(临床诊断学) 仁济临床医学院诊断学教研室 An Introduction to Clinical Diagnostics


Part III Physical Examination



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Part III

Physical Examination

Chapter 1 Basic methods of Examination


A systematic approach to the bedside examination of a patient is essential to determine the significance of an abnormal physical finding. It includes five basic methods-namely, inspection, palpation, percussion, auscultation, and olfactory examination.

Inspection


Inspection is seeking physical signs by observing the patient. Of the several methods of examination inspection is the least mechanical the hardest to learn, but it yields most physical signs. More diagnoses are probably made by inspection than by all other methods combined. The method is the most difficult to learn because no systematic approach can encompass the variety of signs. More than any other method, inspection depends entirely upon the knowledge of the observer; we tend to see things that have meaning for us.

The layman looks at a person and concludes that there is something “peculiar” about him; the physician gives a glance and diagnoses acromegaly. From his study of disease, he can dissect the “peculiarity” and recognize the diagnostic components, such as the enlarged supraorbital ridges, the widely spaced teeth the macroglassia, the buffalo hump, the huge hands and feet. Practice is required to learn inspection.

1. General inspection. The initial act of physical examination is the inspection of the body as a whole. Most clinicians believe that composite pictures of disease, although composed of many sighs, strike them at a glance; they attempt to teach others perceive likewise.

In looking at the patient as a whole, many facts are noted methods in physical examination/inspection.

General inspection about motor activity, body builds, outstanding anatomic malformation, behavior, speech, nutrition, and appearance of illness.

2. Local inspection. Focusing observation on a single anatomic region yields hundreds of physical signs. Since only signs perceived by inspection can be illustrated, the myriad of pictures used in books on surgical diagnosis hint the importance of the method in that field. The dermatologist relies almost entirely on the appearance of skin lesions to make a diagnosis.

3. Usage more or less confines the term inspection to observation with the unaided eyes. Actually, visual, visual signs are the chief or only rewards in the use of the ophthalmoscope, slit lamp, gonioscope, otoscope nasoscope, laryngoscope, bronchoscope, gastrocope, thoracoscope, peritoneoscope, cystoscope, anoscope, and sigmoidoscope. The pathologist uses the microscope; the radiologist inspects the fluoroscopic screen and photographic films.

Palpation


The usual definition of palpation is the act of feeling by the sense of touch. But this is too limited; when the physician lays his lands upon the patient, he perceives physical signs by his tactile sense, temperature sense, and his kinesthetic sense of position and vibration. Palpation is widely used in the physical examination especially in the abdomen examination.

1. Sensitive parts of the Hand: Tactile sense. The tips of the fingers are the most sensitive for fine tactile discrimination, and temperature sense. Use the dorsa of the hands or fingers; the skin is much thinner than elsewhere on the hand. Vibratory sense. Palpate with the palmar aspects of the metacarpophalangeal joints rather than with the finger tips to perceive vibrations such as thrills or the precordial cardiac thrust. Probe the superiority for yourself by touching first the fingertip, then the palmar base of your finger, with a vibrating tuning fork. Sense diagnostic Mode: Symptoms and signs.

Use the grasping fingers, so you perceive with sensations from your joints and muscles.

2. Structures Examined by palpation. Palpation is employed on every part of the body accessible to the examining fingers: all external structures, all structures accessible through the body orifices, the bones, the joints, the muscles, the tendon sheaths, the ligaments, the superficial arteries, thrombosed or thickened veins, superficial nevers, salivary ducts, spermatic cord, solid abdominal viscera, solid contents of hollow ivccera, accumulations of body fluids, pus, or blood.

3. Quality Elicited by palpation: Texture. The skin and hair, Moisture. The skin and mucosa. Skin temperature. At various levels of the body. Masses. The size, shape, consistency, mobility, pulsation (expansile or transmitted) precordial cardiac thrust. Crepitus. In bones, joints, tendon sheaths, pleura, subcutaneous tissue. Tenderness. In all accessible tissues. Thrills, over the heart and blood vessels. Vocal fremitus.

4. Special Methods of palpation: Light palpation. Deep palpation. Ballottement. Fluctuation. Fluid wave.




Percussion


In physical diagnosis, percussion is the method of examination in which the surface of the body is struck to emit sounds that vary in quality according to the underlying tissues.

Methods of percussion: Immediate or indirect percussion. In the method the left middle finger is laid upon the body surface to serve as a pleximeter; it is struck sharp blow with the tip of the right middle finger, the plexor immediate or direct. The body surface is struck directly with one or more fingers of a hand.

1. Sonorous percussion. This term is applied to any method of percussion when its purpose is to ascertain the density of the tissue by the sound emitted when struck. Various densities emit sounds given special meanings. The percussion notes may be arranged in sequence according to the density that produces them, from least to most dense: tympany hyperresonance, resonance, impaired resonance, dullness, flatness. Certain steps in normal tissues. Tympany is the sound emitted by percussing the air-filled stomach; resonance is produced by striking the air-filled lungs; flatness results from the thigh. In general the pitch or frequency of the sounds progresses through the series from lowest for tympany to highest for flatness; the duration of the sound ranges in the series from long to short.

Sonorous percussion is employed to ascertain the density of the lungs, the pleural space, the pleural layers, and the hollow viscera of the abdomen.

2. Definitive percussion, where two structures in apposition have greatly contrasting densities, as demonstrated by their percussion notes, mapping of area of greater density furnishes a concept of the size of the structure or the extent of its border. Any method of percussion used for this purpose is termed definitive percussion.

Definitive percussion is commonly employed to ascertain the location of the lung bases, the width of the lung apices, the height of fluid in the pleural cavity the width of the mediastimum, the size of the heart, the outline of dense masses in the lungs the size and shape of the liver and spleen, the size of a distended gallbladder and urinary bladder, the level of ascitic fluid.


Auscultation


Although auscultation might literally imply the act of hearing to obtain physical signs, usage restricts it almost solely to hearing through the stethoscope. Rales and friction rubs. Crepitus can be heard in joints tendon sheaths, muscles, fractured bones, and in subcutaneous emphysema. The heart makes its various valve sounds with their splitting, murmurs, rhythm disturbances, pericardial rubs and knocks. Auscultation of the abdomen reveals bowel sounds, murmurs from aneurysms and stenotic arteries, especially the renal. The stethoscope is applied to the scrotum to detect bowel sounds in a scrotal hernia.

As every musician knows, the ear can be trained to recognize sounds more accurately. Each person learns to recognize the voices of many associates by patterns of pitch and overtones.



Olfactory examination


In olfactory examination physician makes use of his sense of smell to obtain the abnormal odors of the patients and identify the signs of diseases.



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