Which part of the eye would the nurse palpate gently to assess for nodules or pain?

Inspection and Palpation of the Heart

The apical heartbeat may be visible in thin-chested adults. The left anterior chest wall may heave in patients with enlarged and hyperdynamic left ventricles. Right upper parasternal and sternoclavicular pulsations suggest ascending AAA disease. A left parasternal lift indicates RV pressure or volume overload. A pulsation in the third intercostal space to the left of the sternum can indicate PA hypertension. In very thin, tall patients, or in patients with emphysema and flattened diaphragm, the RV impulse may be visible in the epigastrium and should be distinguished from a pulsatile liver edge.

Palpation of the heart should begin with the patient in the supine position inclined at 30 degrees. If the heart is not palpable in this position, the patient should be examined either in the left lateral decubitus position with the left arm above the head or in the seated position, leaning forward. The point of maximal impulse normally is over the left ventricular (LV) apex beat and should be located in the midclavicular line at the fifth intercostal space. It is smaller than 2 cm (0.8 inch) in diameter and moves quickly away from the fingers. It is best appreciated at end-expiration, when the heart is closest to the chest wall. The normal impulse may not be palpable in obese or muscular patients or in those with thoracic cage deformities. LV cavity enlargement displaces the apex beat leftward and downward. A sustained apex beat is a sign of LV pressure overload (as in aortic stenosis or hypertension). A palpable, presystolic impulse corresponds to a fourth heart sound (S4) and reflects the atrial contribution to ventricular diastolic filling of a noncompliant left ventricle. A prominent, rapid early filling wave in patients with advanced systolic heart failure may result in a palpable third sound (S3), which may be present when the gallop itself is not audible (Video 10.3

Aparasternal lift occurs with RV pressure or volume overload. Signs of TR (jugular venouscv waves) and PA hypertension (loud, single, or palpable P2) should be sought. An enlarged right ventricle can give rise to aprecordial lift that can extend across the precordium and obscure left-sided findings. Rarely, patients with severe MR will have a prominent left parasternal impulse because of systolic expansion of the left atrium and forward displacement of the heart. Lateral retraction of the chest wall may be present with isolated RV enlargement secondary to posterior displacement of the systolic LV impulse. Systolic and diastolic thrills signify turbulent, high-velocity blood flow. Their locations help to identify the origins of heart murmurs.

ADDITIONAL PALPATION CONCEPT FOR THE ROTATOR CUFF

Codman (1934) described palpation of full-thickness tears of the supraspinatus. This transdeltoid palpation has become known as the rent test. This defect or “sulcus” produced a rent in the supraspinatus tendon, which was palpable through the deltoid (Wolf & Agrawal, 2001). The technique of transdeltoid palpation requires a relaxed patient, with palpation performed just anterior to the anterior margin of the acromion through the deltoid. The patient is evaluated in the seated position, with the arm dangling next to the side to promote relaxation. With one hand, the examiner grasps the forearm, with the patient's elbow in 90 degrees of flexion. The examiner's grasp on the forearm is meant to allow for rotational control of the extremity while the examiner's other hand performs the palpation. The arm is brought into extension while the patient's extremity is rotated internally and externally. According to Wolf and Agrawal (2001), both an eminence and a rent are palpated as the arm is brought from extension to slight flexion and internally and externally rotated. The eminence represents the greater tuberosity that is more prominent because of a full-thickness tear of the rotator cuff tendon. The rent is a soft tissue defect (Figure 7-3) created by the rotator cuff that avulsed from the tuberosity. The examination should be performed bilaterally to appreciate the anatomy of the uninvolved shoulder and compare it with the symptomatic side (Wolf & Agrawal, 2001).

Lyons and Tomlinson (1993) correlated clinical palpation using the rent test with the size of the tear at time of surgery. They reported sensitivity of 91% and a specificity of 75% in a population of 42 patients. Wolf and Agrawal (2001) prospectively studied 109 consecutive patients using the rent test. Results of the transdeltoid palpation were compared with arthroscopic findings at the time of surgery. A sensitivity of 95.7% and specificity of 96.8% for the diagnosis of a full-thickness tear of the supraspinatus tendon were reported. The authors concluded that in the trained examiner, transdeltoid palpation is highly accurate. Although the ability of each clinician to palpate the torn rotator cuff via the deltoid and determine the presence of a full-thickness rotator cuff tear remain in question, this information is relevant based on the specific description of both the technique used and the exact location of palpation and positioning of the patient. Determining specific diagnostic conclusions from the palpation of the rotator cuff may not be indicated in the physical therapy evaluation of the patient with shoulder pathology; however, use of this technique can be recommended based on its success in the literature.

Palpation

During palpation of the head and face, the examiner should note any tenderness, deformity, crepitus, or other signs and symptoms that may indicate the source of pathology. The examiner should note the texture of the skin and surrounding bony and soft tissues. Normally, the patient is palpated in the sitting or supine position, beginning with the skull and moving from anterior to posterior, to the face, and finally to the lateral and posterior structures of the head.

The skull is palpated by a gentle rotary movement of the fingers, progressing systematically from front to back. Normally, the skin of the skull moves freely and has no tenderness, swelling, or depressions.

The temporal area and temporalis muscle should be laterally palpated for tenderness and deformity. The external ear or auricle and the periauricular area should also be palpated for tenderness or lacerations.

The occiput should be palpated posteriorly for tenderness. The presence ofBattle sign (seeFig. 2.17) should be noted, if observed, because this signals a possible basilar skull fracture. The sign may take 2 or 3 days to become visible.

The face is palpated beginning superiorly and working inferiorly in a systematic manner. Like the skull, the forehead is palpated by gentle rotary movements of the fingers, feeling the movement of the skin and the occipitofrontalis muscle underneath. Normally, the skin of the forehead moves freely and is smooth and even with no tender areas. The examiner then palpates around the eye socket or orbital rim, moving over the eyebrow and supraorbital rims, around the lateral side of the eye, and along the zygomatic arch to the infraorbital rims, looking for deformity, crepitus, tenderness, and lacerations/scarring from previous lacerations (Fig. 2.69A and B). The orbicularis oculi muscles surround the orbit, and the medial side of the orbital rim and nose are then palpated for tenderness, deformity, and fracture. The nasal bones, including the lateral and alar cartilage, are palpated for any crepitus or deviation (Fig. 2.69C). The septum should be inspected to see if it has widened, possiblyindicating a septal hematoma, which often occurs with a fracture. It should also be determined whether the patient can breathe through the nose or smell.

The frontal and maxillary sinuses should be inspected for swelling. To palpate the frontal sinuses, the examiner uses the thumbs to press up under the bony brow on each side of the nose (Fig. 2.70A). The examiner then presses under the zygomatic processes using either the thumbs or index and middle fingers to palpate the maxillary sinuses (Fig. 2.70B). No tenderness or swelling over the soft tissue should be present. The sinus areas may also be percussed to detect tenderness. A light tap directly over each sinus with the index finger can be used to detect tenderness.

The examiner then moves inferiorly to palpate the jaw. The examiner palpates the mandible along its entire length, noting any tenderness, crepitus, or deformity. The examiner, wearing a rubber glove, may also palpate along the mandible interiorly, noting any tenderness or pain (Fig. 2.69D). The outside hand may be used to stabilize the jaw during this procedure. The mandible may also be tapped with a finger along its length to see if signs of tenderness are elicited. The muscles of the cheek (buccinator) and mouth (orbicularis oris) should be palpated at the same time.

Palpation

Palpation with the joints at rest helps to find the exact localization of lesions in ligaments, tendons or muscles. Palpation is also performed for warmth, swelling and synovial thickening.

Palpation during movement may reveal crepitus. Fine creaking during movement of a tendon in its sheath indicates roughening of the gliding surfaces, the result of overuse. This is quite common in the tendons or muscle bellies of the structures that pass through the first and third tunnels: namely, the abductor and extensors of the wrist. Coarser crepitus can indicate tuberculosis or advanced rheumatoid disease.

Anterior Palpation with Knee Extended

Patella, Patellar Tendon, Patellar Retinaculum, Associated Bursa, Cartilaginous Surface of the Patella, and Plica.

The patella can easily be palpated over the anterior aspect of the knee. The base of the patella lies superiorly, and the apex lies distally. After palpating the apex of the patella (for possible jumper’s knee), the examiner moves distally, palpating the patellar tendon (for paratenonitis or tendinosis) and the overlying infrapatellar bursa (for Parson’s knee), as well as the fat pad that lies behind the tendon (Hoffa’s sign). When the knee is extended, the fat pad often extends beyond the sides of the tendon. Moving distally, the examiner comes to the tibial tuberosity, which should be palpated for enlargement (possible Osgood-Schlatter disease).

Returning to the patella, the examiner can palpate the skin lying over the patella for pathology (prepatellar bursitis or housemaid’s knee) and then extend medially and laterally to palpate the patellar retinaculum on both sides of the patella. With the examiner pushing down on the lateral aspect of the patella, the medial retinaculum can be brought under tension and then palpated for tender areas.The lateral retinaculum can be palpated in a similar fashion with the examiner pushing down on the medial aspect of the patella. By stressing the retinaculum, the examiner is separating the retinaculum from the underlying tissue.

With the quadriceps muscles relaxed, the articular facets of the patella are palpated for tenderness (possible chondromalacia patellae), as shown inFig. 12.156. This palpation is often facilitated by carefully pushing the patella medially to palpate the medial facets and laterally to palpate the lateral facet.

As the medial edge of the patella is palpated, the examiner should carefully feel for the presence of a mediopatellar plica. The plica, if pathological, may be palpated as a thickened ridge medial to the patella. To help confirm the presence of the plica, the examiner flexes the patient’s knee to 30° and pushes the patella medially. If the plica is present and pathological, this maneuver often causes pain.

Palpation

Direct manual palpation of specific structures is performed to evaluate tissue tension, structure size, temperature, swelling, static position, crepitus, and provocation of pain. A systematic procedure for palpation of tissues is advised to facilitate an efficient, yet comprehensive, evaluation. In general, palpation of the anterior and posterior cervical triangles may be more important in patients with postural abnormalities, while palpation of glenohumeral articular structures may be more important when glenohumeral macrotrauma is suspected. Because many structures of the shoulder complex are normally tender to palpation, comparison of findings to the uninvolved side is crucial. Additionally, similar palpation findings are common to many shoulder dysfunctions, so palpation may be the least valuable component in diagnosis of soft tissue dysfunction. Structures commonly palpated by region are shown in Tables 4-6 and 4-7, along with the possible dysfunction(s) when palpation findings are positive.

Palpation

Palpation of superficial structures follows inspection and can help to further narrow the cause of the patient’s pain. Lymph nodes, discrete trigger points, and lipomas can look very similar, but with palpation each lesion can be distinguished. Tenderness to palpation over specific structures suggests that these entities are pain generators. For example, tenderness to palpation over the greater trochanter may be suggestive of trochanteric bursitis. Patients with allodynia, dysesthesia, hyperesthesia, or other sensory derangements often are unable to tolerate this portion of the examination. When tolerated, palpation should be performed in a systematic, comprehensive manner from the least to most painful area with standard pressure. This permits an appreciation of the normal tissues against which to compare the painful region. The objectives of palpation are to identify and delineate subcutaneous masses, edema, and muscle contractures; assess pulses; and to localize tender myofascial trigger points. Remember that unless the pain is bilateral, there is a contralateral structure that can be palpated and used as a control in most patients.

Percussion of specific structures also reveals useful information but, like palpation, is dependent on the patient being able to tolerate it. Pain on percussion of bony structures can indicate a fracture, abscess, or infection. Percussion of spinous processes is often performed to determine whether a vertebral body fracture is a true pain generator or an incidental magnetic resonance imaging (MRI) finding. Pain on percussion over a sensory nerve, or Tinel sign, can indicate nerve entrapment or the presence of a neuroma. Specific nerves commonly tested with this technique are discussed in the section on provocative maneuvers.

Facial palpation is important to identify masses or tenderness over the sinuses. The only major articulation in the face is the temporomandibular joint (TMJ), which can dislocate or freeze and should be palpated to detect any bony asymmetry when patients complain of pain or dysfunction in this region. A detailed facial examination should be performed in patients being evaluated for headache to identify referred pain patterns (supraorbital neuralgia, sinus headache, or headache secondary to TMJ syndrome).3,4

Palpation in the cervical and trunk region can identify muscle spasms, myofascial trigger points, enlarged lymph nodes, occipital nerve entrapment, and pain over the bony posterior spine elements that suggests facet arthropathy. Upper extremity palpation should identify gross sensory changes and pulse symmetry.

Thoracic palpation should mainly focus on ruling out rib and spine fractures. Palpation of the abdominal wall may differentiate between superficial and deep pain generators. Deep palpation can detect pulsatile masses consistent with an abdominal aortic aneurysm that can present as low thoracic back pain.

Palpation in the lumbar spine begins with identification of the bony landmarks, specifically the iliac crests. The horizontal line connecting the iliac crests approximately estimates the L4–L5 level. Severe tenderness to midline palpation may be present with supraspinous or interspinous ligamentous rupture. Moreover, the location of tenderness may provide important clues as to the etiology of lumbar spine pain. For example, discogenic low back pain is nearly always associated with midline tenderness and in most cases paraspinal tenderness, whereby facetogenic pain is associated with paraspinal tenderness in a large majority of cases but is infrequently associated with prominent midline tenderness. In contrast, sacroiliac joint pain is predominantly associated with unilateral pain situated predominantly below L5.5 Common bony pain generators in the lumbar region include the facet joints, sacroiliac joints, and the coccyx. For piriformis syndrome or coccydynia, a digital rectal examination is a valuable tool for diagnosis. Soft tissue palpation is important to evaluate paraspinous muscle tone, the localization of trigger points, and the presence of masses or lipomas.

Enlargement of nerve trunks

Palpation of nerve trunks is an important part of clinical examination, not only in patients with focal or multifocal neuropathy but also in diffuse polyneuropathy. Focal thickening of a nerve trunk can be detected by palpation of the course of the nerve trunk in question in case of neurofibroma or in focal leprous neuropathy. In generalized polyneuropathy enlarged common peroneal nerve trunk near the fibula head, or the ulnar nerve at the elbow, can be palpated in some cases of hereditary hypertrophic neuropathy. However, nerve palpation is not very reliable and over interpretation is common. Currently nerve hypertrophy and primary nerve tumors are more reliably detected by MRI of nerve trunk or by ultrasound (see Chapter 8).

Trigger Point Compression Release: Supraspinatus (Fig. 16-7)

I Introductory Comments on Technique

Palpation of the abdomen may reveal abnormal tenderness, tumors, hernias, aneurysms, or organomegaly (i.e., of the liver, spleen, or gallbladder). To help the patient relax and to minimize pain during palpation, experienced clinicians recommend that the clinician’s hands should be warm, the technique soft and gentle, and the expected tender areas palpated last. Other maneuvers designed to help the patient relax include drawing up the patient’s knees, encouraging deep breathing, or engaging the patient in conversation.

In the days before clinical imaging, palpation of a relaxed abdomen was so essential that patients with tense abdominal muscles were often reexamined after immersion in a hot bath or after anesthesia had been induced with ether or chloroform, to determine whether an abnormality was present or not.1