物理診斷重點(diǎn)課件

LocalizedEnlargement

局部淋巴結(jié)腫大Lymphnoditis:Soft,tenderness,smooth,noadhesionTuberculosis:Multiple,variedsizes,tough,adhensiveLymphaticmetastasisofcarcinoma:Hard,notenderness,smooth,adhesionRightsupraclavicularLN:LungcancerLeftsupraclavicularLN(Virchow’slymphnode):Gastricoresophaguscarcinoma局部淋巴結(jié)炎柔軟壓痛表面光滑無粘連淋巴結(jié)核多發(fā)大小不等質(zhì)稍硬粘連腫瘤轉(zhuǎn)移質(zhì)堅(jiān)硬無壓痛表面光滑粘連右鎖骨上肺癌左鎖骨上(魏爾嘯淋巴結(jié))

胃癌食管癌GeneralizedEnlargement

全身淋巴結(jié)腫大Lymphoma淋巴瘤Leukemia白血病

Systemiclupuserythematosous,SLE系統(tǒng)性紅斑狼瘡Infectiousmononucleosis(kissingdisease)

傳染性單核細(xì)胞增多癥3Horner’sSyndrome

頸交感神經(jīng)麻痹綜合征Waybetweensympatheticnervecentrumandeyecompressedordestroyed

交感神經(jīng)中樞至眼部通路受壓和破壞Myosis瞳孔縮小Enophthalmos眼球內(nèi)陷Ptosis上瞼下垂Adiaphoresisindisorderssideofface患側(cè)面部無汗眼部檢查4EyeSigninHyperthyroidism

甲狀腺功能亢進(jìn)眼部征象Inabilitytoclosecompletely

眼瞼閉合障礙Exophthalmos眼球突出Graefesign

眼球下轉(zhuǎn)時(shí)上瞼不能下垂Stellwag

sign

瞬目減少M(fèi)obius

sign

輻輳運(yùn)動(dòng)減弱Joffroy

sign

上視時(shí)無額紋眼部檢查5TheDegreeofThyroidGlandSwelling

甲狀腺腫大的分度Ⅰ:invisiblebutpalpable不能看到能觸到Ⅱ:visibleandpalpable能看到又能觸到Ⅲ:exceedingtheoutmarginofsterno-mastoidmuscle超過胸鎖乳突肌外緣頸部檢查CompareswithGeneralRhonchiandWheeze

一般干啰音和哮鳴音的比較Heardbothtwophases

吸氣呼氣均可聽到High-pitchedordeep-toned

音調(diào)可高可低Distributingoddsanddispel

散在分布不均Aftercoughing:numberandpartvolatility

咳嗽后數(shù)量和部位易變Onlyinexpiration

在呼氣相High-pitched

音調(diào)高Permeateorlocalization

彌漫或局限固定Aftercoughinginvariability

咳嗽后不變thicksecretionmusclespasmSpecialtyofStridor

喘鳴音的特點(diǎn)Loudaudibleinthroatandtrachea在喉和氣管附近聽到Hearingininspiratoryphase吸氣相明顯Usuallypanyinspiratorydyspnea常伴有吸氣費(fèi)力Usuallypanysignof“threedepressionssign”常伴有“三凹”征視觸叩聽胸廓形態(tài)氣管位置肺音呼吸音(正常，異常)呼吸運(yùn)動(dòng)胸廓擴(kuò)張度肺界(上界，下界)啰音(干，濕)呼吸頻率語音震顫肺下界移動(dòng)度語音共振呼吸深度和節(jié)律胸膜摩擦感胸膜摩擦音Summaryinspection

palpationpercussionauscultationChestshapeTrachealpositonPercussionnoteBreathsoundRespiratorymovementChestexpansionSuperiorInferiorrales(rhonchi，crackles)RespiratoryrateTactilefremitus

DiaphragmaticexcursionVocalResonance

RespiratorydepthPleuralfrictionfeelingPleuralFrictionRubSummaryCommonLungDiseaseSigns

肺部常見疾病體征

emphysema肺氣腫

atelectasis肺不張

pneumonia肺炎實(shí)變

pneumothorax氣胸

pleuraleffusion

胸腔積液Emphysema

肺氣腫Pathology:airtrappinginthelung

機(jī)制雙肺含氣增多Emphysema

肺氣腫Inspection:barrelchestPalpation:decreaseddynamiceventsofrespirationandtactilefremitusPercussion:hyperresonce;Down-shiftingoftheinferiorborderofthelungAuscultation:decreasedbreathsoundsandvocalresonance視診桶狀胸觸診呼吸動(dòng)度減弱語顫減弱叩診過清音肺下界下移聽診呼吸音減弱語音共振減弱Atelectasis

肺不張Pathology:theairwayisobstructedandthelungholdsnoair機(jī)制氣道阻塞肺不含氣Inspection:theaffectedchestwallisflattenedPalpation:decreaseddynamiceventsofrespirationandtactilefremitus;thetracheaisshiftedtotheaffectedsidePercussion:dullnessorflatnessAuscultation:breathsoundsandvocalresonancedisappear.視診患側(cè)胸廓凹陷觸診患側(cè)呼吸動(dòng)度減弱語顫減弱氣管移向患側(cè)叩診患側(cè)濁音或?qū)嵰袈犜\患側(cè)呼吸音消失語音共振消失LobarPneumonia

肺炎性實(shí)變Pathology:toomuchfluidinalveoli機(jī)制氣道通暢肺泡腔充滿液體Inspection:normalchestPalpation:decreaseddynamiceventsofrespiration,increasedtactilefremitus.Percussion:dullnessorflatnessAuscultation:tubularbreathsound,crackles,increasedvocalresonance視診胸廓對稱患側(cè)呼吸運(yùn)動(dòng)減弱觸診氣管居中患側(cè)呼吸動(dòng)度減弱病變區(qū)語顫增強(qiáng)叩診病變區(qū)濁音或?qū)嵰袈犜\管狀呼吸音濕啰音語音共振增強(qiáng)Pneumothorax

氣胸Pathology:airistrappedinpleuralcavity機(jī)制：胸腔內(nèi)氣體存積Inspection:over-inflationoftheaffectedsidePalpation:decreaseddynamiceventsofrespirationandtactilefremitus;thetracheaisshiftedtotheunaffectedsidePercussion:tympanyAuscultation:breathsoundsandvocalresonancedisappear視診患側(cè)飽滿觸診患側(cè)呼吸動(dòng)度減弱語顫減弱氣管移向健側(cè)叩診患側(cè)鼓音聽診患側(cè)呼吸音消失語音共振消失PleuralEffusion

胸腔積液Pathology:fluidistrappedinpleuralcavity機(jī)制胸腔液體存積Inspection:over-inflationoftheaffectedsidePalpation:decreaseddynamiceventsofrespirationandtactilefremitus;thetracheaisshiftedtotheunaffectedsidePercussion:dullnessorflatnessAuscultation:breathsoundsandvocalresonancedisappear視診患側(cè)飽滿觸診患側(cè)呼吸動(dòng)度減弱語顫減弱氣管移向健側(cè)叩診患處濁音或?qū)嵰袈犜\患處呼吸音消失語音共振消失Arrhythmia

心律失常Sinusarrhythmia:quickininspirationandslowinexpiration

竇性心律不齊:吸快呼慢Prematurebeat:appearaheadandintermissionbehind

期前收縮:提前出現(xiàn)后有間歇Atrialfibrillation:arrhythmiaabsolutely,heartsoundintensitydifferingandpulsedeficit

心房顫動(dòng):心律絕對不整心音強(qiáng)度弱不等心率大于脈率(脈搏短絀)DifferencesBetweenS1&S2

第一心音和第二心音的區(qū)分S1

第一心音S2第二心音Pitch音調(diào)Low低High高Intensity強(qiáng)度High強(qiáng)Low弱Quality音質(zhì)Blunter低鈍Brisker清脆Duration持續(xù)時(shí)間

Long長Short短Interval兩者間隔S1-S2<S2-S1Apicalimpulse心尖搏動(dòng)itant一致Post之后Bestsite最響部位Apex心尖Base心底PhysicalS3&PathologicalS3

生理性與病理性第三心音的區(qū)分

NormalS3生理性第三心音PathologicalS3病理性第三心音Individual人群Healthyunderage健康未成年Severeheartdisease嚴(yán)重心臟病HR心率<100/min>100/minPosture體位影響↓whensitorstand

坐起或站立消失Noeffect無影響S2-S3interval心音間隔Short短Long長24MeasureofEnlargedSpleenThefirstline:betweencostalmarginandlowedgeofspleeninleftmidclavicularlineThesecondline:betweenthepointoftheleftmidclaviculcrosscostalmarginandthepointofspleenapoapsis.Thethirdline:betweenrightsideofspleenandmidline,expresswithpositiveornegative25SpleenEnlargementDegreesMildenlargement

<2cmundertheribModerateenlargementnotexceedthelevelofumbilicusSevereenlargement:exceedthelevelofumbilicusormidline12326PathologicalMassesShiftingorswellingofparenchymatousorganDistensionofhollowviscusInflammatorymasses(abscessoradhesion)TumororcystLymphadenopathy

27CharacteristicsofPalpation

Location:relationtoorgansSize:diameterinlong,wideandthickContour:shape,marginandsurfaceTexture:soft,firmandhardTenderness:inflammation,liverswellingPulsation:dilativeandconductiveMovability:shiftbyrespirationorhand28CompareAscitesandOvarianCystSigns

征象Ascites腹水Ovariancyst卵巢囊腫

Dorsalposition仰臥位

Umbilicus臍Percussionsound叩診音

Shiftingdullness移動(dòng)性濁音Rulerpressingtest尺壓試驗(yàn)

Sidedistension側(cè)腹膨隆Extrude突出Middletympanysidedullness中部鼓音兩側(cè)濁音Positive陽性Nojumpiness無跳動(dòng)

Middledistension中腹膨隆Flat平坦Middledullnesssidetympany中部濁音兩側(cè)鼓音Negitive陰性Rhythmjumpiness有節(jié)奏跳動(dòng)29AscitesSignInspection:frogshapeofabdomenindorsalposition,hypogastriumregiondistensionwithhilumherniainstand.Palpation:

fluidthrill(asciteslargethan3000ml)Percussion:shiftingdullness(asciteslargethan1000ml),puddlesign(smallamountsoffluid)Auscultation:umbilicusscratchsound

inelbow-kneeposture(ascites<120ml)30AcutePerforatedGastricorDuodenalUlcerSuddenlyepigastricpain,forcedsupinepositionandtwinlowerlimbsflectionAcuteperitonitissigns,tendernessandreboundpaininepigastriumorroundumbilicusquarterHepaticdullnessregiondecreaseordisappearshiftingdullnessinabdomen31AcutePeritonitisSignsInspection:generaldepressioninabdomen,decreasedordisappearedabdominalrespirationPalpation:tenderness,reboundtenderness,rigidabdominalwall（guarding）Percussion:shiftingdullnessAuscultation:decreasedorabsenceofbowelsounds32IntestinalObstructionSymptom:abdominalpain,vomiting,nodefecateandanusexhaustInspection:fulldistension,intestineformandperistalticwavePalpation:rigidabdominalwall,tendernessandreboundpainPercussion:tympanyregionincreasedAuscultation:mechanicalileuspaniedsharpbowelsoundanddecreasedorabsenceofbowelsoundsinparalysisileus33CommonDiseaseofAbdomenconditionscausingliverchangesascites腹水征

peritonitis腹膜炎

acutegastricorduodenalperforation

34ConditionsCausingLiverChangesPrimaryhepaticcarcinomaandmetastasesRightheartfailureOverinflatedlungsDiffuseinfiltrationCirrhosisofliver35PrimaryhepaticcarcinomaandmetastasesTendernessinepigastriumandwastingLargehardirregularlivereasilypalpableperabdomenHighrightdiaphragmwithdullnesstopercussionanddiminishedbreathsoundsoverlowerchestClinicalsignsmaystimulatepleuraleffusionatrightbaseposteriorly36RightHeartFailureTenderenlargedliverRightdiaphragmnotnecessarilyelevatedDistendedcervicalveinandhepatojuglarrefluxpositiveOthersignsofrightheartfailuresuch