
- Posterior Cervical Chain
- Supraclavicular
**The lymph nodes are normally present but not felt. Infection within lymph nodes are soft, tender and easily moveable. Cancer within lymph nodes are hard, non-tender and non-moveable**
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Palpate Lymphnodes of the Thorax
Check for size, consistency, mobility and condition:
- Supraclavicular
- Infraclavicular
- Epitrochlear
- Lateral Axillary
- Medial Axillary
- Posterior Axillary
- Anterior Axillary
** Lymph nodes are normally present but are not felt. Infection within lymph nodes are soft, tender, and moveable. Cancer within lymph nodes are hard, non-tender and non-moveable**
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Palpation of the Anterior Thorax
I will be palpating for pain, tenderness masses, sensations, and further assess any abnormalities found.
- Male: Palpate ALL of the chest wall
- Female: Exclude breast area
Begin above the clavicles; work down below the clavicles into the ICS spaces, check the slope of the ribs, the axilla and finally the base of the lungs.
If any pain, tenderness, masses, sensations or other abnormalities are found it may indicate Breast Tumor or Cancer.
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Costochondritis Test
If patient complains of chest pain, use knife-edge of hand and apply pressure on either side of the sternum at the sternocostal joints
- **Checking for tenderness or any inflammation of the rib/cartilage junction. Other possible causes are rib or intercostal muscle strain or an anterior vertebra**
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Testing for rib fractures
Use a knife-edge hand and depress the sternum. Pain should radiate from the site
**Indicates Rib Fractures**
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Posterior Palpation of the Thorax
Begin at the apex of the lungs and continue over the trap muscles. At the interscapular area ask patient to cross their arms so the ICS can be felt without hinderance of the scapula. Below the scapula the patient uncrosses the arms and relaxes, continue to palpate out to the axillary area and sown the slope of the ribs.
**Checking for pain, tenderness, masses, sensations, and further assess any abnormalities found. If found, possible tumor or fibromyalgia.**
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Tactile Fremitus
- Using the ball of the hand, have the patient say "blue moon" each time you touch the patient's thorax.
- *Check for symmetry of vibration in the following areas:
- 1,2 Apices of the lungs
- 3,4 Interscapular area
- (arms crossed at
- chest ...avoid tp's)
- 5,6 Triangle of auscultation
- (arms crossed and elevated.
- 7,8 Medial base of lungs
- 9,10 Lateral base of lungs
- **Decreased or absent fremitus indicates air in the lungs such as emphysema or bronchial obstruction. Increased fremitus indicates fluids or a solid mass in the lungs such as pneumonia or a lung tumor.
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Respiratory Excursion:
- Take a tissue pull with the ball of the hand from axillary to mid-line and use thumbs as markers.
- Place thumbs along spinal processes at the level of the 10th rib with palms lightly in contact with the posterolateral surface.
- Watch thumbs diverge during quiet and deep breathing
- Ask patient to to take a deep breath in and out through their mouth. Watch for symmetry of movement bilaterally.
- **Lag indicates and underlining lung problem on that side**
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Palpate heart for pulsations
- A.P.E.T.M.E. areas for pulsations:
- Use the pads of the fingers
- Use gentle touch and let the movements rise to your fingers
- *AT Mitral area; Check for an Apical Impulse for location and amplitude.
- **At Epigastrum: Pulsations coming from superior to inferior to the finger padas may indicate right ventricular hypertrophy. Pulsations coming from inferior to superior to the finger pads may indicate abdominal aortic aneurysm**
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Check for Thrills of the heart:
- Check A.P.E.T.M.E. areas for thrills
- Use the ball of the hand
- ** A thrill is a fine, palpable, rushing vibrations resultiing from:
- Aortic Stenosis
- Mitral Stenosis
- Patient Ductus
- Arteriosclerosis
- Ventricular Septal Defect
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Light Abdominal Palpation:
- Using fingerpads, palpate about 1/2" - 1" deep in three areas of each quadrant of the abdomen.
- **Checking for pain, tenderness, muscle guarding or masses indicating possible sensory nerve involvement or tumor**
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Deep Abdominal Palpation:
- Place the patients knees into flexion in order to relax the abdominal muscles.
- Using fingerpads of one hand backed up by the other hand.
- Palpate 1" - 2" in three areas of each quadrant of the abdomen.
- **Checking for pain, tenderness, muscle guarding or masses indicating possible sensory nerve involvement or tumor**
- Further assess mass to see if it's superficial or deep by having patient do a half sit-up or leg raise...superficial will still be palpable or visible. A deep mass will not be palpable or visible due to the abdominal muscles obscuring it.
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Standard Liver's Edge Maneuver
- Place your left hand under the patient at the 11th and 12th ribs pulling P-A and superior to elevate the liver toward the abdominal wall.
- Place your right hand on the abdomen, fingers pointing toward the head and extended so the tips rest on the right midclavicular line below the level of liver dullness.
- Have the patient breath normally a few times and then take a deep breath and hold. As the patient exhales push fingers gently but deeply in and up.
- Try to feel the liver's edge as the diaphragm pushes it down to meet your fingertips. Repeat across the length of the liver.
- **I am trying to feel for nodules, tenderness and irregularity. Possibly indicating hepatomegally or cirhossis of the liver.**
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Middleton's Maneuver
- Have patient place their fist under ribs 11 and 12 on the right side.
- Place your right hand on the abdomen, fingers pointing toward the head and extended so the tiips rest on the right midclavicular line below the level of liver dullness.
- Have patient breat normally a few times then take a deep breath and hold.
- As the patient exhales push fingers gently but deeply in and up.
- Try to fee the liver's edge as the diaphragm pushes it down to meet your fingertips. Repeat across the length of the liver.
- **I am trying to feel for nodules, tenderness and irregularity. Possibly indicating hepatomegally or cirrhosis of the liver.**
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Hooking Maneuver
- Stand on the patient's right side facing their feet.
- Hook your fingers over the right costal margin below the border of the liver dullness.
- Press in and up toward the costal margin with your fingers.
- Have the patient breath normally a few times and then take a deep breath and hold.
- As the patient exhales push fingers gently but deeply in and up.
- Try to feel the liver edge as the diaphragm pushes it down to meet you fingertips.
- **I am trying to feel for nodules, tenderness and irregularity. Possibly indicating hepatomegally or cirrhosis of the liver.**
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Kidney Entrapment
- On the right side, place one hand under the patient's right flank and the other hand at the right costal margin.
- Ask the patient to take a deep breath.
- At the height of inspiration, press the fingers of both hands together to capture the kidney between the fingers.
- Ask the patient to breath out and hold the exhalation while you slowly release your fingers.
- **Repeat for both sides**
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