第二章一般檢查(熊維寧)

第二章一般檢查

Chapter2GeneralExamination熊維寧Xiong,Weining1GeneralExaminationHeadNeckChestAbdomenSpineLimbsNeurologicExaminationGenitaliaAnus,RectumContentsandsequenceofPE2GeneralExamination

Thegeneralobservationofthepatient’sbodystatus,mainlyrelyingoninspection,supplementedbypalpation,auscultationandolfactoryexamination.3ContentsofGeneralExamination1GeneralstatusexaminationGenderandageVitalsignsDevelopment,HabitusandNutritionMentalstatusToneandVoiceFacialfeaturesandexpressionPositionPostureGait2Skin

3Lymphnodes4Section1Generalstatusexamination51GenderCanbedeterminedanddifferentiatedbyphysiognomy,soundandsexcharacteristicsRelatedtotheincidenceofsomediseases,forexample,gastriccancermoreofteninmale,whilehyperthyroidismandSLEmoreofteninfemaleSomediseasesmayinfluencethesexcharacteristics,suchaslivercirrhosisandadrenalcortextumor6Ageisusuallyacquiredbyinquisition.Ifthepatientisincomaorhidesthetruth,therealagecanbeestimatedbydevelopment,facialfeatures,skinwrinkles,hair,teeth,musclesandsound.Thereiscorrelationbetweenageanddevelopmentorprognosisofthedisease.Forexample,rachitisanddiphtheriaoccurmoreofteninchildren;tuberculosisandrheumaticfeveroccurmoreofteninteenagers;coronaryheartdiseaseandtumoroccursmoreofteninoldpeople.2Age73VitalsignsThemainsignsusedtoevaluatethevitalactivityandriskoflife.ThemostimportantPEitemsTemperatureRespirationPulseBloodPressure

8（1）Temperature①NormalvalueMouth：36.3～37.2℃，5`Rectum：36.5～37.7℃，5`Axilla：36～37℃，10`②TemperaturerecordThetemperatureresultsshouldberecordedonthetemperaturechartandbedrawntoatemperaturecurve,thenthefevertypewillappearinmanyfeverdiseases.

9③MeasurementerroranalysisThemercurycolumndoesnotdropdownbelow35℃.Thepatientcouldnotholdthethermometertightlyenoughifheisthin,seriouslyillornotconscious.Garglingmouthorcleaningaxillawithhotorcoldwaterbeforemeasurementmayleadtothehigherorlowerreadingthantheactual.10（2）RespirationObservefrequencyandrhythmperminuteMethodsandothercontentwillbetaughtinnextchapter.

11（3）PulseObservefrequency,rhythmandintensionofthepulseperminuteMethodsandothercontentwillbetaughtinnextchapter.

12(4)BloodPressure

ExamarterypressureMethodsandothercontentwillbetaughtinnextchapter.

134DevelopmentandHabitus(1)

Development

Judgedbytherelationbetweenageandintelligenceandphysicalstatus(height,weightandthesecondsexcharacteristics)InnormaladultsTheheadlengthisoneseventhoftheheightThechestcircumferenceishalfoftheheightWhenthetwoupperlimbsspread,thedistancebetweenthetwohandsapproximatestheheightThesittingheightapproximatesthelowerlimblength14NormaldevelopmentrelatedcloselytoEndocrine

RaceandheredityNutritionandMetabolismLivingconditionPhysicalexerciseAbnormalstaterelatesmosttotheendocrine

15

EndocrineinfluenceHyperpituitarism→GigantismHypopituitarism→

Pituitarydwarfism16

EndocrineinfluenceHyperthyroidism→beyondthegeneralphysicaldevelopmentHypothyroidism→Cretinism171AsthenictypeTallandthin,slenderneck,narrowshoulders,flatchest,epigastricangle<90°2NormaltypeEachpartandstructureisproper.3OrthosthenictypefatandshortNeck,redface,broadshoulders,bigchest,epigastricangle>90°(2)Habitus

AsthenicNormalOrthosthenic185StateofnutritionItrelatedtointake,digestion,absorptionandmetabolism.Itcanbeevaluatedbyskin,mucosa,hair,subcutaneousfatandmuscles.Amongthemthesubcutaneousfatiscommonlyused.Thepositionistheforearm’sfrontsideortheloweronethirdoftheupperarm’sbackside.Stateofnutritionusuallycanbeusedtoassesshealthordisease.19(1)ClassificationofnutritionstateGood：Skinandmucosaareradiantandglossywithgood

flexibility.Subcutaneousfatisrichandmusclesaresolid.

Nailsandhairisvigorous.Thedepthofintercostalspaceandsupraclavicularfossaisproper.Scapularandthighmusclesarerich.Poor：Skinandmucosaaredrywithpoor

flexibility.Subcutaneousfatislightandmusclesareflaccid.Nailsandhairarecoarseandgloomy.Intercostalspaceandsupraclavicularfossaarecaved.Scapulaandiliumprotruded.

Medium：Betweenthegoodandpoor.

20BodyMassIndex(BMI):BMI＝Weight(kg)/heightsquared(m2)Normalvalues：18.5

24

Standardweight：（height(cm)－100）×0.9（－2.5kginfemale）21(2)Commonabnormalstatesofnutrition1.Malnutrition營(yíng)養(yǎng)不良Emaciation消瘦isdefinedasweightlossover10%ofthestandardweight,orBMI<18.5Extremeemaciationiscalledcachexia惡病質(zhì).Malnutritionisusuallycausedbyinsufficientintakeordigestion,suchasgastricdiseases,orincreasingconsumption,suchastuberculosis,tumor,diabetes,etc.222.Overnutrition營(yíng)養(yǎng)過(guò)度Obesity肥胖isdefinedasover120%ofstandardweight（orBMI>27inmaleor25infemale)It’scausedbytheexcessiveintakewhichexceedstheconsumption.Theexcessistransformedintofataccumulatedinthebody.Inaddition,endocrine,heredity,lifestyle,exerciseandmentalstatemayhaveinfluencetoit.23ClassifyingobesitybasedonetiologyExogenousObesityFatdistributedinequilibrationUsuallywithgeneticpredispositionCommonlynotindicatingspecialdiseasesEndogenousObesityUsuallycausedbysomeendocrinediseases,suchasadrenocorticalhyperfunctionsyndrome(Cushing’ssyndrome).24CachexiaObesity25EndogenousobesityExogenousobesity266Consciousness意識(shí)It’stheintegratedreflectionofbrainandnervefunction.It’stheabilityofrecognizingandobservingthesurroundingsandselfstatus.Normal:clearconsciousness,rapidandaccurateresponse,normalthought,fluentandaccurateexpressionAbnormal:excitedandrestless,chaoticthought,verbaldysfunction,unconsciousacts27Examinationmethodof

consciousness

Inquisitioniscommonlyusedtolearnaboutthepatient’sthought,response,emotion,orientation(judgmentoftime,placeandperson)andcalculationability.Paintestandreflextestarealsousedinseriouscases.

287ToneandVoice語(yǔ)調(diào)和語(yǔ)態(tài)Tonemeanspitch,influencedbynerveandvocalapparatus.

Hoarsenessmaybecausedbyrecurrentlaryngealnerveparalysis,throatorvocalcordedema,laryngealtuberculosis,etc.Voicemeansrhythm.Abnormalitiesmaymanifestasirregularrhythm,chaoticexpressionandunclearsoundinsomepatient,suchasthosewithParkinson'sdiseaseorchorea.

298Facialfeaturesandexpression

面容與表情Normal:NaturalandateaseAnanguishedorworriedortiredface

maymanifestinsomepatientSomediseasesmayhavecharacteristicfacialfeaturesandexpression,whicharevaluableindiagnosing.

30Abnormalfacialfeatures1faceofacuteill:flushedface2faceofchronicill:haggardexpression3anemicface:paleface4faceofliverdisease:gloomyface5faceofkidneydisease:paleandedema316hyperthyroidismfaceandexophthalmos327Faceofmyxedemaduetohypothyroidism33BeforetreatmentAftertreatmentAhypothyroidismpatient348mitralface35Abnormalfacialfeatures9Acromegalyface:skullenlargement10Typhoidface:frozenexpression11Sardonicface:facialspasm,seenintetanus12Maskedface:woodenface,seeninParkinsonism3613MoonfaceCushing’ssyndrome371Activeposition自主體位

2Passiveposition被動(dòng)體位

3Compulsiveposition強(qiáng)迫體位(1)Compulsivesupineposition:acuteperitonitis(2)Compulsiveproneposition：spinaldiseases

(3)Compulsivelateralposition：pleuraldisease(4)Compulsivesittingposition(orthopnea):leftheartfailure(5)Compulsivesquattingposition:congenital

cyanoticheartdisease

(6)Compulsivestandingposition：anginapectoris(7)Restlessposition(alternativeposition)：cholelithiasis,ascariasisofbiliarytract,renalcolic(8)Opisthotonosposition:tetanus

9Position3810Posture姿勢(shì)Influencedbyhealthconditionandmentalstate.

cervicalspondylosis:movementlimitedcongestiveheartfailure:tendencytositabdominalpain:bodytwisted3911Gait步態(tài)PostureofwalkingCharacteristicofsomediseases1Waddlinggate:rachitis2Drinkenmangait:alcoholintoxication,

cerebellumdisease3Ataxicgait:spinaltuberculosis

4Intermittentclaudication:hypertension,arteriosclerosisinarteryoflowerlimbs405Festinatinggait:parkinsonism416Steppagegait:palsiesofnervousperoneuscommunis7Scissorsgait:cerebralpalsy,paraplegia42

Skinabnormalitiescouldbecausedbythediseasesofitselforrelatedtomanyinternalorgansdiseases.Thelesioncanbelocalorgeneral.Theinspectionofcolor,moisture,elasticity,petechia,purpura,edemaandscarisimportant.Sometimespalpationisalsonecessary.Chapter2Skin431Color1Pallor:anemia,kidneydiseases2Redness:fever3Cyanosis:anoxia4Stainedyellow(1)Jaundice(2)Carotenemia(3)Drugscontainingyellowcoloragent445Pigmentation色素沉著Increasedmelanindepositionintheskincanresultfromeitherlocalorsystemicfactors,suchashypocorticism,livercirrhosis.456Depigmentation

色素脫失Lossofnormalskinpigmentationmaybepatchyordiffuse,usuallywithdiscreteborders.Thedistributionandpatternofdepigmentationisimportantinidentificationofthespecificetiology.(1)Vitiligo(2)Leukoplakia(3)Albinismus:hereditarydisease462Moisture濕度Themoistureisrelatedwiththesecretionfunctionofsweatglandsandadjustedbytheautonomicnerves.Theincreasingperspirationisaphysiologicadjustmentinthesituationofhightemperatureandmoisture.Whileintheconditionofdisease,excessivesweatingoranhidrosismaybeavaluablesignfordiagnosis.473Elasticity彈性

Relatedtoage,nutrition,subcutaneousfatandinterstitialfluid.Childrenandteenagers’skinelasticityisgood,whileoldmen’sdecreasesasaresultofatrophictissuesandlesssubcutaneousfat.Method:Pinchtheskinoverthebackofhandortheinsideofupperarmwiththe

forefingerandthumb,andthenreleaseit.Rapidresumetoitsbeginningshapemeansisnormal,whileslowresumemeanselasticitydecrease.

484Skineruption皮疹Commoninsomecontagiousdiseases,skindiseasesandallergicreaction,andvaluableindiagnosisSoimportantarethecarefulobservationanddetailedrecordsoftimeandsequenceoftheoccurrenceandregression,distribution,size,shape,colorandwhetheritfadeswhenpressed,whethercombinedwithpruritusanddesquamation.49Commoneruptions1Macule斑疹red，notelevatedfromskin,notpalpable,seenintyphusfeverand

erysipelas2Roseola玫瑰疹

brightredandround,diameter2～3mm，causedbythevasculardilationnearby,vanishwhenpressed,characteristicoftyphoidandparatyphoidfever3Papules丘疹

red,butelevatedfromskin,palpable,seenindrugeruptionandmeasles50Commoneruptions4Maculopapule斑丘疹Witharedbasaldiscaroundthepapules,seenin

scarletfeveranddrugeruption5Urticaria蕁麻疹

Slightlyelevatedandlocalizededema,pallororred,causedbyallergicreaction515Desquamation脫屑Cornificationandregenerationofthenormalskinepithalliummaycauseslightdesquamation.Muchdesquamationindicatesdisease,forexample,desquamationlikericebrancanbeseeninmeasles,flakydesquamationcanbeseeninscarletfever,silveryandsquamous

desquamationcanbeseeninpsoriasis526Subcutaneoushemorrhage皮下出血Commoninhematologicalsystemdisease,seriousinfection,vasculardiseaseandintoxicationPetechia瘀點(diǎn)diameter≤2mm,withoutcolorfadingPurpura紫癜diameter3～5mmEcchymosis瘀斑diameter>5mmHematoma血腫elevationoftheskin53thrombocytopenicpurpura547SpiderangiomaandliverpalmSpiderangiomaisakindofvascularnevuscausedbythebranchingdilationofs