symposium

1. Physical Examination
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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.
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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.
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4. Inspection
•Technique for inspecting the abdomen.
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5. INSPECTION:-
• Inspection is a series of accurate and
meaningful observations which are the
first step in every physical examination of
the patient.
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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.
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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.
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8. Palpation:-
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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.
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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)
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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)
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12. Palpation:-
潜触诊
潜触诊
深触诊
深触诊
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13. • On inspiration, the liver is palpable about 2~3 cm below
the right costal margin in the mid-clavicular line.
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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)
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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.
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16. 肝脏单手、肝脏双手、脾脏双手
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17. • The enlarged
spleen below is
palpable about 2
cm below the left
costal margin on
deep inspiration.
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18. Percussion
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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.
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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.
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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.
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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.
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23. 04/27/12 No./56 23

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.
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25. Percussion Sounds
• The sounds produced by percussion are
generally classified as follows ：
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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.
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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.
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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.
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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.
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30. Auscultation
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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).
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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.
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33. Area’s of
Auscultation
1)Aortic area
2)Pulmonic area
3)
4)Tricuspid area
5)Mitral area
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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.
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35. 心脏听诊
肺
部
听
诊
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