体格检查PPT课件

1、-,1,Physicalexamination,-,2,Physicalexamination,ItistheprocessofexaminingthepatientsbodytodeterminethepresenceorabsenceofphysicalproblemsThegoalofthephysicalexaminationistoobtainvalidinformationconcerningthehealthofthepatientTheexaminermustbeabletoidentify,analyze,andsynthesizetheaccumulatedinformat

2、ionintoacomprehensiveassessment,-,3,Thefourcardinalprinciplesofphysicalexamination,Inspection（望诊）Palpation（触诊）Percussion（叩诊）Auscultation（听诊）“teachtheeyetosee,thefingertofeel,andtheeartohear”Whatisthefifth?Smelling（嗅诊）,-,4,Equipmentforphysicalexamination,RequiredOptionalStethoscope(听诊器）Gloves（手套）Tong

3、ueblades（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）,-,5,Importantaspectsofphysicalexamination-physician,Elegantappearance（仪

4、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）,-,6,Importantaspectsofphysicalexamination-physician,Washyourhands,preferablywhilethepatientiswatchingWashingwithsoapandwaterisaneffectivewaytoreducethetransmissionofdisease,-,7,Sequential(有顺序的),Conductedinhe

5、adtotoeorder:head-neck-chest-abdomen-spine-extremities-anal-genital-nervesystemPatientstirequicklywhenaskedto“situp”,“liedown”,“turnonyourleftside”,“situp”,“liedown”andsoon,-,8,Importantaspectsofphysicalexamination-patient,ThepatientshouldbemadeascomfortableaspossibleduringtheexaminationThepatientsh

6、ouldbeproperlydraped,-,9,Importantaspectsofphysicalexamination,Whereisthebedplaced?Whenpossible,theexaminingtable/bedbesituatedsothattheexaminerhasaccesstobothsidesofthepatientAnidealarrangementistohavethetablelocatedinthecenteroftheexaminingroom,-,10,Importantaspectsofphysicalexamination,Wheredoest

7、heexaminerstand?StandrightsideofthebedExamwithonerighthand,-,11,Importantaspectsofphysicalexamination,Howtoperformthephysicalexamination?SequentialProperexpose,-,12,Properexpose,ExposingonlytheareathatarebeingexaminedatthattimewithoutundueexposureoftheotherareasWhenexaminingawomensbreasts,itisnecess

8、arytocheckforanyasymmetrybyinspectingbothbreastsatthesametimeAfterinspectionhasbeencompleted,thephysicianmayusethepatientsgowntocoverthebreastsnotbeingexaminedThiscaringforthepatientsprivacygoesalongwayinestablishingagooddoctor-patientrelationship,-,13,Importantaspectsofphysicalexamination,Theexamin

9、ershouldcontinuespeakingtothepatientShowingcaretohisdiseaseandanswertopatientsquestionsItcannotonlyreleasepatientsnervousness,butalsohelptoestablishthegoodphysician-patientrelationship,-,14,Precautiontotake,Theuseofglovesshouldprovideadequateprotectionwhenperformingthephysicalexaminationorwhenhandli

10、ngblood-soiledorbodyfluid-soiledsheetsorclothingGlovesshouldbewornwhenexamininganyindividualwithexudativelesionsorweepingdermatitis,-,15,Precautiontotake,HandsorothercontaminatedskinsurfacesshouldbewashedthoroughlyandimmediatelyitaccidentallysoiledwithbloodorotherbodyfluidsAllsharpitems,suchasneedle

11、,mustbehandledwithextraordinarycaretopreventinjuriesApatientmaybeinisolationoronspecialprecautionsifhe/sheissufferingfromacontagiousdisease,-,16,Inspection,MethodofobservationusedduringphysicalexaminationFirststepinexaminingapatientorbodypartItincludesageneralsurveyofthepatientsmentalstatus(精神状况）pos

12、ture（姿势）bodymovementgait(步态)breathodor(呼吸气味）skinspeechstature(身材)stateofnutrition(营养状况),-,17,Howtoinspect,MakesuretheroomisinacomfortabletemperatureUsegoodlighting,preferablysunlightLookandobservebeforetouchingCompletelyexposethebodypartyouareinspectingwhiledrapingtherestComparesymmetricalbodyparts,

13、-,18,Mentalstatusandpersonalgrooming,Doesthepatientlookwellorsick?Ishecomfortableinbed?Doesheappearindistress?Ishealertorishegroggy(?Doeshelookacutelyorchronicallyill?poornutritionsunkeneyestemporalwastinglooseskinDoesthepatientappearclean?Isherhaircombed?Doesshebitehernails?,-,19,Mentalstatusandper

14、sonalgrooming,Theanswertothesequestionsmayprovideusefulinformationaboutthepatientsself-esteem(自尊心）andmentalstatus（精神状况）,-,20,Posture,ItmayrevealsignificantinformationCongestiveheartfailure:sitinachairtheentirenightPatientswithbody/tailofthepancreaticcancer:assuminganuprightorsittingpostureThusthepos

15、itionsofthepatientatthetimeoftheexaminationmaysuggestcertaindiseasepossibilitiesAhistoryofassumingcertainpositionstoobtainrelieffrompainalsomaybeofdiagnosticimportance,-,21,Palpation,Methodsof“feelingthehandsusedduringphysicalexaminationsTheexaminertouchesandfeelsthepatientsbodypartwithhishandstoexa

16、minesize（大小）consistency（密度）texture（质地）location（部位）tenderness（触痛）ofanorganorbodypartThepalpationofabdomenisparticularlyimportant,-,22,Howtoperformpalpation,Aswithinspection,theinitialstepinpalpationmaybefacilitatedbydistractingconversationorquestionsregardingthehistoryItshouldbeemphasizedthatduringth

17、epreliminarystages,musclerelaxationisthegoalaskthepatienttoflexthethighs（大腿）andknees（膝关节）,-,23,Howtoperformpalpation,Thedegreeofmusclerigidity（硬度）orresistance（阻力）maybemadebylightpalpation（浅部触诊）Oneshoulddeterminewhethertheabdominalwallexhibitsvoluntary（自主性）muscletightening（肌紧张）oractualrigidity（僵硬）Mus

18、clespasm（肌肉痉挛）cannotberelaxedbyvoluntaryeffortVoluntarytensing(自主性紧张)ofthemuscleisbroughtaboutthroughfearornervousness,itcanbeovercomebypropertechniqueAlwaysbeginpalpationinanareaoftheabdomenthatisfarthestfromthelocationofpain,-,24,Typesofpalpation,Lightpalpation（浅部触诊）Deeppalpation（深部触诊）deepslipping

19、palpation（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）,-,25,Lightpalpation,Usingtheflatpartoftherighthandorthepadsofthefingers,notthefingertips（指尖）ThefingersshouldbetogetherSuddenjabs（突然冲击）aretobeavoidedThehandshouldbeliftedfromoneareatoareainsteadofsliding（滑行）overthe

20、abdominalwall,-,26,Lightpalpation,Thepalpatinghandshouldbewarm,becausecoldhandsmayproducevoluntarymuscularspasmcalled“guarding”（肌卫）Engagingthepatientinconversationoftenaidsinrelaxingthepatientsabdominalmusculature（腹部肌肉组织）Askpatienttobeinasupineposition（仰卧位）andtoflex（弯曲）thethighsandknees,-,27,Lightpa

21、lpation,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）,-,28,Lightpalpation,Rigidityisinvoluntaryspasm（非自主性痉挛）oftheabdomin

22、almusclesandisindicative（预示）ofperitonealirritation（腹膜刺激）Rigiditymaybe:diffuse（弥漫性）(diffuseperitonitis)localized（局限性）(overaninflamedappendixorgallbladder)Inpatientswithgeneralizedperitonitis,theabdomenisdescribedas“board-like”（板样）,-,29,Lightpalpation,-,30,Deeppalpation,Usedtodetermineorgansizeaswella

23、sthepresenceofabdominalmassesTheflatportionoftherighthandisplacedontheabdomenPressureshouldbeappliedtotheabdomengentlybutsteadilyThepatientshouldbeinstructedtobreathequietlythroughthemouthandtokeeparmsatthesides,-,31,Deeppalpation,-,32,Deepslippingpalpation,Theexamineruseshisforefinger,middlefingera

24、ndringfingerthataretightlytogether,slowlyandgraduallypalpatetheabdominalorgansormasses,slippingup-,down,rightsideandleftsideItisfrequentlyusedforexaminingthedeepmassofabdomenorGIlesions,-,33,Bimanualpalpation,Usestwohands,oneoneachsideofthebodypartbeingpalpatedPlacingthelefthandoverthepackoforgansto

25、beexamined,inordertofixorelevatetheorgans.ItmaybehelpfulfortherighthandpalpationItisemployedduringtheprocessesofliver,spleen,kidneyorabdominalmassesexamination,-,34,Bimanualpalpation,-,35,-,36,Bimanualpalpation,-,37,Deeppresspalpation,Theexamineruseshisthumbor23fingerstogethertopalpatewithgraduallyi

26、ncreasingpressure,inordertoidentifydeeporganlesionsorlocalizetheareaofabdominalpainSuchasthepainproducedbyinflamedgallbladderorappendicitisInapatientwithabdominalpain,thereboundtenderness（反跳痛）shouldbedetermined,-,38,Reboundtenderness,Itisasignofperitonealirritationandcanbeelicited（引出）bypalpatingdeep

27、lyandslowlyinanareafromthesuspectedareaoflocalinflammationThepalpatinghandisthenquicklyremovedThesensationofpainonthesideofinflammationthatoccursonreleaseofpressureisreboundtenderness,-,39,Ballottement,Theexaminerplaces34fingerstogetheronthesurfaceofsuspectedabdominalareaandpushquicklyandshortlyfors

28、everaltimeswiththemotionfromthewristThefingertipsmightfeeltheabdominalorgansarefloating,becauseitproduceasciticwavesEmployedinpalpatingtheenlargedliver,spleenormassesItmayalsoelicituncomfortableofthepatientItissuggesteddonotpushtoohard,-,40,Percussion,Amethodsof“tapping”ofbodypartsduringphysicalexam

29、inationwithfingers,hands,orsmallinstrumentstoevaluatethesize,consistency,bordersandpresenceoffluidinbodyorgansPercussionofabodypartproducesasoundthatindicatesthetypeoftissuewithintheorganItisparticularlyimportantinexaminingthechestandabdomen,-,41,Percussion,Tappingonthechest/abdominalwallistransmitt

30、edtotheunderlyingtissue,reflectedback,andpickedupbytheexaminerstactile（触觉）andauditorysense（听觉感受）Thesoundheardandtactilesensationfeltaredependentontheair-tissueratio（气体-组织比率）Thevibrations（振动）initiatedbypercussionofthechestenabletheexaminertoevaluatethelungtissuetoadepthofonly56cm,butpercussionisvalua

31、blebecausemanychangesintheair-tissueratioarereadily（容易）apparent,-,42,Percussion,Itisusedtodetectdiaphragmaticmovement（横隔膜运动）,thesizeofheart,edgeofliverandspleenandascitisetal.,-,43,MethodsofPercussion,Indirectpercussion（间接叩诊法）Directpercussion（直接叩诊法）,-,44,IndirectPercussion,Theexaminerplacesthemiddle

32、fingerofonehand(lefthand)firmlyagainstthepatientssurfacewall(chestorabdomen),withpalmandotherfingersheldoff(离开)theskinsurfaceThetipoftherightmiddlefingerofthehandstrikesaquick,sharpblowtotheterminalphalanxoftheleftfingerontheskinsurfaceThemotionofthestrikingfinger（叩击手指的运动）shouldcomefromthewrist（手腕）a

33、ndnotfromtheelbow（肘）Deliver23quicktapsandlistencarefully,-,45,IndirectPercussion,Lightpercussion（轻叩）Moderatepercussion（中度力量叩诊）Heavypercussion（重扣）,-,46,LightPercussion,LocalizedandsuperficiallesionsornormalorgansHeart/liverrelativedullnessborderline,-,47,ModeratePercussion,Deepandgeneralizedlesionsor

34、organsHeart/liverabsolutedullnessborderline,-,48,HeavyPercussion,Deeplesions(7cminsideofthesurface),-,49,Percussion,Itshouldbeperformedfromupsidetodownsidesequential（从上向下顺序)Fromonesidetotheotherside（从一侧向另一侧）Comparison（比较）,-,50,QualityofPercussion,Accordingtotheidentityofthetissue,amountofairgasconta

35、ininganddistanceoftheorganfromtheskinsurface,thepercussionsoundinclude:resonance（清音）Tympany（鼓音）Hyperresonance（过清音）Dullness（浊音）Flatness（实音）,-,51,QualityofPercussion,Resonance:percussionoverastructurecontainingairwithinatissue,suchasthelung,producesaresonant,higher-amplitude（高振幅）,lower-pitchednoteTymp

36、any:percussionoverahollowair-containingstructure,suchasthestomach,producesatympanic,higher-pitched,hollowqualitynote,-,52,QualityofPercussion,Hyperresonance:thequalityofpercussionsoundisbetweentheresonanceandtympany.Suchasinchildren,pulmonaryemphysema（肺气肿）Dullness:percussionoverasolidorgan,suchastheliver,producesadull,low-amplitude,short-durationnotewithoutresonance.Itoccurswhentheaircontentoftheunderlyingtissueisdecreasedanditssolidityisincreased.,-,53,QualityofPercussion,Flatness:veryshort,andhighpitched(absolutedullness).Flatnessoc