What are the different hand surfaces used in palpation techniques?

Palpation uses specific hand surfaces for different purposes. Finger pads, with dense sensory innervation, detect fine details like mass borders and lymph nodes. Fingertips examine structures like nailbeds and liver edges. The palmar surface surveys large body areas during abdominal palpation. The ulnar surface of the hand and fifth finger appreciates vibration during tactile fremitus assessment. The dorsal surface provides rough temperature comparison between body regions.

Why is hand preparation important before performing palpation?

Proper hand preparation ensures patient safety and comfort during palpation. Clinicians must keep fingernails clean, groomed, and trimmed to prevent injury. Hands should be washed with soap and water or disinfected topically. Warming hands with warm water or friction reduces patient discomfort. Protective equipment like gloves should be worn when infection control precautions are needed, though barriers may affect rapport-building with patients.

How should a clinician approach palpating a patient's area of discomfort?

When examining an area of discomfort, ask the patient to point out the exact location first. Palpate the tender area toward the end of the examination to minimize anxiety. Explain your intention clearly: 'I'm going to examine this area last in order just to make it more comfortable for you.' This approach demonstrates empathy, builds trust, and allows the patient to prepare mentally for potential discomfort during the examination.

What role does palpation pressure and duration play in physical examination?

Palpation pressure and duration must be adjusted based on the structure being examined. Insufficient pressure may prevent detection of deep structures, while excessive pressure can occlude pulses and cause discomfort. Duration is equally important; for example, adequate time is needed during lower extremity palpation to reveal pitting edema. Deliberate adjustment of these factors ensures accurate diagnostic information and patient comfort.

How does touch during palpation contribute to patient care beyond diagnosis?

Touch during palpation communicates caring and comfort, shaping patient perceptions of healthcare providers positively. Physical contact from clinicians has been associated with decreased cortisol and increased serotonin levels in patients. Through careful use of palpation and touch, clinicians gain diagnostic information while developing rapport and promoting healing. This therapeutic aspect of touch is fundamental to comprehensive patient care during physical examination.

What is the recommended sequence for beginning a palpation examination?

Begin by palpating the nailbeds with your fingertips to assess capillary refill and pallor, gauging patient comfort with touch. Then palpate the radial pulse using finger pads. After establishing rapport through these initial contacts, move to the anatomic region of interest, such as the abdomen. This sequence allows clinicians to assess patient comfort before proceeding to more sensitive examination areas.

What draping and communication strategies should clinicians use during palpation?

Use draping techniques to balance patient modesty with examination access. Always ask permission before palpating and provide warnings if the procedure may worsen pain. Express empathy when examining sensitive areas. At the examination's end, drape the patient back and thank them for cooperation. These communication strategies, combined with proper adjustment of patient attire during the physical exam, demonstrate respect and build therapeutic relationships.

Palpation

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1. Before the patient encounter

Keep fingernails clean, groomed, and trimmed.
1. Wash your hands with soap and water or topical disinfectant solution.
2. Warm your hands as able (e.g., with warm water or by rubbing them together) before patient contact.
3. If any specific infection control precautions are needed for the clinical encounter (e.g., contact precautions), explain to the patient why you are wearing protective equipment. Be aware that gowns, gloves, and masks can present a barrier to building a relationship with the patient.³

2. Components of the exam

Familiarize oneself with the specific palpation techniques for each regional/anatomic component of the exam; refer to each of the individual videos for exploration of how palpation is utilized.
Perform the palpation directly on the patient's skin. Employ draping techniques to optimize access, while balancing patient modesty. Refer to the videos on draping for specific details.

3. General considerations

In order to slowly invite oneself into the patient's personal space and gauge the patient's comfort with the clinician's touch, many providers start the examination with the hands. Perform gentle palpation of the nailbeds with your fingertips (to assess for capillary refill and pallor) and palpation of the radial pulse with your finger pads to initiate the first contact in a non-threatening way.
Use the finger pads when performing most of palpation, with the following notable exceptions:
1. Use the fingertips to palpate the nailbeds, liver edge, and cervix.
2. Use the ulnar surface of the hands when assessing tactile fremitus.
3. Use the palmar surface of the fingers and/or hands for assessing chest expansion, precordium for PMI/heaves/lifts/thrills, performing light and deep palpation of the abdomen, and strength testing against resistance.
4. Use the dorsal surface of the hands for assessing the relative temperature of the skin (typically in comparison to another portion of the patient's body).
Be aware of the pressure used for palpation, which varies based on the structures being examined. For example, excessive pressure may occlude a pulse, causing discomfort and limiting utility. Insufficient pressure may limit one's ability to palpate deep structures (e.g., aorta).
Be deliberate about the duration when applying pressure, which varies based on the structures being examined. For example, tense lower extremity pitting edema can be missed, if the examiner does not apply steady pressure for at least a few seconds. Similarly, a blanching rash may not be identified as such without ample duration of pressure. Conversely, excessive duration of palpation in a patient with peritoneal signs causes undue discomfort without increasing diagnostic yield.
Consider palpating areas of known discomfort toward the end of the examination, making it clear to patients this is done in the interest of their comfort. For example, if a patient has acute right knee pain, initiating the exam on the left lower extremity, followed by examination of the right ankle and hip, may make the patient less guarded when the painful right knee is examined.
Express empathy while acknowledging that certain parts of the examination may cause the patient discomfort. Patients expect to be examined, but ask permission and provide a warning if you are about to do something that is likely to worsen a patient's pain (e.g., palpation of the abdomen in a patient with suspected appendicitis).

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!