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General palpation

按诊 〔按診〕àn zhěn

Also body palpation. Part of the palpation examination (which also notably includes the pulse examination) in which the body's surface is palpated with the hand to determine the presence of heat or cold, moistness or dryness, swelling, and distension, and to observe the patient’s reaction to pressure to determine the presence of pain. General palpation may be divided into five parts: palpation of the skin, the limbs, the chest and abdomen, and acupoints.

Scope and Aims

General palpation involves feeling the body's surface with the hand to determine the presence of heat, cold, moistness, distension, and pain, and to observe the patient’s reaction to pressure. Body palpation may be divided into four parts: palpation of the skin, limbs, abdomen, and acupoints.

Techniques

There are four basic palpation techniques: touching, feeling, pressing (or palpating), and percussing (tapping). The first three of these entail differences in the amount of pressure applied.

Touching is light contact with the skin. It is used to detect the presence of heat or cold and the presence of moistness or dryness. Note that the back of the hand is often more sensitive to heat than the palmar aspect.

Feeling means exploring with the hands for the presence of masses and for determining their shape or size.

Pressing means applying relatively light pressure (but greater pressure than in feeling) to determine the borders and consistency of masses.

Heavy pressing means applying the greatest pressure on an area. It is used to determine if there is pain or if there is pus.

Percussion means tapping an area with the fingers or hand for sounds, rippling, or vibrations (direct percussion) or for the patient’s reactions (indirect percussion).

Precautions

When conducting palpation, the practitioner must take care that patients do not catch cold if required to undress. The patient should be completely relaxed. The practitioner should ensure that her hands are warm and that she applies pressure gently and evenly.

Palpation of the Skin

The principal goal of skin palpation is to assess the degree of heat or cold and the degree of moistness on the skin.

Cold and Heat

Palpating the skin to see if it is cold or hot to the touch enables the practitioner to determine the presence of heat or cold, as well as of vacuity or repletion.

Moistness and Dryness

Feeling the skin for moistness and dryness enables the practitioner to detect the presence or absence of sweating and whether or not the fluids have been damaged.

Swelling

A broad distinction is made between (a) localized red, hot, and tender swelling, which constitutes toxin swelling (肿毒 zhǒng dú) and (b) swelling and enlargement of the face, limbs, and sometimes the whole body, without any redness or pain on pressure, usually referred to puffy swelling (浮肿 fú zhǒng). Especially when it pits under pressure and does not rebound easily when pressure is released, it is sometimes called vacuity puffiness (虚浮 xū fú).

Puffy swelling and vacuity puffiness are symptoms indicating water swelling (水肿 shuǐ zhǒng), which in Chinese medicine is the name given to the disease. Distinction is made between yīn water or yáng water. In addition, there is qì swelling and toxin swelling. These are described under water swelling.

Welling- and Flat-Abscesses; Sores

These are lesions characterized by localized swelling and suppuration. They are mostly attributable to heat toxin, which gives rise to painful red swelling, often called toxin swelling (肿毒 zhǒng dú). Palpation of welling-abscesses and sores helps to determine whether they form yīn or yáng patterns and whether or not pus has formed.

Palpation of the Limbs

Cold and Heat in the Extremities

Lack of warmth in the extremities and cold limbs denote mild conditions; counterflow cold of the limbs (四肢逆冷 sì zhī nì lěng) (also called reversal cold of the extremities 四肢厥冷 sì zhī jué lěng) denotes more severe conditions of pronounced cold up from the tips of the limbs to the elbows and knees.

Cold and Heat in Specific Parts of the Hands and Feet

Heat and cold in specific parts of the hands and feet are often of great diagnostic significance.

Palpation of the Chest and Abdomen

Palpation of the chest and rib-side is limited by the presence of the ribs, which prevent the tissues they enclose from being felt. However, the palpation of the apical pulse just below the left nipple is of value in some cases. Palpation of the abdomen enables the practitioner to detect cold or heat, softness or hardness, fullness and distension, and abdominal masses. Palpable symptoms indicate disorders of the specific bowels and viscera. These should be correlated with any subjective sensations reported by the patient in the context of the inquiry examination.

Correspondence of abdominal positions and the bowels and viscera: The correspondences between location of pathologic symptoms and the relevant diseased organs are as follows:

Apical pulse, Vacuous Lǐ: Palpation of the apical pulse, which in Chinese medicine is called Vacuous Lǐ, is the main aspect of chest palpation. Vacuous Lǐ is located just below the left nipple. Described as being the source of all blood vessels, it is the point where the heart is closest to the body surface. The strength of the pulsation at Vacuous Lǐ can help to assess the strength of ancestral qì, identify vacuity and repletion, and gauge the patient’s prognosis. Inspection of the Vacuous Lǐ is especially important in severe vacuity or repletion patients, where the radial pulse may not be felt.

The pulsation is best felt with the patient in supine posture. The practitioner stands at the patient’s right side and places her hand gently on the spot. The pulsation can be felt by pressing gently. In a healthy person, the pulsation is gentle and relaxed, and unhurried. The pulsation is relatively indistinct in corpulent people and more pronounced in thin people. These variations have no clinical significance.

Palpation of the rib cage: Palpation just below the rib cage allows abdominal masses stretching up into the rib cage to be felt. The liver is partially enclosed by the rib cage. Enlargement of the liver felt through palpation indicates qì stagnation or blood stasis. If the surface of the liver feels bumpy, this may indicate liver cancer (not traditionally recognized as such in Chinese medicine). If there is distending pain in the right rib-side that feels palpably hot and tender, this is a welling-abscess of the liver. In malarial disease, there may be a palpable mass under the rib cage, which is traditionally called mother-of-malaria, corresponding to hepatosplenomegaly in biomedicine.

Abdominal palpation: The purpose of this is to determine the nature of fullness, distension, and pain. Fullness is a subjective feeling of bloating in the chest or abdomen. Distension means pronounced fullness that is objectively palpable or even visible expansion of the abdomen. Fullness and distension may or may not be associated with pain. Pain may or may not be associated with fullness and distension.

Abdominal masses: Abdominal masses are often referred to as glomus lumps (痞块 pǐ kuài). (Remember that glomus is a lump or localized feeling of blockage and fullness.) Distinction is made between concretions (癥 zhēng), conglomerations (瘕 jiǎ), accumulations (积 ), and gatherings (聚 ): Also called glomus lump.

In short: Concretions are hard lower burner masses, while conglomerations are soft lower burner masses; accumulations are hard center burner masses, while gatherings are soft center burner masses.

Masses that are large, irregular in shape, and do not feel smooth indicate a serious condition, especially if as a hard as stone.

An abdominal mass that feels like a sinew and that on long palpation appears to move or even wriggle or that gathers and disperses intermittently is usually a sign of a worm accumulation.

Palpation of Acupoints

Morbidity of the organs may be reflected in palpatory tenderness (that is, when pressure applied causes pain) or sensitivity at many acupoints. The following deserve special attention.

Diseases are not only reflected at these points but may also be treated by acupuncture or tuī-ná (massage therapy) at the sensitive spots.

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