体格检查课件.ppt

Physicalexamination,Physicalexamination,ItistheprocessofexaminingthepatientsbodytodeterminethepresenceorabsenceofphysicalproblemsThegoalofthephysicalexaminationistoobtainvalidinformationconcerningthehealthofthepatientTheexaminermustbeabletoidentify,analyze,andsynthesizetheaccumulatedinformationintoacomprehensiveassessment,Thefourcardinalprinciplesofphysicalexamination,Inspection（望诊）Palpation（触诊）Percussion（叩诊）Auscultation（听诊）“teachtheeyetosee,thefingertofeel,andtheeartohear”Whatisthefifth?Smelling（嗅诊）,Equipmentforphysicalexamination,RequiredOptionalStethoscope(听诊器）Gloves（手套）Tongueblades（压舌板）Gauzepads（纱布垫）Penlight（电筒）Lubricantgel（润滑油）Tapemeasure（卷尺）Nasalspeculum（鼻反射镜）Sphygmomanometer（血压计）Turningfork:128Hz,512HzReflexhammer（叩诊锤）（旋转叉）Safetypins（大头针）Pocketvisualacuitycard（袖珍视觉检测卡）Oto-ophthalmoscope（检耳-检眼镜）,Importantaspectsofphysicalexamination-physician,Elegantappearance（仪表端庄）Decentmanner（举止得体）Kindattitude（态度和蔼）Highlyresponsibility（有高度责任性）Goodmedicalmorals（良好的医德）,Importantaspectsofphysicalexamination-physician,Washyourhands,preferablywhilethepatientiswatchingWashingwithsoapandwaterisaneffectivewaytoreducethetransmissionofdisease,Sequential(有顺序的),Conductedinheadtotoeorder:head-neck-chest-abdomen-spine-extremities-anal-genital-nervesystemPatientstirequicklywhenaskedto“situp”,“liedown”,“turnonyourleftside”,“situp”,“liedown”andsoon,Importantaspectsofphysicalexamination-patient,ThepatientshouldbemadeascomfortableaspossibleduringtheexaminationThepatientshouldbeproperlydraped,Importantaspectsofphysicalexamination,Whereisthebedplaced?Whenpossible,theexaminingtable/bedbesituatedsothattheexaminerhasaccesstobothsidesofthepatientAnidealarrangementistohavethetablelocatedinthecenteroftheexaminingroom,Importantaspectsofphysicalexamination,Wheredoestheexaminerstand?StandrightsideofthebedExamwithonerighthand,Importantaspectsofphysicalexamination,Howtoperformthephysicalexamination?SequentialProperexpose,Properexpose,ExposingonlytheareathatarebeingexaminedatthattimewithoutundueexposureoftheotherareasWhenexaminingawomensbreasts,itisnecessarytocheckforanyasymmetrybyinspectingbothbreastsatthesametimeAfterinspectionhasbeencompleted,thephysicianmayusethepatientsgowntocoverthebreastsnotbeingexaminedThiscaringforthepatientsprivacygoesalongwayinestablishingagooddoctor-patientrelationship,Importantaspectsofphysicalexamination,TheexaminershouldcontinuespeakingtothepatientShowingcaretohisdiseaseandanswertopatientsquestionsItcannotonlyreleasepatientsnervousness,butalsohelptoestablishthegoodphysician-patientrelationship,Precautiontotake,Theuseofglovesshouldprovideadequateprotectionwhenperformingthephysicalexaminationorwhenhandlingblood-soiledorbodyfluid-soiledsheetsorclothingGlovesshouldbewornwhenexamininganyindividualwithexudativelesionsorweepingdermatitis,Precautiontotake,HandsorothercontaminatedskinsurfacesshouldbewashedthoroughlyandimmediatelyitaccidentallysoiledwithbloodorotherbodyfluidsAllsharpitems,suchasneedle,mustbehandledwithextraordinarycaretopreventinjuriesApatientmaybeinisolationoronspecialprecautionsifhe/sheissufferingfromacontagiousdisease,Inspection,MethodofobservationusedduringphysicalexaminationFirststepinexaminingapatientorbodypartItincludesageneralsurveyofthepatientsmentalstatus(精神状况）posture（姿势）bodymovementgait(步态)breathodor(呼吸气味）skinspeechstature(身材)stateofnutrition(营养状况),Howtoinspect,MakesuretheroomisinacomfortabletemperatureUsegoodlighting,preferablysunlightLookandobservebeforetouchingCompletelyexposethebodypartyouareinspectingwhiledrapingtherestComparesymmetricalbodyparts,Mentalstatusandpersonalgrooming,Doesthepatientlookwellorsick?Ishecomfortableinbed?Doesheappearindistress?Ishealertorishegroggy(?Doeshelookacutelyorchronicallyill?poornutritionsunkeneyestemporalwastinglooseskinDoesthepatientappearclean?Isherhaircombed?Doesshebitehernails?,Mentalstatusandpersonalgrooming,Theanswertothesequestionsmayprovideusefulinformationaboutthepatientsself-esteem(自尊心）andmentalstatus（精神状况）,Posture,ItmayrevealsignificantinformationCongestiveheartfailure:sitinachairtheentirenightPatientswithbody/tailofthepancreaticcancer:assuminganuprightorsittingpostureThusthepositionsofthepatientatthetimeoftheexaminationmaysuggestcertaindiseasepossibilitiesAhistoryofassumingcertainpositionstoobtainrelieffrompainalsomaybeofdiagnosticimportance,Palpation,Methodsof“feelingthehandsusedduringphysicalexaminationsTheexaminertouchesandfeelsthepatientsbodypartwithhishandstoexaminesize（大小）consistency（密度）texture（质地）location（部位）tenderness（触痛）ofanorganorbodypartThepalpationofabdomenisparticularlyimportant,Howtoperformpalpation,Aswithinspection,theinitialstepinpalpationmaybefacilitatedbydistractingconversationorquestionsregardingthehistoryItshouldbeemphasizedthatduringthepreliminarystages,musclerelaxationisthegoalaskthepatienttoflexthethighs（大腿）andknees（膝关节）,Howtoperformpalpation,Thedegreeofmusclerigidity（硬度）orresistance（阻力）maybemadebylightpalpation（浅部触诊）Oneshoulddeterminewhethertheabdominalwallexhibitsvoluntary（自主性）muscletightening（肌紧张）oractualrigidity（僵硬）Musclespasm（肌肉痉挛）cannotberelaxedbyvoluntaryeffortVoluntarytensing(自主性紧张)ofthemuscleisbroughtaboutthroughfearornervousness,itcanbeovercomebypropertechniqueAlwaysbeginpalpationinanareaoftheabdomenthatisfarthestfromthelocationofpain,Typesofpalpation,Lightpalpation（浅部触诊）Deeppalpation（深部触诊）deepslippingpalpation（深部滑行触诊法）bimanualpalpation（双手触诊法）deeppresspalpation（深压触诊法）ballottement（冲击触诊法）,Lightpalpation,Usingtheflatpartoftherighthandorthepadsofthefingers,notthefingertips（指尖）ThefingersshouldbetogetherSuddenjabs（突然冲击）aretobeavoidedThehandshouldbeliftedfromoneareatoareainsteadofsliding（滑行）overtheabdominalwall,Lightpalpation,Thepalpatinghandshouldbewarm,becausecoldhandsmayproducevoluntarymuscularspasmcalled“guarding”（肌卫）Engagingthepatientinconversationoftenaidsinrelaxingthepatientsabdominalmusculature（腹部肌肉组织）Askpatienttobeinasupineposition（仰卧位）andtoflex（弯曲）thethighsandknees,Lightpalpation,Duringexpiration（呼气）,therectusmuscles（直肌）usuallyrelax（放松）andsoften（变柔软）Usedtofeelforpulses,tenderness,musclespasm,（肌痉挛）rigidity（硬度）,surfaceskintexture（质地）,temperature,moisture（湿度）ormass,itssize,location,hardnessandoutline（轮廓）,Lightpalpation,Rigidityisinvoluntaryspasm（非自主性痉挛）oftheabdominalmusclesandisindicative（预示）ofperitonealirritation（腹膜刺激）Rigiditymaybe:diffuse（弥漫性）(diffuseperitonitis)localized（局限性）(overaninflamedappendixorgallbladder)Inpatientswithgeneralizedperitonitis,theabdomenisdescribedas“board-like”（板样）,Lightpalpation,Deeppalpation,UsedtodetermineorgansizeaswellasthepresenceofabdominalmassesTheflatportionoftherighthandisplacedontheabdomenPressureshouldbeappliedtotheabdomengentlybutsteadilyThepatientshouldbeinstructedtobreathequietlythroughthemouthandtokeeparmsatthesides,Deeppalpation,Deepslippingpalpation,Theexamineruseshisforefinger,middlefingerandringfingerthataretightlytogether,slowlyandgraduallypalpatetheabdominalorgansormasses,slippingup-,down,rightsideandleftsideItisfrequentlyusedforexaminingthedeepmassofabdomenorGIlesions,Bimanualpalpation,Usestwohands,oneoneachsideofthebodypartbeingpalpatedPlacingthelefthandoverthepackoforganstobeexamined,inordertofixorelevatetheorgans.ItmaybehelpfulfortherighthandpalpationItisemployedduringtheprocessesofliver,spleen,kidneyorabdominalmassesexamination,Bimanualpalpation,Bimanualpalpation,Deeppresspalpation,Theexamineruseshisthumbor23fingerstogethertopalpatewithgraduallyincreasingpressure,inordertoidentifydeeporganlesionsorlocalizetheareaofabdominalpainSuchasthepainproducedbyinflamedgallbladderorappendicitisInapatientwithabdominalpain,thereboundtenderness（反跳痛）shouldbedetermined,Reboundtenderness,Itisasignofperitonealirritationandcanbeelicited（引出）bypalpatingdeeplyandslowlyinanareafromthesuspectedareaoflocalinflammationThepalpatinghandisthenquicklyremovedThesensationofpainonthesideofinflammationthatoccursonreleaseofpressureisreboundtenderness,Ballottement,Theexaminerplaces34fingerstogetheronthesurfaceofsuspectedabdominalareaandpushquicklyandshortlyforseveraltimeswiththemotionfromthewristThefingertipsmightfeeltheabdominalorgansarefloating,becauseitproduceasciticwavesEmployedinpalpatingtheenlargedliver,spleenormassesItmayalsoelicituncomfortableofthepatientItissuggesteddonotpushtoohard,Percussion,Amethodsof“tapping”ofbodypartsduringphysicalexaminationwithfingers,hands,orsmallinstrumentstoevaluatethesize,consistency,bordersandpresenceoffluidinbodyorgansPercussionofabodypartproducesasoundthatindicatesthetypeoftissuewithintheorganItisparticularlyimportantinexaminingthechestandabdomen,Percussion,Tappingonthechest/abdominalwallistransmittedtotheunderlyingtissue,reflectedback,andpickedupbytheexaminerstactile（触觉）andauditorysense（听觉感受）Thesoundheardandtactilesensationfeltaredependentontheair-tissueratio（气体-组织比率）Thevibrations（振动）initiatedbypercussionofthechestenabletheexaminertoevaluatethelungtissuetoadepthofonly56cm,butpercussionisvaluablebecausemanychangesintheair-tissueratioarereadily（容易）apparent,Percussion,Itisusedtodetectdiaphragmaticmovement（横隔膜运动）,thesizeofheart,edgeofliverandspleenandascitisetal.,MethodsofPercussion,Indirectpercussion（间接叩诊法）Directpercussion（直接叩诊法）,IndirectPercussion,Theexaminerplacesthemiddlefingerofonehand(lefthand)firmlyagainstthepatientssurfacewall(chestorabdomen),withpalmandotherfingersheldoff(离开)theskinsurfaceThetipoftherightmiddlefingerofthehandstrikesaquick,sharpblowtotheterminalphalanxoftheleftfingerontheskinsurfaceThemotionofthestrikingfinger（叩击手指的运动）shouldcomefromthewrist（手腕）andnotfromtheelbow（肘）Deliver23quicktapsandlistencarefully,IndirectPercussion,Lightpercussion（轻叩）Moderatepercussion（中度力量叩诊）Heavypercussion（重扣）,LightPercussion,LocalizedandsuperficiallesionsornormalorgansHeart/liverrelativedullnessborderline,ModeratePercussion,DeepandgeneralizedlesionsororgansHeart/liverabsolutedullnessborderline,HeavyPercussion,Deeplesions(7cminsideofthesurface),Percussion,Itshouldbeperformedfromupsidetodownsidesequential（从上向下顺序)Fromonesidetotheotherside（从一侧向另一侧）Comparison（比较）,QualityofPercussion,Accordingtotheidentityofthetissue,amountofairgascontaininganddistanceoftheorganfromtheskinsurface,thepercussionsoundinclude:resonance（清音）Tympany（鼓音）Hyperresonance（过清音）Dullness（浊音）Flatness（实音）,QualityofPercussion,Resonance:percussionoverastructurecontainingairwithinatissue,suchasthelung,producesaresonant,higher-amplitude（高振幅）,lower-pitchednoteTympany:percussionoverahollowair-containingstructure,suchasthestomach,producesatympanic,higher-pitched,hollowqualitynote,QualityofPercussion,Hyperresonance:thequalityofpercussionsoundisbetweentheresonanceandtympany.Suchasinchildren,pulmonaryemphysema（肺气肿）Dullness:percussionoverasolidorgan,suchastheliver,producesadull,low-amplitude,short-durationnotewithoutresonance.Itoccurswhentheaircontentoftheunderlyingtissueisdecreasedanditssolidityisincreased.,QualityofPercussion,Flatness:veryshort,andhighpitched(absolutedullness).Flat