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  1. 1. Physical Examination04/27/12 No./56 1
  2. 2. Introduction:-• The patient should be made as comfortable as possible during the examination. When possible, the examining table should be situated so that the examiner has access to both sides of the patient. When one side of the examining table is placed against wall, it is difficult for the physician to conduct satisfactory examination. An ideal arrangement is to have the table located in the center of the examining room.04/27/12 No./56 2
  3. 3. Introduction:-• The Patient should be properly draped and prepared for the examination. In most instances, it is advisable to have the patient completely undress and wear an examining gown. This is suitable for either sex and can be adjusted as necessary to expose those areas to be examined. It is to be emphasized that failure to expose the area to be examined will often result in inadequate findings that lead to an erroneous diagnosis.04/27/12 No./56 3
  4. 4. Inspection •Technique for inspecting the abdomen.04/27/12 No./56 4
  5. 5. INSPECTION:-• Inspection is a series of accurate and meaningful observations which are the first step in every physical examination of the patient.04/27/12 No./56 5
  6. 6. Inspection:-• To satisfactorily inspect the patient, the physician should be constantly alert to any unusual personality traits. For example, slow speech, dull, expressionless puffy face, sparse eyebrows, thick lips, and waxy pallor of the skin are indicative of thyroid insufficiency. We do not necessarily stress the significance of “ snap diagnosis”, but it is essential to appreciate the importance of alert observation in arriving at correct diagnosis.04/27/12 No./56 6
  7. 7. Inspection:-• Careful observation, cerebration or integration is inseparably interrelated, and careful observation should enhance our ability of analysis. It is a highly developed art that requires time and experience to perfect but can be acquired and developed by all who aspire to attain this goal.04/27/12 No./56 7
  8. 8. Palpation:-04/27/12 No./56 8
  9. 9. Palpation:-• Palpation is the act of feeling with the hand or hands. Palpation further defines things we see and reveal things we cannot see. It is used to confirm and amplify the findings observed on inspection. Therefore, inspection and palpation are inseparably interrelated.04/27/12 No./56 9
  10. 10. Techniques and methods of palpation• If there is reason to suspect pathology or pain in any area, palpate the area last. Using the pads of fingers with hand parallel to the area to be examined, first palpate slowly and gently. In each area, slowly increase the pressure of the examining hand until you are satisfied with the results.( light palpation)04/27/12 No./56 10
  11. 11. Technique and method of palpation• If additional depth is required, put your other hand on the palpating hand to add addition pressure. OR give more force. ( deep palpation)04/27/12 No./56 11
  12. 12. Palpation:- 潜触诊 潜触诊 深触诊 深触诊04/27/12 No./56 12
  13. 13. • On inspiration, the liver is palpable about 2~3 cm below the right costal margin in the mid-clavicular line.04/27/12 No./56 13
  14. 14. • The experienced examiner will distract the patient during the examination with the idle discussion, all the while watching the patient’s face for signs of discomfort during palpation. A helpful way of deep palpation is to have the patient respire slowly and deeply. For example, getting deep into the abdomen, with each expiration the abdomen falls in, and the position is maintained until the next expiration, when the hands are advanced even deeper. (deep slipping palpation) 04/27/12 No./56 14
  15. 15. • Bimanual palpation is useful to outline organs, vascular structures, or masses by getting on the opposite sides of the structure. This is accomplished either front to back through the flanks or by indenting both sides of the structure anteriorly. Palpating kidney involve deep palpation with one hand anteriorly while the other hand thrust forward from the flank. 04/27/12 No./56 15
  16. 16. 肝脏单手、肝脏双手、脾脏双手04/27/12 No./56 16
  17. 17. • The enlarged spleen below is palpable about 2 cm below the left costal margin on deep inspiration.04/27/12 No./56 17
  18. 18. Percussion04/27/12 No./56 18
  19. 19. Percussion• Percussion is a bit harder to define. Crudely, it is thumping with the hand or instrument on a part of the body to produce vibrations and note what happens to the sound waves.04/27/12 No./56 19
  20. 20. Methods of percussion• There are various ways to percuss. Two principal methods may be used for percussion of the thorax, abdomen, or other structures.04/27/12 No./56 20
  21. 21. Methods of percussion• Mediate percussion ( Indirect percussion) : This is the method in almost universal use today. The tip of the right middle finger ( plexor) strikes the tip of the left middle finger ( pleximeter) laid firmly against the skin, thus producing a sound.04/27/12 No./56 21
  22. 22. Method of percussion• Immediate percussion (direct Percussion) : The immediate technique can use only plexor, or, that is, a direct blow to the area to be examined with either the palmar aspect or the tips of the right middle three fingers held together. Occasionally the thumb may be used in this technique by holding the hand parallel to skin and quickly pronating the hand.04/27/12 No./56 22
  23. 23. 04/27/12 No./56 23
  24. 24. Analysis of percussion tones• When we tap on the chest, the lung, the heart and the thoracic wall are all set into motion and the waves pass from the vibrating chest through the air to the ear producing a characteristic sound. The sound waves produced by percussion are influenced more by the character of the immediate underlying structures than those more distant. Consequently the tone produced by percussion over the air-filled lung will be definitely different from the tone heard over a solid structure, such as the heart or liver. Careful attention to the character of the percussion sound will help to detect abnormalities as well as to locate normal structures.04/27/12 No./56 24
  25. 25. Percussion Sounds• The sounds produced by percussion are generally classified as follows :04/27/12 No./56 25
  26. 26. • Resonance : the sound heard normally over lungs, although not loud, is usually heard with ease, is well sustained, and is moderately low in pitch. In addition, it has a characteristic quality.• Hyperresonance : is of lower pitch than normal resonance. It is a well-sustained sound that has a deep “ booming” character. It is relatively intense and consequently is usually heard with ease.04/27/12 No./56 26
  27. 27. • Tympany : is a relatively musical sound in which the fundamental pitch can often be distinguished. ( somewhat similar to the sound of a drum). The sound, as a rule, tends to be higher than that of normal resonance, is only moderately well sustained in duration, and is moderate or loud in intensity. It results from air in an enclosed chamber (the stomach and bowel), and in general the greater the tension within the viscous, the higher the pitch. Tympany is the sound heard anteriorly and laterally over the abdomen except in the area of the liver.04/27/12 No./56 27
  28. 28. • Dullness : is essentially the opposite of resonance and hyperresonace in that a dull note is short, high pitched, and is not loud.• It should be emphasized that a dull percussion note is dull only as it compares with other percussion notes, not in terms of measurable scales of frequency and amplitude. Dullness will be found in pneumonia or occurs in the pleural space with moderate amount of fluid.04/27/12 No./56 28
  29. 29. Cautions of percussion• To obtain the maximum information from percussion :• The pleximeter finger must be pressed firmly on the skin, otherwise, a clear note is not obtained.• 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.04/27/12 No./56 29
  30. 30. Auscultation04/27/12 No./56 30
  31. 31. Auscultation• Auscultation, which is the act of listening to sounds produced within the body, may be accomplished in two ways, 1 with the unaided ear (immediate auscultation) or 2 with stethoscope (mediate auscultation).04/27/12 No./56 31
  32. 32. • The best examples are the murmur of mitral stenosis—a deep, low pitched rumble, which often heard better with the bell, and the relatively high pitched, soft murmur of aortic regurgitation, which is heard better with the diaphragm.04/27/12 No./56 32
  33. 33. Area’s of Auscultation 1)Aortic area 2)Pulmonic area 3) 4)Tricuspid area 5)Mitral area04/27/12 No./56 33
  34. 34. Cautions aspects of auscultation :• It is essential that the earpieces fit properly and comfortably so that the examiner can use the stethoscope for hrs at a time, if necessary without discomfort.• 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.04/27/12 No./56 34
  35. 35. 心脏听诊 肺 部 听 诊04/27/12 No./56 35