PALPATION (Latin palpatio stroking) — one of the main clinical methods of a direct research of the patient by means of touch for studying of physical properties of fabrics and bodies, topographical ratios between them, their sensitivity and detection of the nek-ry functional phenomena in an organism. The item is widely applied in daily medical practice at inspection of the patient (see).
To the item it was known still in the ancient time; it it is mentioned in Hippocrates's compositions. However this method continues to be improved. History of use of P. demonstrates that for receiving valuable the wedge, given with its help not only is necessary experience, but also carefully developed general technique. Fiziol, P.'s basis are touch and temperature feeling the feeling fingers. At palpation of any body or education through intermediate agent, napr, through an abdominal wall, the tactile feeling turns out only if density of the palpated body exceeds density of intermediate agent. At the movement of the feeling fingers the tactile feeling arises at the time of change of a consistence of fabrics under fingers or at an obstacle to the movement; rather soft body (e.g., a gut) can be palpated during the movement of fingers only by pressing it to a firm basis.
Depending on the pursued purpose at a research of body or system P. conduct variously, but always by certain rules; non-compliance gives them to not clear, and sometimes and oshibochnsh to results. E.g., skin or muscles are probed, having taken them pleated for establishment of thickness, elasticity, elasticity. For determination of temperature of parts of a body of a hand put flatwise on a trunk and an extremity (at shock, e.g., the sharp difference of temperature is found), on symmetric joints (skin over the inflamed joint is warmer), etc.
Pulse is felt, pressing down to a wall of an artery the fabrics lying over it two fingers. Voice trembling (see) define, having laid a hand flatwise to a thorax and forcing the patient to say abrupt sounds loudly. At the Item. stomach (see) a hand flatwise put on a stomach and make it various movements at superficial, approximate P. or press a hand, having bent fingers definitely at deep P., at the same time use their approach to a back abdominal wall during an exhalation and slide on it (the sliding P.). At inspection of patients ginekol. or the Urals, can be carried out by P.'s disease with introduction of fingers to a vagina or a rectum (see. Gynecologic research , Rectal research ).
On a way distinguish superficial and deep P. Raznovidnostyyu of the last the getting P. by impression of a top of one finger in any point of a body for definition of painful points is. Besides, allocate P. with both hands — bimanual P., tolchkoobrazny P. — for definition of balloting of dense bodies in liquid (e.g., a liver in an abdominal cavity at ascites) and the sliding P. — for a research of bodies in the depth of an abdominal cavity.
Despite broad use of a X-ray analysis, P. did not lose value for recognition even of diseases of bones and joints, and for a research lymph nodes (see) remains by an irreplaceable method. Along with other main direct methods the wedge, researches P. has special value during the studying a wedge, anatomy and physiology of internals.
Palpation of heart it is made for the purpose of determination of location of an apical beat, studying of its properties, and also for search of the nek-ry fluctuations and tremblings in chest (precordial) area («cat's purring», short pushes at a cantering rhythm, a pericardial rub) which are observed at a disease of valves of heart, myocardium or pericardium. Items of heart make in vertical and lying position of the patient.
At P. of an apical beat define its location, frequency, a rhythm and force. In nek-ry cases the apical beat gains the following features: it can become dome-shaped, making an impression driven during a systole under the palpating fingers of a semicircle that is observed at a considerable hypertrophy of a left heart, hl. obr. at insufficiency of valves of an aorta. At aneurism of a left ventricle the cardiac impulse can be diffuse and gains idiosyncrasies from passive movements of the changed wall of heart in vrvkhmya systoles; sometimes to an apical beat, before it in a presystole or after it in a protodiastole, additional pushes join, in time to-rykh additional tones (cantering rhythm) are also listened. At aortic incompetence the additional push can be so expressed that the apical beat of heart becomes double. Sometimes in time or instead of a push concussion of all pectus is observed that happens at early extrasystoles or at coincidence of an auricular systole to a ventricular systole at a full cross heart block. By a palpation in nek-ry cases also cardiac sounds at their strengthening can be defined (as short pushes).
Special jingle is felt during the narrowing or expansion of openings of heart. It reminds cat's purring and depends on sound vibrations of low frequency, to-rye makes a blood flow on site of narrowing or expansions of a bed or patol, changes of valves of heart. This jingle occurs most often at a top at a mitral stenosis, in the second intercostal space on the right — at an aortostenosis and at the left — during the narrowing of a pulmonary artery. It can be observed also at a xiphoidal shoot during the narrowing of the right atrioventricular opening and at aortic incompetence.
The palpation of pulse was always of great importance in recognition of a disease. The item of pulse gives the chance to judge a rhythm and a stroke output of heart, the ABP, a condition of walls of arteries, sometimes a disease of valves of heart and a feverish state. It is possible to palpate any available artery, but it is more convenient to feel superficially located arteries as, e.g., a beam artery, temporal or sleepy arteries. Most often palpate a beam artery. It is necessary to probe at the same time or consistently beam arteries on both hands to avoid mistakes at anomaly of development or an arrangement of a beam artery, and also for establishment of a difference of properties of pulse of beam arteries (aneurism or coarctations of an aorta, narrowing of a humeral artery). During palpation press on an artery one, other finger; pressing it to the subject bone, make the sliding movements of fingers in the direction, cross to an axis of an artery, for clarification of physical properties of walls of an artery. For the item of arteries of legs it is necessary for diagnosis of an endarteritis, atherosclerosis and other diseases of peripheral arteries.
Palpation of a thorax allows to define a condition of bones, it forming (edges, a backbone, shovels), changes of their form, ossification of costal cartilages, mobility of a thorax, and also morbidity of edges, shovels and vertebrae, a cut, except P., apply to definition also percussion. At P. of a thorax note temperature of skin, possible crepitation in it and other physical properties of soft tissues, and also their morbidity, in particular painful points in mezhreberye. The item gives the chance to define in a thorax purulent superficial accumulations (abscess, phlegmon), breaks under skin of purulent pleurisy. Rattles in lungs, a pleural rub, and also changes in the nature of voice trembling can be established to Palpatorno through a thorax.
Palpation of a stomach along with rentgenol. a research is the main method of a physical research at diagnosis of diseases of abdominal organs. This method, value to-rogo for clinic before others were estimated by fr. doctors, in particular F. Glenard, the hl is developed. obr. the Russian therapists V.P. Obraztsov, N. D. Strazhesko, etc. V.P. Obraztsov for the first time gave the detailed description of physical properties of each of the probed departments of the alimentary system in their normal state. It, first, formed the basis for use of G1. a stomach in a wedge, practice on an equal basis with other physical methods of inspection, secondly, allowed to study during a dorentgenovsky era the topographical relations in an abdominal cavity on the living person; thirdly, gave the chance, comparing physical properties of bodies and their topographical relations is normal also at various patol. states to do extremely valuable conclusions for diagnosis of diseases of an abdominal cavity. V. P. Obraztsov and his pupils developed the equipment P. of an abdominal cavity in details.
At P. by Obraztsov's method — Strazhesko muscles of a prelum abdominale at investigated shall be relaxed, and investigating the touches and receptions shall not cause its tension. For this purpose the patient, having relaxed all muscles, shall lie quietly on convenient, not too soft bed or on a couch with the extended legs and hands put on a breast and to breathe quietly, deeply, using diaphragmal respiration; iod the head of the patient enclose a small pillow. The doctor sits down facing the patient on the right side of a bed on a rigid chair, height to-rogo shall be at the level of a bed of the patient. The room where inspect the patient, shall be warm; hands at the doctor — warm and dry.
The research needs to be made carefully and gently, without hurting, whenever possible, since any hiting at to a naked stomach cold hands or a rough, offending research causes reflex reduction of muscles of a prelum abdominale that complicates palpation of abdominal organs. At abdominal distention the patient sometimes should appoint previously laxative or enemas to release intestines, and the research needs to be made for achievement of full relaxation of muscles of a prelum abdominale in a heat bath. Nek-ry bodies or their departments (the left hepatic lobe, small curvature of a stomach, a spleen, a kidney, a caecum), tumors are more available to palpation in vertical position of the patient. In vertical position of the patient inspect hl. obr. to a nadchrevya (anticardium) and side areas of an abdominal cavity. For detection patol, the process changing morfol, the condition of bodies and their topographical ratios or perverting their function, use superficial and deep palpation. Superficial P. is approximate. The doctor puts the right hand on a stomach of the patient having flatwise or slightly bent fingers and gradually, carefully probes all areas of a stomach, paying first of all attention to tension of a prelum abdominale, morbidity and its localization. In case of significant increase in parenchymatous bodies, tension of a stomach or loops of guts, and also in the presence of big tumors even superficial P. gives many data for diagnosis. However more valuable information is given by deep systematic P., for a cut of the most acceptable the following sequence is: a sigmoid gut, a caecum with a shoot, the final part of an ileal gut ascending and the descending parts of a colon, a stomach with its departments, a cross colon, a liver, a spleen, a duodenum, a pancreas and kidneys.
It is necessary to apply the deep sliding P. to palpation of a stomach and guts by Obraztsov's method.
Deep P. is based that fingers immerse in an abdominal cavity gradually, using the relaxation of an abdominal wall occurring at an exhalation and reach a back wall of an abdominal cavity or the subject body. Zate.m axes of the studied body slide tops of fingers in the direction, cross, at the same time press down body to a back wall and, continuing sliding, are rolled through the palpated gut or curvature of a stomach. Depending on position of body the sliding movements make or from within a knaruzha (S-shaped curvature, a caecum), or from top to down (a stomach, a cross colon), passing into more or less slanting direction in process of a deviation of these bodies from the horizontal or vertical course. The sliding movements of fingers begin on nek-rum distance from one side of the studied body and finish on other its side. The movements of the palpating hand surely make together with skin, but not on skin. Items make or one hand, having put on it other hand for strengthening of pressure, or both hands at the same time (bimanual P.). If palpate one hand, then another can be used or for pressing on a prelum abdominale away from the field P. with the purpose to reduce or overcome resistance of an abdominal wall in this place, to promote relaxation of a prelum abdominale around palpation, or for approach of the studied body to the palpating hand.
The palpation of a sigmoid gut is conducted from right to left, perpendicularly to an axis of a gut, edges is usually located slantwise in the left ileal hollow on border of an average and outside third of the line connecting a navel to a front upper awn of an ileal bone (linea umbilicoiliaca). Items make four fingers or lateral side of a little finger of the right hand put together and slightly bent. Having shipped fingers of a knutra from the estimated provision of a gut and having reached them a back wall of an abdominal cavity, knaruzh and from top to bottom slide on it in the specified direction, i.e. At this movement a gut, being pressed down to a back wall, at first slides on it, and then (since the mesentery has it a certain width and stretches) at the further movement of a hand slips out from under fingers, and at this moment the palpating fingers bypass it almost on all periphery, i.e. probe. Applying the described technique, it is possible to probe a sigmoid gut at 90 — 95 of 100 people. Normal the sigmoid gut is probed throughout 20 — 25 cm in the form of the smooth plotnovaty cylinder 2 — 3 cm thick, to-ry it is possible to displace within 3 — 5 cm aside. It is painless, faded and seldom peristaltirut, the humming sound at P. is absent.
Palpation of a caecum and worm-shaped shoot. At P. of a caecum the same technique is applied, as at P. of a sigmoid gut. At P. find not only a cul-de-sac, but probe the ascending gut throughout 10 — 12 cm. The caecum is normal probed in 80 — 85% of cases in the form of moderately intense, a little extending from top to bottom cylinder to dia. 2 — 3 cm with the rounded-off bottom. During the pressing on it rumbling is heard. The item of a gut does not hurt and allows to be convinced of its passive mobility within 2 — 3 cm. The bottom edge of a cul-de-sac at men is located 0,5 cm above the mezhostny line, at women — is 1 — 1,5 cm lower than it.
At P. the right inguinal area manages to probe in 80 — 85% of cases throughout 15 — 20 cm the final piece of an ileal gut rising from below and at the left from a small pelvis to connect to a large intestine. The direction of this piece mostly from below and at the left up and to the right owing to what P. is conducted almost parallel to linea umbilicoiliaca, but below it. The final piece of an ileal gut in the depth of the right ileal pole in the form of soft easily peristaltiruyushchy passively traveling barrel by thickness about a little finger or a pencil is probed; at its vyskalzyvaniye from under fingers rumbling is heard. Having found a final piece of an ileal gut, it is possible to make attempt to find above or below its worm-shaped shoot. It is easier to find it, previously having probed an abdomen of a big lumbar muscle, stay to-rogo it is facilitated if investigated slightly raises the straightened right leg. The item of a shoot is facilitated on the reduced myogaster. He is probed in 20 — 25% of cases in the form of thin by thickness about a goose quill of the painless cylinder, to-ry does not change at hand the consistence and does not hum. However, if this cylinder is probed above or below an ileal gut, it is impossible to be sure that it is a worm-shaped shoot since it can imitate a duplikatur of a mesentery and limf, a bunch. P.'s difficulty of a worm-shaped shoot is also that it holds at different people unequal position in relation to a caecum; e.g., during the finding of a shoot behind a gut it is impossible to probe it. At an inflammation of a shoot owing to its thickening, a disfiguration, fixing and consolidation the possibility of its search by P. considerably increases. Palpation of a caecum, final piece of an ileal gut and worm-shaped shoot is made by the right hand with four fingers put together a little bent in joints. At a muscle tension of a prelum abdominale to cause relaxation them in the area P., it is necessary to press beam side of the left hand in a navel.
And the internal gut descending about odes apply bimanual palpation to the palpation ascending. By the method offered V. of X. Vasilenko, a brush of the left hand enclose under left and then the right half of a waist, and fingers of the right hand shipped in an abdominal cavity before contact with the left hand knaruzh perpendicular to an axis of a gut slide.
The palpation of a cross colon is made by one right hand with the put and a little bent four fingers or both hands. Since the provision of this gut is changeable, for its search define the provision of the lower bound of a stomach by means of «a percussion palpation of Obraztsov» and conduct a research otstupya from top to bottom on 2 — 3 cm of P. make, having put the right hand or both hands with the bent fingers of the white line of a stomach (bilateral P.) on each side and having removed skin a little up; then gradually immerse a hand, using relaxation of a prelum abdominale during an exhalation, up to contact with a back wall of a stomach; having reached a back wall, slide on it from top to bottom. The gut is probed (if it is possible to propalyshrovat it) in the form of the cylinder of moderate density 2 — 2,5 cm thick going dugoobrazno and cross easily moving up and down not humming and painless. If on the specified place the gut is not probed, then the same reception inspect an abdominal cavity below and in side flankovy areas, having changed as appropriate position of the palpating hands. The cross colon is normal probed in 60 — 70% of cases.
Except the specified pieces of guts, in rare instances it is possible to probe .gorizontalny parts of a duodenum and curvature of a colon, and also the loop of a small bowel which accidentally got to ileal poles. In general the small bowel does not give in to palpation. Due to the deep arrangement, big mobility and thin walls it is not possible to press it to a back wall of an abdominal cavity, and without it it is impossible to probe a piece of a gut in a normality.
Manual palpation of a rectum after prerefining by its enema is made in genucubital position of the patient (see. Rectal research ). Enter the index finger greased with fat and the slow movements into a rectum carefully advance on possible depth. At extremely big sensitivity of the patient, cracks and inflammatory processes it is necessary to anesthetize before introduction of a finger a sphincter of an anus and an ampoule of a rectum by insertion of the tampon moistened with 1 — 2% solution of cocaine. Having passed a sphincter, the finger meets ahead at men a prostate, and at women a vulval part of a neck of uterus; on it the finger needs to be advanced up and, having bypassed a sacrococcygeal fold, whenever possible, to reach the final fold closing an entrance to a sigmoid gut, edges is 11 — 13 cm above an anus. The item of initial (deep) departments of a rectum is facilitated if the patient sits down on hunkers and natuzhitsya slightly. Having inspected a finger a front wall, turn a finger of a kzada and feel back and sacral, and then and sidewalls. On the basis of P. the doctor makes idea of a condition of a mucous membrane (ulcers, papillomas, polyps, varicose nodes, puffiness and swelling of a mucous membrane, cicatricial narrowings, new growths and so forth), and also about a condition of the cellulose surrounding a rectum, a duglasov of space (rectouterine deepening, T; excavatio rectouterina), a prostate, a uterus with its appendages and pelvic bones.
A palpation of a stomach — see. Stomach .
At P. of abdominal organs V.P. Obraztsov adhered to the principle of double check of the found phenomena. E.g., to make sure that the probed piece of a gut is a final piece of an ileal gut, it is necessary to find a caecum; for establishment of size of a stomach these P. check percussion and «a percussion palpation» of a stomach.
At palpation of bodies it is necessary to use their respiratory excursions. Items begin with more available bodies, passing then to less available. At palpation of edge of body it is necessary to put the ends of the put fingers of the right hand on this edge, to press a little abdominal wall and to hold fingers not movably, forcing investigated deeply to breathe a diaphragm. Then the body moving to time of breath slips out from under fingers, again approaches them that gives the chance to probe it and to make idea of its physical properties.
The palpation of a liver and gall bladder is made in position of the patient standing or lying on spin. In nek-ry cases palpation of a liver is facilitated at diagonal position of the patient on the left side; at the same time the liver by gravity leaves hypochondrium and its nizhneperedny edge is easier probed. Palpation of a liver and gall bladder is made by the general rules P., and the attention to an anteroinferior liver edge is most of all paid, on properties to-rogo judge physical condition of the liver, its situation and a form. In many cases (especially at omission or increase in body), except a liver edge, to-ry it is palpatorno possible to track often from the left subcostal area to right, it is possible to probe both verkhneperedny and nizhnezadny its surfaces.
Investigating sits down near a bed of the patient on a chair or a stool facing investigated on the right, puts a palm and four fingers of the left hand on the right lumbar area, and a thumb of the left hand presses sideways and in front on a costal arch that promotes approach of a liver to the palpating right hand, and, complicating expansion of a thorax during a breath, creates an opportunity for big excursions of the right dome of a diaphragm. The palm of the right hand is put flatwise with slightly bent fingers on a stomach of the patient directly at a costal arch, on the mamillar line, and the ends of fingers press an abdominal wall a little. After such installation of hands suggest investigated to make a deep breath, and a liver, falling, at first approaches fingers, then bypasses them and, at last, slips out from under fingers, i.e. it is probed. The hand investigating all the time remains motionless; reception repeats several times. Since the provision of a liver edge can be various, in order that the nobility, where to arrange fingers of the palpating hand, it is necessary to determine previously position of bottom edge of a liver by percussion. The edge of a normal liver probed at the end of a deep breath is 1 — 2 cm lower than a costal arch, it is represented soft, acute, easily sprained and insensitive. According to V.P. Obraztsov, the normal liver is probed in 88% of cases. At strong abdominal distention it is better to make a research for simplification of palpation on an empty stomach, after giving laxative, and at big accumulations of liquid in an abdominal cavity — after preliminary laparocentesis (see).
The gall bladder in view of the fact that it is soft and acts very little from under a liver edge, normal is not probed. But at increase in a bubble (an edema, filling by stones, cancer and so forth) it becomes available to a palpation. Palpation of a bubble is conducted in the same position of the patient, as at P. of a liver. Find a liver edge and at once below it, at the outer edge of the right direct muscle of a stomach, make a palpation of a gall bladder by rules of palpation of the liver. The easiest it is possible to obnaruyachit it the movement of fingers cross of an axis of a bubble. The gall bladder is palpatorno defined in the form of a pear-shaped body of various size, density and morbidity depending on character patol, process in him or in the bodies surrounding it, napr, a myagkoelastichesky bubble — at obstruction of the general bilious channel (Courvoisier's sign — Terje), a plotnobugristy bubble — at overflow by stones and at an inflammation of a wall. The increased bubble is mobile at breath and makes the lateral pendulum motions. Mobility of a bubble is lost at an inflammation of the peritoneum covering it — a pericholecystitis.
The palpation of a spleen is made in position of the patient on spin or in the right side diagonal situation. Investigating puts flatwise the left hand on the left half of a thorax in the VII—X area of edges and slightly pressures her, than fixation of the left half of a thorax and increase in respiratory excursions of the left dome of a diaphragm is reached. The right hand with slightly bent fingers is put flatwise below costal edge on the line representing continuation of the X edge and slightly press an abdominal wall then suggest the patient to make a deep breath; the edge of a spleen approaches fingers, bypasses them and slips out, i.e. is probed. Such reception is made several times, and the palpating hand remains motionless all the time. At a nenakhozhde-niya of edge of a spleen is lower than a costal arch, especially at feeling of not clear resistance at once as from some body which is in this place, fingers of the right hand advance on 2 — 3 cm to a nshka or a little sideways and ask at the same time the patient to take deep breaths. Sometimes palpation is facilitated by what the left hand brought under the patient is pressed behind on the lower edges. The normal, not increased spleen is not probed; it can be propalpirovat only at a big enteroptosia. Having probed a spleen, try to define its consistence, morbidity, a condition of its edge and a surface.
The palpation of a pancreas is extremely difficult in view of deep position and a soft consistence of body. Only at thin patients with the weakened prelum abdominale and omission of interiors it is possible to probe normal gland (in 4 — 5% of cases at women and in 1 — 2% of cases at men). The condensed pancreas at its cirrhosis or a new growth or at a cyst in it is probed much easier. The item of a pancreas needs to be made in the morning on an empty stomach after reception of laxative. Previously it is necessary to probe big curvature of a stomach, to define position of the gatekeeper and to propalpirovat the right bend of a cross colon. It is palpatorno desirable to find and a horizontal (lower) part of a duodenum. Then the place where it is necessary to look for palpation a head of a pancreas will be defined; it is easier to probe it, than a body of gland in view of the bigger size and more frequent consolidation. Palpation is made by rules of the deep sliding P., usually above the right part of big curvature of a stomach. With the conclusions relatively pro-probes-vayemosti of gland it is necessary to be extremely careful since it is possible to take easily for gland a part of a stomach, a part of a cross colon, a package limf, nodes and so forth.
The palpation of kidneys is the simplest and available method of a research of kidneys having exclusive value at their surgical diseases. Palpation of kidneys needs to be made in standing and in lying position of the patient as it was recommended still by S. P. Botkin. Palpation in a standing position is made by a technique so-called f kidskin P, the Doctor sits on a chair facing the standing naked patient. Having arranged the left hand cross to a trunk of the patient behind lower than XII edges, the right hand is put in front and sideways flatwise on the flank (i.e. side area of a stomach, a knaruzha from a direct muscle) by lower than XII edges, parallel to an axis of a trunk of the patient, i.e. vertically. The patient takes deep breaths, and the doctor, using relaxation of a prelum abdominale during an exhalation, aims to cramp fingers of both hands before contact through abdominal walls, i.e. palpates bimanualno. Thus the right, and then and left flank is explored at first.
Normally located kidney is not probed; the proshchupyvayemost of a kidney at a flankovy palpation always indicates its omission or increase.
For detailed acquaintance with a form, size, a consistence and a configuration of kidneys, and also it is necessary to make P. in lying position of the patient on spin for definition of degree of their mobility and on one side. Position of the patient and receptions the same P., as at palpation of a liver (for a right kidney) or spleens (for a left kidney). At palpation of a right kidney put the right hand with slightly bent fingers on a stomach to the patient of a knaruzha from the outer edge of a direct muscle so that the ends of fingers were 2 — 3 cm below than a costal arch, and bring the left hand under lumbar area. At each exhalation the doctor aims to advance the ends of fingers of the right hand more and more deeply before contact with a back wall of an abdominal cavity and through the last with the left hand. Then the movements of the left hand through thickness of lumbar muscles it raises the kidney lying on them and brings it under fingers of the right hand; at this time the patient shall make a superficial breath. If the kidney is probed, then it entirely or only its lower round pole approaches under fingers of the right hand, it occupies regions, having strengthened pressure of a kzada. Then, without weakening pressure and without reducing the data of both hands, begin to slide fingers of the right hand to a vyskalzyvaniye of a kidney from top to bottom and at this moment make final idea of its size, a form, consistence and degree of mobility. If the kidney is sharply mobile or wanders, it is necessary to capture her the right hand and to establish by shift in the parties, up and down limits of its mobility. It is useful to apply also to definition of character of a renomegaly the method of balloting offered by F. Gyuyon. Along with II. kidneys in the provision of a sick pas to a back P. on one side shall be carried out. At a research of a left kidney of the patient lies on the right side, at a research of a right kidney — on the left side. Having probed a kidney between two hands, put by abrupt bendings of fingers of the hand lying behind, a number of pushes on lumbar area, to-rye are transmitted through a kidney to other hand; it allows to judge its morbidity, a consistence, contents of a cystic tumor of a kidney etc. better.
The ureter is normal painless and is not probed. In the presence in it infiltrates or big stones these educations can sometimes be probed at women with a flabby stomach or at very thin men, but full confidence that it is an ureter, without X-ray inspection cannot be.
The item of pubic area allows to find a bladder at overflow by its urine in the form of a spherical uprugoplotny body, the increased uterus at pregnancy or a tumor.
The palpation of tumors of an abdominal cavity is one of the most important ways of their diagnosis. By means of palpation find a tumor, define its belonging to an abdominal cavity and the relation to the next bodies, mobility, make idea of its nature (an inflammation, a new growth) and of a possibility of removal in its operational way. Palpation of a tumor is made also under control of roentgenoscopy.
Tumors of an abdominal wall, unlike intraperitoneal and retroperitoneal, are located more superficially, quite often are found at survey, clearly are probed, at a tension of a prelum abdominale are fixed, but worse probed, and at reduction of muscles do not disappear from the field P. at all as it happens at intraperitoneal tumors. At respiratory excursions they move in the perednezadny direction at protrusion of a prelum abdominale during a breath and sink down during an exhalation.
The tumors located behind a peritoneum quite closely adjoin to a back wall of an abdominal cavity, are slow-moving at breath and are less mobile at P., and, above all — are always covered with guts or a stomach. An exception concerning mobility are small tumors of kidneys and a tumor of a tail of a pancreas, to-rye happen, despite the retroperitoneal arrangement, are quite often rather mobile. The tumors located intraperitoneally differ in a bigger respiratory and passive mobility; the closer they are located to a diaphragm, the from top to down they differ in bigger mobility at a breath. Depending on width or length of the covering linking of that body, Krom possesses a tumor, there is its passive mobility. However sometimes tumors of the departments which are well strengthened normal went. - kish. a path gain big mobility thanks to the inborn excessive length of a mesentery and sheaves or stretching of the strengthening device during growth of a tumor. E.g., quite often have big mobility of a tumor of a pylorus or a tumor of a caecum. Intraperitoneal tumors lose both respiratory, and passive mobility if around them the inflammation of a peritoneum develops, later to-rogo dense unions of a tumor with the bodies surrounding it are observed.
Finding of a tumor, establishment of its intraperitoneal localization are the first moment in the course of recognition. After that study its physical properties in detail — a form, density, elasticity, tuberosity, existence in it of fluctuation, morbidity and so forth. Definition of accessory of a tumor to this or that intraperitoneal body becomes possible only after preliminary topographical P. of all abdominal cavity and specific establishment at sick position and properties of each body separately. Such specific studying of the topographical relations is necessary since because of growth of a tumor the normal relations in localization of bodies are often broken and perverted.
See also Stomach , fig. 5 — 13.
Features of a palpation of children of early age.
Palpation of children shall be run by warm and dry hands with close-cut nails. Shall be the item superficial, it needs to be seen off gently and not to cause to the child of pain, especially on site inflammatory infiltrates, at to-rykh inevitably there is unpleasant and often pain. It is necessary to watch closely a mimicry of the child, a conversation to distract its attention from inspection.
By means of P. humidity and a xeroderma, temperature, sensitivity, thickness and its elasticity and hypodermic cellulose are defined. Humidity of skin is investigated by stroking of skin palmar or a dorsum of a brush on symmetric body parts of the child: on a breast, a trunk, in axillary poles and inguinal areas, on extremities, including on palms and soles (especially at children prepubertatny the period), at babies — on a nape. Thickness and elasticity of skin are determined, collecting skin by fingers pleated. If the fold finishes at once, elasticity of skin is considered normal if the fold finishes gradually — elasticity is reduced. Thickness of a skin fold at children of early age on a breast of 1,5 — 2 cm, on a stomach — 2 — 2,5 cm, on a hip — 3 — 4 cm, on a shoulder — is not less than 1,5 cm. At P. it is necessary to consider quality and a consistence of hypodermic cellulose. Babies have elastic cellulose, after one year — more flabby. At nek-ry children hypodermic cellulose is defined locally (at a sclerodermitis), or diffuzno (at a sclerema). Along with consolidation also puffiness of hypodermic cellulose can be observed. Puffiness differs from consolidation in the fact that in the first case during the pressing deepening is formed, a cut is quickly leveled, in the second case the pole during the pressing is not formed. Definition of turgor of soft tissues is run by a prelum big and index by fingers of the right hand of skin and all soft tissues on the medial surface of a hip or shoulder. At the same time the feeling of resilience or elasticity is perceived.
The palpation of lymph nodes is the main method of their inspection and is carried out in a certain sequence: occipital, mastoidal, Submandibular, mental, front and lateral cervical, supraclavicular, axillary, elbow, limf, nodes of a breast, inguinal, subnodal. Most difficult P. mental, axillary and elbow limf, nodes give in. Mental limf, nodes are felt by the easy movements of fingers behind beforehand about the centerline of mental area. At P. of axillary nodes it is necessary to take slightly hands of the child aside, to enter fingers as it is possible more deeply in an axillary hollow and from it for their message on a thorax from top to bottom. Elbow limf, nodes are probed so: having taken a hand the lower third of a forearm of an opposite hand of the inspected child, bend his hand in an elbow joint under a right or obtuse angle and then index and average fingers of other hand the longitudinal sliding motions probe sulci bicipitales lat. et med. at the level of an elbow and is slightly higher. If limf, nodes managed to be probed, note their quantity, size (the size I — about prosyany grain, the size II — about lentil, the size III — about a pea, the size IV — about a bean, the size V — about hazelnut * the size VI — about pigeon egg), a consistence (soft, elastic, dense), mobility, the relation to adjacent cross-links, surrounding fabrics, skin and hypodermic cellulose (are soldered or not), sensitivity at a palpation (are painful or painless).
The palpation of muscular system gives the chance to define extent of its development. At children of early age it not always works well in connection with well developed hypodermic cellulose.
The palpation of bone system is made consistently in the following order: head (skull), trunk (thorax, backbone), top and bottom extremities. At palpation of the head inspect fontanels, seams, and also density of bones. Palpation is made by both hands. Pay attention to a softening of bones especially in a nape (craniotabes), parietal, temporal bones, to existence of defects, considerable consolidation of bones of a skull. At a palpation of a big fontanel determine its size (distance between two opposite sides), a condition of edges (softness, a pliability, a crenation), protrusion and sticking.
At palpation of upper extremities pay attention to thickenings in the field of an epiphysis of a beam bone («brasletka») and a diaphysis of phalanxes («thread of pearls»). At palpation of joints find out the skin temperature and morbidity in their area.
The palpation of a thorax is run by both hands by easy stroking. Hands are put symmetrically on the explored sites on both sides. At the same time define a condition of skin in a thorax (perspiration, a hyperesthesia, puffiness), a thickening of a skin fold from one or both parties, existence of hypodermic emphysema, children of early age have an existence or lack of rachitic beads (V — UIII of an edge). Rigidity of a thorax investigate by a prelum it both hands in front back or from sides. At children of chest age the thorax is rigid, in more senior — is elastic. Lag of one half of a thorax at breath can be established, holding the ends of index fingers at vane angles. At P. define morbidity of a thorax, its localization and degree. For definition of voice trembling of a hand put on a breast of the child on both sides of (the child «forty three» ask to pronounce words of «pussycats pussycats»; at the small child define during the crying). Normal voice trembling is carried out on both half of a thorax.
The palpation of area of heart allows to specify properties of its apical beat. At the healthy child the area of an apical beat makes 1 — 2 sm1. Distinguish a high and low apical beat, on force — moderate, strong, weak. By a palpation diagnose also a symptom of cat's purring (systolic or diastolic trembling); for this purpose it is necessary to put a palm flatwise on all area of heart. In the same way sometimes it is possible to palpate a pericardial rub. The palpation of pulse is made at the child in several places. Pulse on a beam artery should be felt on both hands, in the absence of a difference in properties of pulse the further research is continued on one hand. Pulse on a femoral artery is investigated in vertical and horizontal provisions of the child, it is palpated index and average fingers of the right hand in an inguinal fold, in the place of an exit of an artery from under a pupartovy sheaf. Pulse on a back artery of foot is defined in horizontal position of the child, the brush of investigating is located at the outer edge of foot of the child, arteries are palpated by two, three or four fingers. At a research of pulse note its frequency, a rhythm, tension, filling, a form.
The palpation of abdominal organs and kidneys at children significantly does not differ from a palpation at adults.
Bibliography: Vasilenko V. H. Technique palpatsp coli ascendentis et descendentis, Medich. zhurn., t. 5, century 1, page 203, 1935; Gubergrits A. Ya. Direct research of the patient, M., 1972; Ignatov S. I. Guide to clinical trial of the child, M., 1978; V. P Is model. To a physical research of the gastrointestinal channel and heart, Kiev, 1915; about N, the Chosen works, Kiev, 1950; Propaedeutics of internal diseases, under the editorship of V. of X. Vasilenko, etc., page 41, etc., M., 1974; With t r even e with - to about N. D. Bases of physical diagnosis of diseases of an abdominal cavity, Kiev, 1951; Round A. F. Propedevtika of children's diseases, page 325, JI., 1971; With about h n T. Die Palpablen Gebilde des normalen menschlichen Korpers und deren methodische Palpation, Bd 1 — 3, B., 1905 — 1911; Gastroenterology, ed. by H. L. Bockus, v. 1, Philadelphia a. o., 1974; Glenard F. Les ptoses visc6rales, P., 1899; Goldschei-d e r, tiber die Physiologie des Palpiereris, Klin. Wschr., S. 961, 1923; Hausma nn T h. Die methodische Intestmalpalpation, B., 1910; N an e g e 1 i T h. Klinische Diagnose der Bauchgeschwulste, Miinchen, 1926.
B. H. Vasilenko, H. D. Strazhesko; B. P. Bisyarina (ped.).