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Physical Examination angina pectoris by mikesanye

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									 Physical
Examination
Department of Gastroenterology
         Qiao Wen
   Physical examination is the second
step in arriving at a diagnosis for
patients. It is the basic method by
which the doctor can get the healthy
information of patients.
   Generally physical examination
techniques include
    -- inspection
    -- palpation
    -- percussion
    -- auscultation
    -- smelling.
1. 以病人为中心,关心爱护病人;
2. 医师应站在病人的右侧;
3. 检查病人时光线应适当,室内应温暖,环境应安静;
4. 全身体格检查时应力求全面、系统,同时注意重点突
出;
5. 体格检查要按一定顺序进行,避免重复和遗漏,避免
反复翻动病人。顺序:生命征、一般检查、头、颈、胸、
腹、脊柱、四肢和神经系统,必要时进行生殖器、肛门和
直肠检查;
6. 应注意左、右及相邻部位等的对照检查;
7. 根据病情变化进行复查。
General Principles
Inspection

    Inspection is a diagnosis technique
to observe whole and local
manifestations of patient by vision. It
is the first step in every physical
examination.
                                 Inspection

   The patient should be examined in the
presence of good light conditions.

    Physicians must do a series of
accurate and meaningful observations to
patient. This can find the more important
clinical signs that are very critical to
diagnosis.
Palpation


Palpation is a diagnosis technique to
determine the characters of organs
by sense of touch. the act of feeling
with a hand and hands.
                                Palpation



   further define things we see and
several things we can not see.
   To confirm and amplify the findings
observed on inspection. Inspection and
palpation are inseparably interrelated.
                                         Palpation
Palpation methods
There are two type methods
   -- light palpation
   -- deep palpation

The deep palpation can be divided into four types:
  * deep slipping palpation
  * bimanual palpation
  * deep press palpation
  * ballottement.
                                   Palpation

Light palpation
   It is used in examination of hidden
focus of body surface, such as joint, soft
tissue, light artery, vein, nerve. The
palpation deep is 1~2 cm.
   Method: Using the pads of fingers,
gently press the area to be examined.
                                      Palpation

Deep palpation
It can be examined by one or two hands.
from the light to deep, gradually increase
pressure to the aim of deep palpation.

It is used to examine and evaluate abdominal
lesion and organ.

The palpated deep is 4~5cm.
Deep slipping palpation
Method: put the 2,3,4 fingers of right hand on
the abdominal wall, using the ends of finger
gradually palpate the organ or mass of
abdominal cavity, slipping palpate the up,
down, left and right of mass.

This palpation is mainly used to examine
abdominal deep mass and gastroenterology
lesion.
                                   Palpation

Bimanual palpation
    To put the left hand palmar on the
examined organ or back of mass, to make
the mass or organ between the two hands,
and nearer the body surface.
  It is used to examine the liver, spleen,
kidney, and abdominal mass.
Deep press palpation
By using one or two fingers gradually deep press the
examined focus of abdominal wall. This method is
used to detect the tenderness focus of deep lesion in
abdominal cavity or confirm the tenderness focus of
abdominal cavity.
When the rebound tenderness is examined, the finger
quickly rises on the basis of deep press, and notice
the expression of patient and ask the patient if the
pain aggravates.
                                        Palpation

Ballottement
To make the index finger, middle finger, ring
finger of right hand to 70~900C , put on the
abdominal wall, make quickly and pithiness
concussion for several times.

When the patient with a large amount of ascites,
the liver, spleen, and mass is difficult to be
palpated.
Ballottement
触诊注意事项
1.检查前讲明检查目的;
2.医师动作要轻;
3.病人应采取适当体位;
4.触诊下腹部应排尿;
5.触诊应手脑并用。
Percussion

  Taping with a hand or instrument on
a part of the body to produce vibrations
and note what happens to the sound
waves.
                               Percussion

Percussion methods
There are two methods of percussion.
    -- mediate percussion(indirect
      percussion)
    -- immediate percussion(direct
      percussion)
                                 Percussion

Indirect percussion
   The tip of the right middle finger
(plexor) strikes the second knuckle of the
left middle finger laid firmly against the
skin, thus producing a sound.
                                Percussion


Direct percussion
The palmar of middle three fingers
held firmly together directly percuss the
examined focus.
叩诊注意事项
1.环境安静
2.根据叩诊部位不同,采用适当体位
3.注意对称部位的比较和鉴别
4.注意叩诊音的变化
5.叩诊用力要适当。
*病灶或检查部位范围小或位置浅,轻叩诊;
*病灶或检查部位范围大或位置深,中度叩诊;
*病灶位置距体表约达7cm,深叩诊。
                              Percussion

Classification of percussion sounds
 Resonance
    — the sound heard normally over
 lungs. The normal resonant note can
 only be learned from percussion of
 many normal chests.
                              Percussion sounds


Hyperresonance
   — lower pitch than normal resonance and
a deep “ booming" character.
  In the adult, it is the result of emphysema.
  In normal children, the related hyperresonance
  may occur.
                            Percussion sounds

Tympany
  — is somewhat similar to the sounds of a
 drum.

 Normal, tympanitic area over gastric bubble;
 Pathology, pulmonary cavitation,
 pneumatothorax, sign of pneumoperitoneum.
                            Percussion sounds

Dullness
    — is the opposite of resonance and
hyperresonance in character.
    Dullness will be found in pneumonia or
occurs in the pleural space with moderate
amount of fluid (pleural effusion).
                               Percussion sounds


Flatness
    — is the percussion note when resonance
is absent. The sound and the feeling are very
similar to striking a barrel or other container
filled with water.
, a large amount of pleural effusion
                           Percussion sounds



    Flatness will be present when there is a
very large fluid such as an extensive pleural
effusion or lung consolidation
    Normally, it is heard over a solid such
as the liver and the heart.
                                      Percussion

Cautions of percussion
•     The pleximeter finger must be pressed
    firmly on the skin otherwise a clear note
    is not obtained.

•    The plexor finger should strike the
    pleximeter finger instantly and must be
    immediately taken back.
                           Cautions of percussion


•    The examiner must compare one side of
    the percussed with the opposite side as
    he proceeds with percussion.

•    As the examiner listens to the sound
    elicited by percussion a careful analysis
    should be made.
  Auscultation
   The  act of listening to sounds produced
within the body.
   There are two ways of auscultation
     ---indirect auscultation
     ---direct auscultation
                                 Auscultation

Methods of auscultation

    Indirect auscultation is acted with
    stethoscope.

   Direct auscultation is acted with
    naked ear.
                                 Auscultation


What is a stethoscope?
    The stethoscope is an instrument to aid
in auscultation.
    It consists of a bell or diaphragm
connecting with rubber tube to earpieces
for the clear transmission of sound from
the patient to the ear of the examiner.
                                   Auscultation

Cautions of auscultation
    The stethoscope should be placed firmly
against the skin to exclude as much extraneous
sound as possible, as well as to eliminate any
sounds that may result from slight contact with
the skin during respirations.
                            Auscultation


    Care must be taken to avoid
movement of the stethoscope on the
skin, since skin movement will produce
confusing noise.
                                   Auscultation


    The patient should be instructed to breathe
a little deep than usual with his mouth open.
    Breathing through the open mouth
minimizes the sound produced in the nose and
throat.
                               Auscultation



  Corresponding areas of each side are
auscultated as the examiner goes from
top to bottom.
 Smelling(odors)
   Smell is occasionally useful in physical
diagnosis. Such as:
   Fetor hepaticus indicates liver disease.
   Ammonial urine might indicate infection
of the urinary tract.
   Halitosis indicates poor oral and dental
disease.
           Summary

   Each area examined as a rule
includes inspection, palpation,
percussion, auscultation, and smell.
   Subsequent chapters will elaborate
the methods.
General Examination
   General examination is the first step in the whole
physical examination.
    The contents of general examination:
    -- sex, age
    -- vital signs
    -- development and habits
    -- state of nutrition
    -- consciousness
    -- facial and expression
    -- position and posture, gait
    -- skin
    -- distribution of lymph nodes
      Part I

General inspection
 and vital signs
    Sex

     Sex is not difficult to determine.
     Secondary sex traits are related to the
effects of androgens(male and female) and
estrogens(female).
     Lack of sufficient and effective
stimulation by the hormones will result in
unhealthy structures.
  Age

   Development of physique varies with age.
Age is closely related to the occurrence and
prognosis of the sickness.
    Malignant diseases often occur in the
adult, especially in the elder patients.
   Congential diseases are usually diagnosed
in the childhood.
  Vital signs

  Temperature
   It should be recorded as part of physical
examination.
   Normal body temperature is kept within
a narrow range(36 ℃ ~37 ℃ of axillary
temperature).
   Fever means the elevation of body
temperature that is due to disease.
                                  Vital signs
 Pulse

   There is much to be learned through
careful assessment of the pulse.
   The pulse is best counted for a full
minute.
   When counting the pulse, note the rate
rhythm, volume, and contour.

   Normal person is 60~100 times/minute
                                  Vital signs
Respiration

  The respiratory rate is the number of
inspiration perminute.
   It should be counted for a full minute to
reduce the error (aberration).
   The normal adult respiratory rate is 14-
18/minute.

Blood pressure
正常成人的血压参考值
(1999年2月《WHO / ISH高血压治疗指南》)
理想血压:收缩压<120mmHg, 舒张压<80mmHg;
正常血压:收缩压<130mmHg, 舒张压<85mmHg;
正常血压高值:收缩压130~139mmHg,
         舒张压85~89mmHg;
高血压:收缩压>140mmHg, 舒张压>90mmHg;
低血压:血压<90/60mmHg
脉压:30-40mmHg
Development and habitus

   Whether development is normal or not
completely depends on the interrelation of
age, intellect and physique (including
height, weight, and secondary sex traits).
                        Development and habitus


  The normal development indexes are
   a. The height of head equals to 1/7~1/8 of
the body height;

  b. Chest circumference equals to 1/2 of
body height;
                        Development and habitus


    c. when the two upper limbs outstretch,
distance of the left finger tip to right finger
tip equals to body height;

   d. Sitting height is equal to the length of
lower limb.
                      Development and habitus
  The influencing factors of development
  The determinants influencing development
known factors include :
  -- genetic factor (hormone)
  -- connective tissue
  -- living condition
  -- nutrition
  -- physical exercise
                             Developement



  Chromosomal errors produce
abnormal body characteristics.
    Most of these involve the sex
chromosomes.
                             Developement



  Nutrition profoundly affects growth
 and development.
   Cachexia, severe malnutrition in
childhood, and obesity are examples.
                             Developement



   Connective tissue (bone, fat, muscle,
cartilage, collagen, elastin, skin).
   Any factors influencing connective
tissue may yield disordered growth and
development.
   Body habitus

    Clinically adult habitus can be divided
into three types according to distributive
symmetry of paired structures including
skeletons, muscles, and fats.
                                       Habitus
   Asthenic type (slender): tall height, long
neck, thin muscle, narrow and falling
shoulders, flat thoracic contour.

     Orthosthenic type: Normal adult habitus
is the best example. All parts of structures are
symmetric.
                                       Habitus


    Sthenic type: Compared with asthenic
type, sthenic type shows converse
expression (short height, short neck, thick
muscle, full thoracic contour).
    Disordered growth and development
is mostly related to endocrine.
异常体型
1. 矮小体型:成年男性身高<145cm, 女性
<135cm。
2.高大体型:
(1)体质性高身材(Constitution tall structure)
    身高体重明显高于常人。
(2)青春期提前 女孩7岁以前,男孩10岁以
前开始发育者。
(3)疾病所致的高大体型
State of nutrition

     The state of a patient' s nutrition is easy to
determine, usually is synthetical analyzed by
the development of skin, hair, subcutaneous
fat, and muscles.
     The simplest and rapidest approach is to
watch the fullness of the subcutaneous fat.
常用营养状态的测量指标
1.身高和体重
理想体重(ideal body weight)(kg)=身高(cm)-105
或=[身高(cm)-100]x0.95(女性0.90)
正常:理想体重±10%
超重: >正常的10%~20%
肥胖: >正常的20%
消瘦:< 正常的10%~20%
明显消瘦:< 正常的20%
恶液质:极度消瘦
2. 体重指数(body mass index, BMI)
用于衡量体重是否正常,以除外身高的影响。
BMI=体重(kg)/身高(m)2
我国的BMI正常范围:18.5~24
消瘦:<18.5
肥胖: >25
学龄前儿童:正常15~22
           消瘦<15
           营养不良<13
           肥胖>22
3.上臂周径
1~5岁
营养状况正常 >13.5cm
中度营养不良 12.5~13.5cm
重度营养不良 <12.5cm


4. 皮褶厚度
                                  State of nutrition

   Clinically the state of nutrition usually is
divided into three types — well, fairly, and
poorly.
   Well: The mucosa is the rosy, skin is
brightness and with good elasticity,
subcutaneous fat is fullness and elasticity,
muscles are burliness, nail and the hair is
lustrous, the muscles of shoulder and femur
are fullness.
                              State of nutrition


  Poorly: Skin and mucosa is dry and with
poor elasticity, subcutaneous fat is thin,
muscles are laxation and weakness, nail is
rough and no brightness, hair is rare.
  Fairly: The manifestation is between
well and poorly.
                                State of nutrition



   Pathologically, a patient’s state of
nutrition is evaluated in terms of being
overweight and underweight.
                            State of nutrition
 Overweight (Obesity): The weight is
more than 20% of the standard weight,
BMI >25, child >22 is defined as obesity.
 The obesity can be divided into two types
   -- simple obesity(excessive caloric
     intake)
   -- secondary obesity (some endocrine
     diseases).
                                State of nutrition

    Underweight: When the weight is
lower than 10% of the normal weight is
defined as emaciation. BMI <18.5,child <13,
Extremely severe underweight is name as
cachexia.
    People may lose weight as the result of
decreased caloric intake or because of
various wasting diseases, such as malignant,
tuberculosis.
  State of consciousness

   Disturbance of consciousness can be
divided into the following according to the
degree of consciousness loss.
   Somnolence the mildest disturbance of
consciousness. The pathologic sleep can
be waken by calling.
                         State of consciousness

   Confusion often indicates a disturbance
of orientation to time, spot, and people.
   Stupor State of sleep soundly which
can’t be waken easily.
   Coma the most severe disturbance of
consciousness. Coma is rarely responsible
to foreign stimuli or reaction almost
completely.
昏迷分类:
浅昏迷:运动丧失,周围事物、声、光无反应,
疼痛刺激有反应,但不能唤醒。浅反射尚存在,
眼球能转动。
中度昏迷:防御反射、角膜反射减弱,瞳孔光反
射迟钝,眼球无转动。
深昏迷:
Delirium
It is a acute brain dysfunction, the manifestation is
excitability elevates.
Facial feature and expression

Acute facial feature: Redness, excitement,
and conflicted expression.
    It is often seen in the acute infection
diseases.
                                   Facial feature



  Chronic facial feature: It is thin and pallid.
  the color of face is dark and gloomy.
    It is seen in such conditions as malignancy,
liver cirrhosis, severe tuberculosis.
                                  Facial feature


   Nephrotic facial feature: is characteristic
of a pale face and an edema in the eyelids.

  Hepatic facial feature: Chronic facies
with spider angioma and pigmentation.
                                  Facial feature


   Hyperthyroidism facial feature:
   widened palpebral fissures, being startled
expression, alter, and flushed facial feature
and the apparent white sclera around the
cornea.
Hyperthyroidism face
                                 Facial feature

  Myxedema face: Coarse feature, dull
expression, periodicit edema, puffy face
blepharoptosis, sparse eyebrows and hair.

  Mitral face: is seen in the condition of
mitral stenosis of rheumatic heart disease.
Myxedema face
                                  Facial feature


  Acromegaly face: prominent nose and
jaw, enlarged skull, macroglossia and spade
like hands and feet.

  Typhoid face: expressionless apperance.
                                  Facial feature


   Moon face: redish skin accompanying
with acne fullmoon, buffalo shoulder. The
trunk and face are obese with limb wasting.
  The result of adrenal cortical hyperfunction
presents with characteristic abnormalities of
fat distribution.
Mitral face   Acromegaly face   Moon face
  Position

  The position shows a state of a patient’s
body.
  The position of the patient at the time of
the examination may suggest certain disease
possibilities.
                                    Position

  Active position: Body movements are not
limited.

  Passive position: Patients cannot modify
the position of their own requiring some
help from others.
                                        Position
  Compulsive position: Patients have to take
position to obtain relief from pain or dyspnea.

    The position of orthopnea is the best
example. Patients with congestive heart failure
often sit in a chair at the entire night in order
to reduce blood flow which is pumped into the
heart and reduce dyspnea.
                                  Position



Forced stand position: occurs in the
course of a patient’s walking on
account of an attack of his angina
pectoris.
 Gait

    The manner in which a patient walks is
often of diagnostic value. There are a number
of abnormal gaits, many of which are either
typical or suggestive of certain diseases.
                                      Gait

Festinating gait: is seen in parkinsonsim.
     The patient walks with his body held
rigid and with his trunk and head bent
toward.
     He takes short steps and his arms don’t
swing as he walks.
                                      Gait




  Ataxic gait: Diseases of cerebellum
are often accompanied by an ataxic gait,
resembling alcoholic intoxication, in which
the patient staggers or waddle.
Part II

Skin
   Although examination of the skin is quite
simple, it is performed inadequately.
   Inspection is the most important part of
the examination of the skin.
 Color

  Pallor: The hemoglobin of the blood
decreases, as in anemia or shock.

  Redness: Amounts of oxygenated blood in
the dermal vessels increase, such as might
occur with fever or sunburn.
                                        Color

  Cyanosis: Deoxygenated blood hemoglobin
increases, can be seen in such condition as
congestive heart failure, pneumonia,
congenital heart disease with right-to-left
shunts.

  Jaundice: Bilirubin in the skin and sclera
increases.
 Moisture

   If the skin is warm and wet, the sweating is
 probably acting.
   Sweating results from autonomic discharge
arising from stimulation of either the central
nervous system or the peripheral nervous
system.
  The cool wet hands indicate vasoconstriction.
                                     Moisture
   Anxiety may stimulate autonomic nervous
system resulting in cool warming and wetting .
   Profuse sweating is indicative of
reumatic diseases, tuberculosis, hyper-
thyroidism, rickets.
   Sweating at night is the character of
tuberculosis.
 Skin Eruption

  Skin eruption is often of a significant
evidence in diagnosis of certain diseases.
  Maculae: a flat, limited skin lesion with
redness (less than 1cm in diameter).

  Papulae: a solid elevation with redness of
the skin lesion ( less than 1cm in diameter).
                               Skin Eruption



 Maculopapulae: may be either macular
or papular but larger than 1cm in diameter.

  Urticaria: it is common clinical finding
caused by fast allergic reaction in the skin.
 Subcutaneous hemorrhage

   A common sign of bleeding in the skin
or beneath the membrane.
   Petechia: A bleeding sign is less than
2mm in diameter.
   Purpura: The bleeding sign is more
than 3mm but less than 5mm in diameter.
                   Subcutaneous hemorrhage



  Ecchymosis: It is more than 5mm in
diameter.

  Hematoma: A patch of bleeding with
pronounced protrude of the skin.
  Spider angioma and hepatic palmar

  Spider angioma: They are highly branched
stellate arterial lesions which blanch as well
as disappear on pressure.
  Hepatic palmar: It indicates the redness
with muscular atrophy of the thenar and
hypothenar.
Spider angioma
   Edema

    Edema is because of the accumulation
of fluid in subcutaneous tissue.
    There are three types of causes—
        Hydrostatic pressure elevated;
       Capillary permeability elevated;
       Decreased oncolic pressure.
                                   Edema



  Pitting edema: The tissue in edema
pits when pressed with finger.

   Nonpitting edema: The tissue doesn’t
pit when pressed with finger.
    Part III

Lymphatic nodes
    Normally lymphatic nodes are small,
nonfixed, soft lymph nodes which can be
found in the triangles of the neck and in
almost every adult groin. The axillaes
also frequently hide small palpable
nodes.
        浅表淋巴结检查
分组            引流(收集)范围


耳后、乳突区        头皮
胸锁乳突肌上部(颈后)   鼻咽部
胸锁乳突肌上部(颈前)   咽喉、气管、甲状腺左
左锁骨上窝         食管、胃
右锁骨上窝         气管、胸膜、肺
颌下            口底、颊膜炎、牙龈
颏下            颏下三角区、唇、舌部
腋窝            躯干上部。乳腺、胸壁
腹股沟           下肢、会阴
 What is the sequence of examination of
lymph nodes?

  For the sake of not being omitted, lymph
nodes must be detected in terms of definite
order, meanwhile paying attention to the rule
from left to right and top to bottom.
   The sequence is such the following as:
      preauricular mastoid
      postauricular mastoid
      suboccipital
      posterior cervical triangle
      anterior cervical triangle
      supraclavicular fossa
      axillary fossa
      groins
耳前   耳后




颌下   锁骨上
腹股沟   颈前




颏下    滑车上
     枕骨下




腋窝



腋窝
    How to palpate lymph nodes ?
    The palmar of the finger tips are primarily
used.
• A gentle, slow to and fro rotary motion
is especially helpful in detecting and
evaluating the character of every palpable
lymph nodes. Because deep, firm palpation
may force nodes into surrounding structure so
that they cannot be detected.
•   Palpation of the lymph nodes of neck
is done with the examiner standing behind
the patient to be examined.
   First, with the patient’s neck relaxed,
the occiput, anterior or posterior triangle
are palpated for lymph nodes.

  Then with the head titled slightly toward
the side being examined, the lateral neck is
palpated.
•   Palpating the supraclavicular fossa.
Let the patient sit in the chair and palpate
lymph nodes with both hands simultaneously.
    Left side is done with right hand and
right side is palpated with left hand.
    The axillae may be considered as a
pyramid consisting of
      an apex
      four walls ( anterior, posterior, lateral,
and medial)
    It is essential to palpate all dimensions
of this pyramid.
   The axilla should be examined with the
arm first partially adducted and then
abducted to palpate enlarged lymph nodes.
   How to note and record the enlarged
lymph nodes?
   If there is significant enlargement of the
lymph nodes, the examiner should be them
and describe them to be
    Exact location
    Size
    Presence or absence of tenderness
    Consistency
 Presence of absence of visible or
palpable surrounding inflammation
 Moveable, adherent to the deep
structure, or matted together
  Significance of enlarged lymph nodes
    A careful description of lymph nodes
will often give valuable clues to the diagnosis

    Enlargement of a single lymph node in
the left supraclavicular group is a sign of
cancerous metastasis from a origin lesion in
the upper abdomen.
   Enlargement of the right supraclavicular
lymph node may indicate neoplasm arising
in the lungs.

   Acute localized inflammation of the
mouth and throat produces enlargement of
the lymph nodes in the anterior cervical
triangle.

								
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