Palpation
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Palpation is the process of using one's hands to check the body, especially while perceiving/diagnosing a disease or illness. Usually performed by a
health care Health care, or healthcare, is the improvement or maintenance of health via the preventive healthcare, prevention, diagnosis, therapy, treatment, wikt:amelioration, amelioration or cure of disease, illness, injury, and other disability, physic ...
practitioner, it is the process of feeling an object in or on the body to determine its size, shape, firmness, or location (for example, a
veterinarian A veterinarian (vet) or veterinary surgeon is a medical professional who practices veterinary medicine. They manage a wide range of health conditions and injuries in non-human animals. Along with this, veterinarians also play a role in animal r ...
can feel the stomach of a pregnant animal to ensure good health and successful delivery). Palpation is an important part of the
physical examination In a physical examination, medical examination, clinical examination, or medical checkup, a medical practitioner examines a patient for any possible medical signs or symptoms of a Disease, medical condition. It generally consists of a series of ...
; the sense of touch is just as important in this examination as the sense of sight is. Physicians develop great skill in palpating problems below the surface of the body, becoming able to detect things that untrained persons would not. Mastery of
anatomy Anatomy () is the branch of morphology concerned with the study of the internal structure of organisms and their parts. Anatomy is a branch of natural science that deals with the structural organization of living things. It is an old scien ...
and much practice are required to achieve a high level of skill. The concept of being able to detect or notice subtle tactile signs and to recognize their significance or implications is called appreciating them (just as in general vocabulary one can speak of appreciating the importance of something). Nonetheless, some things are not palpable, which is why additional
medical test A medical test is a medical procedure performed to detect, diagnose, or monitor diseases, disease processes, susceptibility, or to determine a course of treatment. Medical tests such as, physical and visual exams, diagnostic imaging, genetic ...
s, such as
medical imaging Medical imaging is the technique and process of imaging the interior of a body for clinical analysis and medical intervention, as well as visual representation of the function of some organs or tissues (physiology). Medical imaging seeks to revea ...
and
laboratory A laboratory (; ; colloquially lab) is a facility that provides controlled conditions in which scientific or technological research, experiments, and measurement may be performed. Laboratories are found in a variety of settings such as schools ...
tests, are often needed to make a
diagnosis Diagnosis (: diagnoses) is the identification of the nature and cause of a certain phenomenon. Diagnosis is used in a lot of different academic discipline, disciplines, with variations in the use of logic, analytics, and experience, to determine " ...
. However, many other problems ''are'' palpable. Examples include
pulse In medicine, the pulse refers to the rhythmic pulsations (expansion and contraction) of an artery in response to the cardiac cycle (heartbeat). The pulse may be felt ( palpated) in any place that allows an artery to be compressed near the surfac ...
s,
abdominal distension Abdominal distension occurs when substances, such as air (gas) or fluid, accumulate in the abdomen causing its expansion. It is typically a symptom of an underlying disease or dysfunction in the body, rather than an illness in its own right. Peo ...
, cardiac thrills, fremitus, and various
hernia A hernia (: hernias or herniae, from Latin, meaning 'rupture') is the abnormal exit of tissue or an organ (anatomy), organ, such as the bowel, through the wall of the cavity in which it normally resides. The term is also used for the normal Devel ...
s,
joint dislocation A joint dislocation, also called luxation, occurs when there is an abnormal separation in the joint, where two or more bones meet. A partial dislocation is referred to as a subluxation. Dislocations are commonly caused by sudden Trauma (medic ...
s,
bone fracture A bone fracture (abbreviated FRX or Fx, Fx, or #) is a medical condition in which there is a partial or complete break in the continuity of any bone in the body. In more severe cases, the bone may be broken into several fragments, known as a ''c ...
s, and
tumor A neoplasm () is a type of abnormal and excessive growth of tissue. The process that occurs to form or produce a neoplasm is called neoplasia. The growth of a neoplasm is uncoordinated with that of the normal surrounding tissue, and persists ...
s, among others.


Uses

Palpation is used by
physicians A physician, medical practitioner (British English), medical doctor, or simply doctor is a health professional who practices medicine, which is concerned with promoting, maintaining or restoring health through the study, diagnosis, prognosis ...
, as well as
chiropractor Chiropractic () is a form of alternative medicine concerned with the diagnosis, treatment and prevention of physical disorder, mechanical disorders of the musculoskeletal system, especially of the vertebral column, spine. It is based on sever ...
s,
nurse Nursing is a health care profession that "integrates the art and science of caring and focuses on the protection, promotion, and optimization of health and human functioning; prevention of illness and injury; facilitation of healing; and alle ...
s, massage therapists,
physical therapist Physical therapy (PT), also known as physiotherapy, is a healthcare profession, as well as the care provided by physical therapists who promote, maintain, or restore health through patient education, physical intervention, disease prevention ...
s, osteopaths and
occupational therapist Occupational therapists (OTs) are health care professionals specializing in occupational therapy and occupational science. OTs and occupational therapy assistants (OTAs) use evidence-based practice, scientific bases and a Holism, holistic perspec ...
s, to assess the texture of a patient's tissue (such as swelling or muscle tone), to locate the spatial coordinates of particular anatomical landmarks (e.g., to assess range and quality of
joint A joint or articulation (or articular surface) is the connection made between bones, ossicles, or other hard structures in the body which link an animal's skeletal system into a functional whole.Saladin, Ken. Anatomy & Physiology. 7th ed. McGraw- ...
motion), and assess tenderness through tissue deformation (e.g. provoking pain with pressure or stretching). In summary, palpation might be used either to determine painful areas and to qualify pain felt by patients, or to locate three-dimensional coordinates of anatomical landmarks to quantify some aspects of the palpated subject. Palpation is typically used for
thoracic The thorax (: thoraces or thoraxes) or chest is a part of the anatomy of mammals and other tetrapod animals located between the neck and the abdomen. In insects, crustaceans, and the extinct trilobites, the thorax is one of the three main ...
and
abdominal The abdomen (colloquially called the gut, belly, tummy, midriff, tucky, or stomach) is the front part of the torso between the thorax (chest) and pelvis in humans and in other vertebrates. The area occupied by the abdomen is called the abdominal ...
examinations, but can also be used to diagnose
edema Edema (American English), also spelled oedema (British English), and also known as fluid retention, swelling, dropsy and hydropsy, is the build-up of fluid in the body's tissue (biology), tissue. Most commonly, the legs or arms are affected. S ...
. Palpation is also a simple method of examining the pulse. It is used by
veterinarians A veterinarian (vet) or veterinary surgeon is a medical professional who practices veterinary medicine. They manage a wide range of health conditions and injuries in non-human animals. Along with this, veterinarians also play a role in animal r ...
to check animals for
pregnancy Pregnancy is the time during which one or more offspring gestation, gestates inside a woman's uterus. A multiple birth, multiple pregnancy involves more than one offspring, such as with twins. Conception (biology), Conception usually occurs ...
, and by
midwives A midwife (: midwives) is a health professional who cares for mothers and newborns around childbirth, a specialisation known as midwifery. The education and training for a midwife concentrates extensively on the care of women throughout their ...
to determine the position of a
fetus A fetus or foetus (; : fetuses, foetuses, rarely feti or foeti) is the unborn offspring of a viviparous animal that develops from an embryo. Following the embryonic development, embryonic stage, the fetal stage of development takes place. Pren ...
. Tactile palpation is one of the oldest, simplest, and least expensive methods for approximate
intraocular pressure Intraocular pressure (IOP) is the fluid pressure inside the eye. Tonometry is the method eye care professionals use to determine this. IOP is an important aspect in the evaluation of patients at risk of glaucoma. Most tonometers are calibrated t ...
assessment. Quantitative palpation of anatomical landmarks for measurements must occur according to strict protocols if one wishes to achieve reproducible measurements. Palpation protocols are usually based on well-described definitions for the location of anatomical, usually skeletal, landmarks.


Locating anatomical landmarks

Locating anatomical landmarks can be performed using two palpation protocols: 1) ''manual palpation'' that allows the spatial location of landmarks using hands combined or not with three-dimensional (3D) digitizing, and 2) ''virtual palpation'' on 3D computer models obtained, for example, from medical imaging. Image:manual_palpation_palpator.jpg, ''Manual palpation'' of skeletal landmarks combined with 3D digitizing (see text below for explanations). Image:virtual_palpation.jpg, ''Virtual palpation'' of skeletal landmarks. ''Manual palpation'' of skeletal landmarks (illustrated here on a patient's shoulder, see left image). The palpating hand locates the palpated landmarks with a satisfactory accuracy (below 1 cm). Reflective markers are part of the scientific protocol and allow further quantified motion analysis for joint disorders follow-up.
''Virtual palpation'' of skeletal landmarks located on a 3D bone model (illustrated here on a patient's knee model obtained from medical imaging, see right image). Colored spheres on bones indicate palpated skeletal landmarks. This method combined with quantified manual palpation allows subject-specific visualization of joint behavior during particular motion tasks (e.g., walking, stair climbing, etc.). The above protocols can be used independently. ''Manual palpation'' is used in clinical activities for various aims: identification of painful areas; positioning of particular pieces of equipment (
electromyography Electromyography (EMG) is a technique for evaluating and recording the electrical activity produced by skeletal muscles. EMG is performed using an instrument called an electromyograph to produce a record called an electromyogram. An electromyo ...
electrodes, auscultation, external landmarks used in clinical
motion analysis Motion analysis is used in computer vision, image processing, high-speed photography and machine vision that studies methods and applications in which two or more consecutive images from an image sequences, e.g., produced by a video camera or high-s ...
or body surface scanning); or measurements of morphological parameters (e.g., limb length). ''Virtual palpation'' alone is useful to quantify individual morphological parameters from
medical imaging Medical imaging is the technique and process of imaging the interior of a body for clinical analysis and medical intervention, as well as visual representation of the function of some organs or tissues (physiology). Medical imaging seeks to revea ...
: limb length; limb orientation; joint angle; or distance between various skeletal locations. Combining data from both manual and virtual palpation protocols allows achieving supplementary analysis: registration protocols aiming at building reference frames for motion representation according reproducible clinical conventions; to modelize joint kinematics accurately during musculoskeletal analysis; to align precisely orthopedic tools according to the individual anatomy of a patient; or to wrap and to scale surface textures to motion data when creating animation characters. Use of standardized definitions for the above activities allows better result comparison and exchange; this is a key element for patient follow-up or the elaboration of quality clinical and research databases. Such definitions also allow acceptable repeat ability by individuals with different backgrounds (physiotherapists, medical doctors, nurses, engineers, etc.). If applied strictly, these definitions allow better data exchange and result comparison thanks to standardization of the procedure. Without anatomical landmark standardization, palpation is prone to error and poorly reproducible.


Elastography

Nowadays, the
medical imaging Medical imaging is the technique and process of imaging the interior of a body for clinical analysis and medical intervention, as well as visual representation of the function of some organs or tissues (physiology). Medical imaging seeks to revea ...
modality of elastography can also be used to determine the stiffness of tissues. Manual palpation has several important limitations: it is limited to tissues accessible to the physician's hand, it is distorted by any intervening tissue, and it is qualitative but not
quantitative Quantitative may refer to: * Quantitative research, scientific investigation of quantitative properties * Quantitative analysis (disambiguation) * Quantitative verse, a metrical system in poetry * Statistics, also known as quantitative analysis ...
. Elastography is able to overcome many these challenges and improve on the benefits of palpation. Elastography is a relatively new technology and entered the clinic primarily in the last decade. The most prominent techniques use
ultrasound Ultrasound is sound with frequency, frequencies greater than 20 Hertz, kilohertz. This frequency is the approximate upper audible hearing range, limit of human hearing in healthy young adults. The physical principles of acoustic waves apply ...
or
magnetic resonance imaging Magnetic resonance imaging (MRI) is a medical imaging technique used in radiology to generate pictures of the anatomy and the physiological processes inside the body. MRI scanners use strong magnetic fields, magnetic field gradients, and ...
(MRI) to make both the stiffness map and an anatomical image for comparison.


Computerized palpation

While not widespread amongst elastography methods, computerized palpation is of interest here because it essentially uses palpation to measure the stiffness, whereas other techniques will obtain data using other methods. Computerized palpation, also called "
tactile imaging Elastography is any of a class of medical imaging diagnostic methods that map the elasticity (physics), elastic properties and stiffness of soft tissue. The main idea is that whether the tissue is hard or soft will give diagnostic information ab ...
", "mechanical imaging" or "stress imaging", is a medical imaging modality that translates the sense of touch into a digital image. The tactile image is a function of P(x,y,z), where P is the pressure on soft tissue surface under applied deformation and x,y,z are coordinates where pressure P was measured. Tactile imaging closely mimics manual palpation, since the probe of the device with a pressure
sensor array A sensor array is a group of sensors, usually deployed in a certain geometry pattern, used for collecting and processing electromagnetic or acoustic signals. The advantage of using a sensor array over using a single sensor lies in the fact that an ...
mounted on its face acts similar to human fingers during clinical examination, slightly deforming soft tissue by the probe and detecting resulting changes in the pressure pattern.


Palpation under general anesthesia

Palpation under
general anesthesia General anaesthesia (UK) or general anesthesia (US) is medically induced loss of consciousness that renders a patient unarousable even by painful stimuli. It is achieved through medications, which can be injected or inhaled, often with an analgesi ...
is sometimes necessary, such as when there is a need to palpate structures deep in the
abdominal The abdomen (colloquially called the gut, belly, tummy, midriff, tucky, or stomach) is the front part of the torso between the thorax (chest) and pelvis in humans and in other vertebrates. The area occupied by the abdomen is called the abdominal ...
or
pelvic cavity The pelvic cavity is a body cavity that is bounded by the bones of the pelvis. Its oblique roof is the pelvic inlet (the superior opening of the pelvis). Its lower boundary is the pelvic floor. The pelvic cavity primarily contains the reproduc ...
, since it would otherwise cause considerable patient discomfort and subsequent contraction of the abdominal muscles which would make the examination difficult.Pelvic examination under anesthesia
at
Uptodate UpToDate, Inc. is a company in the Wolters Kluwer Health division of Wolters Kluwer, the main product of which is the eponymous UpToDate, a software system that is a Point of care medical information summary, point-of-care medical resource. The Up ...
. Author: William J Mann, Jr, MD. This topic last updated: Oct 8, 2012. It is used, for example, in the staging of cervical cancer.


See also


References

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