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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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