diagnosis by palpation

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DIAGNOSIS BY PALPATION DME-312 HANDOUTS 7,8,9

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Feel free to download and view as a presentation. Presenter's notes are highly filled with information. Presentation used briefly to explain the basics of Traditional Chinese Medicine diagnosis by palpation. It includes (and mainly focuses on) pulse diagnosis, skin palpation, abdomen palpation, point palpation and limb palpation. References cited include Chinese Acupuncture and Moxibustion, Foundations of Chinese Medicine, Diagnosis in Chinese Medicine, A Manual of Acupuncture, Pulse Diagnosis.

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Page 1: Diagnosis by Palpation

DIAGNOSIS BY PALPATIONDME-312 HANDOUTS 7,8,9

Page 2: Diagnosis by Palpation

PALPATION

Diagnosis by feeling generally includes the following

• Palpation of the pulse

• Palpation of the skin

• Palpation of the limbs

• Palpation of the hands

• Palpation of the chest

• Palpation of the abdomen

• Palpation of the points

Page 3: Diagnosis by Palpation

Performed by placing fingers along the Radial Artery.

Pressure is applied with different kinds of strength at three different points.

The patient’s arm should be horizontal and not held higher than heart level.

PULSE DIAGNOSIS

Page 4: Diagnosis by Palpation

We use the pads of the fingers to take the pulse because they are the most sensitive area.

We place the first three fingers (not counting the thumb) on the Radial artery.

PULSE DIAGNOSIS

Page 5: Diagnosis by Palpation

Pulse is felt by moving the fingers in 4 different ways:

• Lifting (upwards)

• Pressing (downwards)

• Pushing (side to side)

• Rolling (proximal – distal)

We also keep the fingers still (searching) in order to be able to decide the speed of the pulse.

PULSE DIAGNOSIS

Page 6: Diagnosis by Palpation

PULSE DIAGNOSIS

Sections of Pulse

• Inch (CUN) - Front

• Barrier (GUAN) - Middle

• Cubit (CHI) - Back

Pulse Depth

• Superficial – resting fingers very gently on the artery

• Deep – almost obliterate pulse then release very slightly

• Middle – in between these two kinds of pressure

Altogether, 3 Sections x 3 Depths = The 9 Regions

Page 7: Diagnosis by Palpation

PULSE DIAGNOSIS

Correspondence of each organ and section / levelaccording to the Mai Jing (Pulse Classic)

Page 8: Diagnosis by Palpation

PULSE DIAGNOSIS

Main importance of Pulse Diagnosis

1. Gives detailed information about state of internal organs

2. Reflects whole complex of Qi and Blood

Other Notes

• Pulse counts as a clinical manifestation that shows you the entire body

• The tongue also does this, but with less clarity

Page 9: Diagnosis by Palpation

PULSE DIAGNOSIS

Drawbacks to Pulse Diagnosis

• Extremely subjective

• Skill is subtle and hard to master

• Subject to external, short-term influences

Advantages to Pulse Diagnosis

• It can reflect older disharmonies not showing on tongue, as well as others due to discoloration or physical manipulation of it (such as scraping)

Page 10: Diagnosis by Palpation

PULSE DIAGNOSIS

What you should pay attention to (IN THIS SPECIFIC ORDER)

1. Feel the Pulse as a whole

2. Feel whether the pulse has spirit, Stomach Qi and root

3. Feel the three levels and the three positions

4. Feel the strength of the pulse

5. Feel the quality of the pulse

Page 11: Diagnosis by Palpation

PULSE DIAGNOSIS

Qualities of Pulse that we are looking for

• Force

• Movement

• Rate

• Rhythm

• Shape

• Presence of Shen

Page 12: Diagnosis by Palpation

PULSE DIAGNOSIS

What is a Normal Pulse?

• Has Stomach-Qi

• Feels “gentle”, “calm” and relatively slow (4 beats per respiratory cycle / breath)

• Has Spirit

• Soft but with strength; neither big or small• Regulated – should not change type very easily

• Has root

• Deep level is clearly felt along with rear position• Kidneys are felt strong

Page 13: Diagnosis by Palpation

PULSE DIAGNOSIS

Factors that affect the Pulse

• Seasons

• Pulse is deeper in wintertime; superficial in summertime• Gender

• Male pulse is naturally stronger than women’s• Men have stronger left pulse; women, the right pulse• Men have stronger front pulse; women, the rear

• Occupation

• People who perform strong physical labor should have a stronger pulse than those who do not

Page 14: Diagnosis by Palpation

PULSE DIAGNOSIS

Factors that affect the Pulse

• Body build

• Pulse will be stronger, larger and longer in robust, large people; weaker, smaller and shorter in small, frail people

• Menstruation

• Becomes slippery the week before the onset, especially on the right rear position; then it becomes weak and slower

• Pregnancy

• Becomes slippery, therefore it is considered normal• Fan Guan Mai and Xie Fei Mai

• These are abnormalities on the pulse

Page 15: Diagnosis by Palpation

PULSE DIAGNOSIS

Fan Guan Mai is a radial artery displacement that is present in about 5% of people.

The radial artery lies in the dorsal aspect of the arm instead of the inner aspect.

In these cases, the pulses on the nine regions of the head, hand and feet are recommended.

Page 16: Diagnosis by Palpation

DEEP PULSE

Chinese Name

• Chen Mai, a.k.a. Sinking

Description

• Can only be felt with heavy pressure; felt near the bone

Clinical Significance

• Indicates an interior condition

• Indicates the Yin organs to be the problem

Indications

• Deep and Weak: Yang and Qi deficiency

• Deep and Full: a) Stasis of Qi; b) Blood in the Interior;c) Interior Cold or Heat

Page 17: Diagnosis by Palpation

FLOATING PULSE

Chinese Name

• Fu Mai

Description

• Can be felt with a light pressure, resting fingers on artery

Clinical Significance

• Indicates presence of exterior pattern from pathogen

Indications

• Floating and Tight: Wind-Cold

• Floating and Rapid: Wind-Heat

• Floating Superficial / Empty Deep: Yin deficiency

Page 18: Diagnosis by Palpation

SLOW PULSE

Chinese Name

• Chi Mai

Description

• Three beats per respiration cycle (breath) of practicioner

• Can also be counted using a watch

Clinical Significance

• Indicates a Cold pattern

Indications

• Slow and Empty – Empty-Cold from Yang Deficiency

• Slow and Full – Full Cold

Page 19: Diagnosis by Palpation

SLOW PULSE

Typical Slow Pulse Speeds (estimated)

Age (Year) Rate (beat/min)

1 – 4 90 or more

4 – 10 84

10 – 16 78 / 80

16 – 35 76

35 – 50 70 / 72

50+ 68

Page 20: Diagnosis by Palpation

RAPID PULSE

Chinese Name

• Shu Mai

Description

• 5 or more beats per cycle (or higher than slow chart)

Clinical Significance

• Indicates a Heat pattern

Indications

• Rapid and Empty – Empty-Heat from Yin Deficiency

• Rapid and Full – Full Heat or Excessive Heat

Page 21: Diagnosis by Palpation

EMPTY PULSE

Chinese Name

• Xu Mai (a.k.a. Vacuous, Deficiency)

Description

• Feels rather big, but soft; feels empty with more pressure

Clinical Significance

• Indicates Qi or Qi AND Blood deficiency

Page 22: Diagnosis by Palpation

FULL PULSE

Chinese Name

• Shi Mai (a.k.a. Excess type, Replete)

Description

• Feels full; rather hard and long

Clinical Significance

• Indicates a Full pattern

Indications

• Full and Rapid – Full-Heat

• Full and Slow – Full-Cold

Page 23: Diagnosis by Palpation

SLIPPERY PULSE

Chinese Name

• Hua Mai

Description

• Feels smooth, round, oily to the touch; rolls under fingers

• Feels like “rolling pearls in a porcelain bowl”

Clinical Significance

• Indicates Phlegm, Dampness, Food retention, Pregnancy

Indications

• It’s full by definition, but can be weak as well

• It can be weak, indicating Phlegm, Dampness and Qi deficiency

Page 24: Diagnosis by Palpation

CHOPPY PULSE

Chinese Name

• Se Mai a.k.a. Hesitant, Rough

Description

• Rough under the fingers; like a jagged edge

• Feels like “a knife scraping bamboo”

• Also means a pulse that changes rapidly in rate and quality

Clinical Significance

• Indicates stasis or deficiency of blood

• Could mean exhaustion of fluids, especially after profuse sweating or vomiting

Page 25: Diagnosis by Palpation

LONG PULSE

Chinese Name

• Chang Mai

Description

• Longer than normal; extends slightly beyond normal pulse

Clinical Significance

• Indicates a Heat pattern

• May indicate that there is no Pathological condition

Page 26: Diagnosis by Palpation

SHORT PULSE

Chinese Name

• Duan Mai

Description

• Occupies shorter space than normal position

Clinical Significance

• Indicates a severe Qi deficiency

• Frequently appears on Front position; either left or right

• Specifically denotes deficiency of Stomach-Qi

Page 27: Diagnosis by Palpation

OVERFLOWINGPULSEChinese Name

• Hong Mai, a.k.a. Surging, Flooding

Description

• Feels big and extending beyond normal pulse position

• Superficial; generally “overflows” normal pulse channel

Clinical Significance

• Indicates an Extreme Heat pattern

• Frequently appears during Fever, and Interior Heat diseases

Indications

• Overflowing and Empty on pressure – Empty Heat from Yin deficiency

Page 28: Diagnosis by Palpation

FINE PULSE

Chinese Name

• Xi Mai, a.k.a. Thready, Thin

Description

• Feels thinner than normal

Clinical Significance

• Indicates a deficiency of Blood

• May indicate Dampness with severe Qi deficiency

Indications

• Thin and Rapid – Heat brought by Yin deficiency

Page 29: Diagnosis by Palpation

MINUTE PULSE

Chinese Name

• Wei Mai, a.k.a. Faint

Description

• Thinner than the Fine pulse; harder to feel; very small

Clinical Significance

• Severe deficiency of Qi and Blood

Page 30: Diagnosis by Palpation

TIGHT PULSE

Chinese Name

• Jin Mai, a.k.a. Tense

Description

• Feels twisted, like a thick rope

• It also can be felt as it “vibrates”

Clinical Significance

• Indicates a Cold pattern, exterior (i.e. Wind-Cold) or Interior

• May indicate pain from an interior condition

Indications

• Tight and Floating – Exterior Cold

• Tight and Deep – Interior Cold

Page 31: Diagnosis by Palpation

WIRY PULSE

Chinese Name

• Xian Mai, a.k.a. Stringlike, Bowstring

Description

• Feels taut, like a guitar string

• Thinner, more taut and harder than the Tight pulse

• “No fluidity or wave-like qualities”

Clinical Significance

• May indicate Liver disharmony

• May indicate Pain

• May indicate Phlegm

Page 32: Diagnosis by Palpation

SLOWED-DOWNPULSE

Chinese Name

• Huan Mai, a.k.a. Moderate

Description

• Four beats per respiration cycle

Clinical Significance

• Generally considered a healthy pulse

• If Dampness is suspected by other signs, it can be used to indicate its presence

Page 33: Diagnosis by Palpation

HOLLOW PULSE

Chinese Name

• Kong/Kou Mai, a.k.a. Scallion-stalk

Description

• Felt at superficial and deep; any middle pressure makes it empty

Clinical Significance

• Indicates a loss of Blood

• Usually appears after a hemorrhage

Indications

• Hollow and slightly Rapid – Forthcoming loss of Blood

Page 34: Diagnosis by Palpation

LEATHER PULSE

Chinese Name

• Ge Mai, a.k.a. Drumskin

Description

• Hard, tight and stretched superficially; empty at Deep level

• Large pulse, not thin

Clinical Significance

• Indicates severe deficiency of Kidney-Essence or Yin

Page 35: Diagnosis by Palpation

FIRM PULSE

Chinese Name

• Lao Mai, a.k.a. Confined, Prison

Description

• Only felt at Deep level; felt hard and rather wiry

• Could be described as a Wiry pulse at the Deep level

Clinical Significance

• Indicates Interior Cold (if it is also Slow)

• Indicates Interior Stagnation and Pain

Page 36: Diagnosis by Palpation

SOGGY PULSE

Chinese Name

• Ru Mai, a.k.a. Soft, Weak-Floating

Description

• Only felt on superficial level; very soft and slightly floating

• Disappears when pressure is applied to feel Deep level

Clinical Significance

• Indicates presence of Dampness if there are other signs that represent a Qi deficiency

• May also indicate lack of Yin or Essence

Page 37: Diagnosis by Palpation

WEAK PULSE

Chinese Name

• Ruo Mai, a.k.a. Frail

Description

• Only felt on Deep level; also soft

Clinical Significance

• Indicates a deficiency of Yang or of Blood

Page 38: Diagnosis by Palpation

SCATTERED PULSE

Chinese Name

• San Mai

Description

• Small and relatively superficial

• Feels as if it was broken into small dots

Clinical Significance

• Severe deficiency of Qi and Blood, especially Kidney-Qi

• ALWAYS indicates a serious condition

Page 39: Diagnosis by Palpation

HIDDEN PULSE

Chinese Name

• Fu Mai

Description

• As if it was hidden beneath the bone

• Extreme case of Deep pulse

Clinical Significance

• Extreme deficiency of Yang

• If strong, indicates an obstruction of Cold

Page 40: Diagnosis by Palpation

MOVING PULSE

Chinese Name

• Dong Mai, a.k.a. Spinning-Bean

Description

• It is short and “trembles” under the finger

• Does not have a definite shape; shaking and also slippery

• Combination of short, tight, slippery and rapid pulses

Clinical Significance

• Indicates shock, anxiety, fright or extreme pain

• Found in people with deep emotional problems, especially fear, or those who have suffered severe emotional shock

Page 41: Diagnosis by Palpation

HASTYPULSE

Chinese Name

• Cu Mai, a.k.a. Abrupt, Skipping, Hurried

Description

• Rapid pulse, stops at irregular intervals

Clinical Significance

• Indicates extreme Heat and a deficiency of Heart-Qi

• Also felt in conditions of Heart-Fire

Page 42: Diagnosis by Palpation

KNOTTEDPULSE

Chinese Name

• Jie Mai, a.k.a. Bound

Description

• Slow and stops at irregular intervals

Clinical Significance

• Indicates cold

• Indicates deficiency of Heart-Qi or Heart-Yang

Page 43: Diagnosis by Palpation

INTERMITTENTPULSE

Chinese Name

• Dai Mai, a.k.a. Regularly Interrupted

Description

• Stops at regular intervals; feel the pulse and feel the stops

Clinical Significance

• Indicates a serious internal problem of one or more Yin organs

• If it stops every four beats or less, the condition is serious

• It can also indicate a serious heart problem (in the Western medical sense)

Page 44: Diagnosis by Palpation

RACING PULSE

Chinese Name

• Ji Mai, a.k.a. Swift

Description

• Pulse is very rapid, but agitated and very urgent

Clinical Significance

• Indicates an Excess of Yang, with Fire in the body exhausting Yin

Page 45: Diagnosis by Palpation

PULSE DIAGNOSIS

28 Different Pulse Qualities (with similar Grouping)

(The groups have been been grouped on a Yin-Yang level)

Deep Floating Slow Rapid Empty Full

Deep Floating Slow Rapid Empty Full

Firm Hollow Knotted Hasty Weak Overflow

Hidden Leather Choppy Hurried Fine Wiry

Soggy Moving Minute Tight

Rolling Soggy Long

Short Firm

Scattered

Page 46: Diagnosis by Palpation

PULSE DIAGNOSIS8 Principles General

Pulse QualityDescription Specific Pulse Quality

Exterior (Yang)

superficial Felt with light pressure

Superficial; floating; hollow; leather; soft

Interior (Yin) deep Felt with deep pressure

Deep; Firm; Hidden

Hot (Yang) rapid More than 80 BPM (>5 per breath)

Rapid; Hasty; Moving

Cold (Yin) slow Less than 65 BPM (3> per breath)

Slow; Tight; Knotted; Intermittent (not necessarily slow but often)

Full (Yang) full Large, long, substancial

Full; Big; Overflowing; Wiry; Tight; Long; Slippery; Flooding;

Empty (Yin) empty Small, short, insubstancial

Empty; Weak; Fine; Minute; Short; Scattered; Choppy

Page 47: Diagnosis by Palpation

SKIN PALPATION

Palpating the skin involves focusing on three major topics:

• Temperature of the skin

• Moisture of the skin

• Texture of the skin

We do this by three different methods:

• Touching

• Stroking

• Pressing

Page 48: Diagnosis by Palpation

PALPATING THE BODY

There are three different palpation techniques:

• Touching - Light touch of the patient’s skin

• Detecting temperature, moisture and sweat• Stroking – stroking in the skin and deeper tissues of the

patient

• Usually carried out in chest, abdomen and limbs• Determines presence of tenderness and swelling

• Pressing – pressing relatively hard to deeper levels

• Usually done in the abdomen• Determines presence of pain or masses

Page 49: Diagnosis by Palpation

SKIN PALPATIONKey things to Know

• Temperature

• Subjective feeling of heat does not always correspond to the objective feeling of heat of the skin

• Skin feels hot to the touch – often indicates Damp-Heat• Cold feeling indicates Cold pattern; often felt in loins, lower

abdomen or lower back (indicates Kidney-Yang deficiency)• Hot on first touch, ceasing to feel hot with sustained

pressure – indicates Wind-Heat invasion, still on exterior• Skin over vessel hot on medium pressure but not on heavy

pressure – interior Heat in Middle Jiao or Heart• Skin hot on heavy pressure nearly nearing the bone –

Empty Heat from Yin deficiency

Page 50: Diagnosis by Palpation

SKIN PALPATION

Key Things to Know

• Moisture and Texture

• Moist skin may indicate invasion of the Exterior by Wind-Cold, or more commonly, Wind-Heat

• Moist skin with absence of exterior symptoms indicates spontaneous sweating from Lung-Qi deficiency

• Dry skin indicates Blood or Lung-Yin deficiency• Rough-like skin may indicate Painful Obstruction

Syndrome from Wind• Scaly and dry skin indicates exhaustion of body fluids• Swollen skin with a pit left after pressing indicates oedema• Swollen skin, no pit indicates retention of Dampness

Page 51: Diagnosis by Palpation

LIMB PALPATION

Key Things to Remember:

• Hands and feet cold to the touch indicate Yang deficiency

• Whole arm and leg feel cold indicate Kidney-Yang deficiency (Empty-Cold)

• Only forearm and lower leg feel cold may indicate Interior Cold from Qi stagnation (Full-Cold)

• Only hands and feet feel cold may indicate Qi stagnation

• Limbs feeling hot indicate a Heat pattern

• Hands hot on the dorsum indicate Full-Heat

• Hands hot on palms indicate Empty-Heat from Yin deficiency

Page 52: Diagnosis by Palpation

CHEST PALPATION

Process

• Palpate the area over the left ventricle of the heart (called “Interior Emptiness” or Xu Li in Chinese Medicine)

• Pulse of heart can be felt in this area; sometimes seen

• Area reflects the state of Zong Qi (Gathering Qi)

Page 53: Diagnosis by Palpation

CHEST PALPATION

Key Things to Remember

• Faint but clear pulsation indicates Gathering Qi deficiency

• Too strong pulsations indicate “outpouring” of Gathering Qi, i.e. a state of hyperactivity due to over-pushing oneself

• Pulsation not felt indicates Phlegm or a hiatus hernia

• Area below xyphoid process feeling full and painful on pressure indicates a Full pattern

Page 54: Diagnosis by Palpation

ABDOMEN PALPATION

The Abdomen is generally palpated in 5 areas:

• Hypochondrium

• Epigastrium

• Umbilical area

• Lateral-lower abdomen

• Central-lower abdomen

Page 55: Diagnosis by Palpation

ABDOMEN PALPATION

Hypochondrium

• Includes the lateral side of the rib cage and area immediately below it

• Reflects state of the Liver and Gall-Bladder

Page 56: Diagnosis by Palpation

ABDOMEN PALPATION

Epigastrium

• Area contained between the xyphoid process, costal margins and the umbilicus

• Reveals the condition of the Stomach and Spleen

Page 57: Diagnosis by Palpation

ABDOMEN PALPATION

Umbilical Region

• It is the area right around the umbilicus

• It reflects the state of the Kidneys, the Penetrating and Directing Vessels

• Umbilical area has a palpable pulse as well

Page 58: Diagnosis by Palpation

ABDOMEN PALPATION

Lateral-lower Abdomen

• Also called Shao Fu

• Reflect the state of the Intestines and the Penetrating Vessel

Page 59: Diagnosis by Palpation

ABDOMEN PALPATION

Central-lower Abdomen

• Also called Xiao Fu

• Reflects the state of the Small Intestine, Kidneys, Bladder, Uterus and Liver

Page 60: Diagnosis by Palpation

JAPANESE HARA DX

Step 1: Compare Big and Small Abdomen

• Big Abdomen Deficient – LU or SP

• Small Abdomen Deficient – LV or KD

Page 61: Diagnosis by Palpation

JAPANESE HARA DX

Step 2: Determin Nan Jing Abdominal Diagnosis Area:

• SP – Umbilical, CV7 – CV12

• HT – Substernal, CV12 – CV15

• LU – Right of Navel / Right Ab

• LV – Lower left of Navel / Left Ab

• KD – Subumbilical, CV7 - Pubis

Page 62: Diagnosis by Palpation

POINT PALPATION

Main point of point palpation is checking for tenderness

• Very tender on superficial pressure – Full condition on that channel or local stagnation

• Pressure relieves pain – Empty condition on that channel

• Pressure relieves but then causes discomfort – mixed Deficiency and Excess condition

All acupuncture points (and Ah Shi points) can be used diagnostically.

Page 63: Diagnosis by Palpation

POINT PALPATION

Main Points for Palpation Diagnosis

• Front Collecting (Mu) Points

• Back Transporting (Shu) Points

• Lower Sea Points

• Source (Yuan) Points

• Ah Shi Points

Page 64: Diagnosis by Palpation

FRONT MU POINTS

Mu – “raise, collect, enlist, recruit”

Points where the Qi of the relevant organs get collected

Page 65: Diagnosis by Palpation

BACK SHU POINTS

Points are all located on the Bladder channel

Reflect specifically the condition of the relevant internal organ instead of its channel

Page 66: Diagnosis by Palpation

BACK SHU POINTS

Page 67: Diagnosis by Palpation

LOWER SEA POINTS

Points are used to treat their respective Yang organs

Organ Point Channel Organ Point

L.Int. ST-37 Yang Ming Stomach ST-36

San Jiao UB-39 Shao Yang Gall-Bladder GB-34

S. Int. ST-39 Tai Yang U. Bladder UB-40

Page 68: Diagnosis by Palpation

YUAN POINTS

“If the 5 Yin organs are diseased, abnormal reactions will appear at the 12 Source points. If we know the

correspondence of Source points to the relevant Yin organ, we can diagnose when a Yin organ is diseased.”

Spiritual Axis, Ch. 1

Page 69: Diagnosis by Palpation

YUAN POINTS

Source Points for the Yin Organs

Yin Organ Source Point

Lungs LU-9 Taiyuan

Heart PE-7 Daling

Spleen SP-3 Taibai

Liver LIV-3 Taichong

Kidneys KI-3 Taixi

Page 70: Diagnosis by Palpation

AH SHI POINTS

Ah Shi Theory

• If there is soreness on pressure (whether on a channel or not), there is a point

• Body is completely covered by different channels so every area is irrigated by them

• Pressure and description of the condition will reflect the channel which it is closest to

Page 71: Diagnosis by Palpation

REFERENCE / CREDITS• Kaptchuk, Ted - “The Web that has no Weaver

• Maciocia, Giovanni – “Diagnosis in Chinese Medicine”

• Maciocia, Giovanni – “Foundations of Chinese Medicine”

• Xin Nong, Cheng – “Chinese Acupuncture and Moxibustion”

• Zheng, Li Shi - “Pulse Diagnosis”

• Flaws, Bob – “The Secret of Chinese Pulse Diagnosis”