Palpación
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概述
Fuente: Jaideep S. Talwalkar, MD, medicina interna y Pediatría, Facultad de medicina de Yale, New Haven, CT
El examen físico requiere el uso de todos los sentidos del proveedor para obtener información sobre el paciente. El sentido del tacto se utiliza para obtener información diagnóstica a través de la palpación.
Las partes específicas de la mano del examinador para palpación difieren de acuerdo con la parte del cuerpo examinada. Debido a su densa inervación sensorial, los cojines del dedo son útiles para la discriminación fina (p. ej., definición de las fronteras de las masas, ganglios linfáticos) (figura 1). La superficie dorsal de la mano proporciona una sensación áspera de temperatura relativa (figura 2). Las superficies palmares de los dedos y las manos son más útiles para examinar áreas grandes del cuerpo (por ejemplo, abdomen) (figura 3). La vibración se aprecia mejor con la superficie cubital de las manos y 5 dedos deth (e.g., fremitus táctil) (figura 4).
Aunque la palpación es fundamental en el aspecto diagnóstico del examen físico, también es importante reconocer el papel que juega en la comunicación cuidado y comodidad durante el encuentro paciente. Generalmente los pacientes perciben tacto de un médico en una luz positiva, y sus percepciones de un proveedor médico pueden ser formados por el uso experto del tacto durante los encuentros clínicos. 1 contacto físico se ha asociado con alteraciones hormonales y neurotransmisor los niveles, especialmente disminución de cortisol y aumenta en serotonina. 2
Por lo tanto, mediante el uso cuidadoso de palpación y tacto en general, durante el examen físico, el médico tiene la oportunidad de obtener información de diagnóstico importante, desarrollar rapport y promover la curación.
Figura 1. Examen de ganglios linfáticos con cojines del dedo.
Figura 2. Usando el dorso de la mano para evaluar para el calor.
Figura 3. Palpación abdominal con la superficie palmar de los dedos y las manos.
Figura 4. Usando la superficie cubital de la mano para evaluar para el fremitus táctil.
Procedure
Applications and Summary
This demonstration covered the general considerations related to palpation during the physical examination. While specific techniques vary based on each individual portion of the exam, many general principles related to palpation hold throughout the exam. Attention to patient safety and comfort is achieved through hand-washing, proper grooming, warming of the hands, infection control precautions, and sensitive draping. The correct part of the fingers and hands should be used for different types of palpation, with finger pads being used most commonly during the exam. The clinician should be deliberate about the amount and duration of pressure being applied during palpation; these variables change based on the part of the body being examined and specific patient circumstances. Finally, the clinician should remember the important role that touch plays in the patient encounter in terms of therapeutic value and the clinician-patient relationship. The most direct physical contact during the encounter occurs through palpation, which provides an opportunity to secure the bond the clinician has started to develop during history taking.
References
- McCann, K., McKenna, H.P. An examination of touch between nurses and elderly patients in a continuing care setting in Northern Ireland. Journal of Advanced Nursing. 18, 838-46 (1993).
- Field, T. Violence and touch deprivation in adolescents. Adolescence. 37 (148), 735-749 (2002).
- Verrees, M. Touch me. JAMA. 276 (16), 1285-1286 (1996).
成績單
During a physical exam, the clinician uses the sense of touch through palpation to obtain useful diagnostic information. It is an assessment technique in which the examiner uses the surface of the fingers and hands to feel and examine an organ or body part. While palpation is fundamental to the diagnostic aspect of the physical exam, it is also important to acknowledge the role that touch plays in communicating caring and comfort during the patient encounter.
This video will illustrate the different palpation techniques, and discuss the approach and considerations for this procedure.
First, let’s discuss the different types of palpation techniques that are based on the specific parts of the examiner’s hand used to perform the procedure. Finger pads are used for palpation of most of the body parts. Because of their dense sensory innervation, the finger pads are useful for fine discrimination, for example defining the borders of masses, or while examining the lymph nodes. Fingertips are used for palpating specific structures like the nailbeds, liver edge, and cervix. In addition to fingertips and finger pads, physicians also use the ulnar surface of the hands and fifth fingers to appreciate vibration when performing specialized test like tactile fremitus. One should use the palmar surface of the fingers and hands for assessing functions like chest expansion, palpation of the precordium, light and deep abdominal palpation, and muscle strength testing. Lastly, the dorsal surface of the hands is used for getting rough sense of relative temperature, typically in comparison to another portion of the patient’s body.
Now that you know about different palpation techniques, let’s discuss the general approach to palpation during any clinical exam.
Before every patient encounter, make sure that your fingernails are clean, groomed, and trimmed. Wash your hands with soap and water or apply topical disinfectant solution. Warm your hands either with warm water or by rubbing them together. If any specific infection control precautions are needed, then wear the protective equipment and explain to the patient why it’s necessary. Remember: gowns, gloves, and masks can present a barrier to building a relationship with the patient.
In order to gauge the patient’s comfort with the clinician’s touch, you may start the examination with the hands. First, perform palpation of the nailbeds with your fingertips to assess for capillary refill and pallor. Then, palpate the radial pulse with your finger pads. After that, move to the anatomic region of interest, in this case the abdominal region. Employ draping techniques to optimize access, while balancing patient’s modesty. Next, ask the patient to point to the area of discomfort. Consider palpating it towards the end, making it clear to patients this is done in the interest of their comfort, “I’m going to examine this area last in order just to make it more comfortable for you.”
In general, be aware of the pressure used for palpation, which varies based on the structures being examined. For example, insufficient pressure may limit one’s ability to palpate deep structures, and excessive pressure may occlude a pulse, causing discomfort and limiting utility. Be deliberate about the palpation duration as well, which again differs based on the structure under examination. For example, while examining the lower extremities, the palpation needs to be performed for sufficient amount of time to reveal pitting edema, if present. This kind of information can be missed if palpation duration is insufficient. In addition, express empathy while acknowledging that examination of certain parts may cause the patient discomfort. Although patient expects to be examined, always ask permission and provide a warning if you are about to do something that may worsen the pain. At the end of the exam, drape the patient back and thank them for their cooperation.
You’ve just watched JoVE’s introduction to palpation. This demonstration covered the types and general considerations related to palpation during a physical exam. Through the careful use of this technique, the clinician has the opportunity to gain important diagnostic information, while developing rapport and promoting healing. As always, thanks for watching!