Sensitive Parts of the HandTactile sense. The tips of the fingers are most sensitive for fine tactile discrimination

Vibratory sense. Palpate with the palmar aspects of the metacarpophalangealjoints or the ulnar side of the hand (fifth metacarpal and fifth phalanges) ratherthanwith the fingertips to perceive vibrations such as thrills. Prove the superiority

Temperature sense. Use the dorsa of the hands or fingers; the skin is muchthinner than elsewhere on the hand.

Deep palpation. Firm pressure is applied to displace the superficial tissues allowingpalpation for deeper lesions. This is especially useful in the abdomen, butis also useful in the neck, breasts, and large muscle masses. Avoid firm palpationover nerves or other tender structures whenever possible

Bimanual palpation. In this technique, the tissue is examined between the fingersof the two hands. It is useful for soft tissue such as the breasts, intraoral,abdominal and pelvic examinations, and examination of the muscles and joints

Gastrointestinal Examination: positioning the patient

Hyperpigmentation in Cronkhite-Canada syndrome

Carcinoid syndrome involving the chest and abdomen

Glucagonoma: migratory rash involving the groin

Dermatitis herpetiformis

Peutz-Jeghers syndrome, with discrete brown-black lesions of the lips

Acanthosis nigricans: (a) axilla; (b) chest wallAXILLA

CHEST WALL

Hereditary haemorrhagic telangiectasia involving the lips

Porphyria cutanea tarda-scarring from photosensitivity

Leuconychia-Terry's nails

A large crop of spider naevi

Scleral icterus

Kayser-Fleischer rings

Amyloidosis causing macroglossia

Parotid gland examination

Aphthous ulceration

Abdominal scars

Detecting the direction of flow of a vein

Prominent veins on the abdominal wall

(a) Regions of the abdomen (b) Quadrants of the abdomen

Abdominal examination: the liver

Percussing the liver span: (a) upper border; (b) lower borderUPPER BORDER

LOWER BORDER

Massive splenomegaly: note the splenic notch

Palpation of the spleen(a) Palpation begins in the lower mid-abdomen and finishes up under the left costal margin.

(b) The examiner's hand supports the patient's side

(c) and then rests over the lower costal margin to reduce skin resistance.

(d) If the spleen is not palpable when the patient is flat, he or she should be rolled towards the examiner.

Detecting an expansile impulse

Percussion of the spleen

Shifting dullness(a) Percuss out to the left flank until the percussion note becomes dull. Mark this spot with your finger.

(b) Roll the patient towards you, wait 30 seconds. Shifting dullness is present if the left lateral dull area is now resonant.