物理診斷diagnosis白皮英文

Whatisdiagnosis?什么叫診斷？Diagnosisisinvestigationand 診斷就是診察和判斷Investigationisdatacollecting.診察是收集疾病信息Judgmentissynthesisandyzedatatodeterminethenatureofillness. 判斷是綜合分析信息確定所患疾病Thediagnosisistakingaboutthemethodofdatacollectingandhowtomakeacorrectjudgment. StepsofDiagnosis診斷步驟Datacollectinghistoryintervewingphysicalexamination laboratoryexamination examinationDatayzingDeterminationof thenatureofthe ClassificationofClinicalDiagnosis臨床診斷的分類Etiologicdiagnosishepatitis RheumaticheartdiseasePathological-anatomicdiagnosis AorticregurgitationLivercirrhosisPathophysiologicdiagnosis 病因診 Inquiry問(wèn)診Inquiryisonemethodfromtheinterviewbetweendoctorandpatientorrelativefordiseasehistory,andmakingtheclinicaldeterminationbyyzinghistory.通過(guò)對(duì)患者或相關(guān)人員的詢問(wèn)獲取病史資 經(jīng)過(guò)綜合分析ContentsofQuestioning問(wèn)診的內(nèi)IdentifyinginformationSourceandreliabilityChiefcomplaintsPresentillnessPastmedicalhistoryalhistoryMaritalhistoryMenstrualandobstetrichistoryinwomenFamilyhistory患者個(gè)人信息敘述者和可信度主訴現(xiàn)病史既往史個(gè)人史史月經(jīng)史史IdentifyingInformation患者個(gè)人信息NameSexandAgeNativeplaceBirthplaceNationalityMarriageAddressWorkplaceOccupation和籍貫出生地國(guó)籍或民族住址工作地點(diǎn)職OthersInformationChiefComplaint主 fortanditsMakesuretobe: persistingheadachefor3daysMakesuretoavoidusing: onsettimeofthedisease 書寫注要簡(jiǎn)明扼要按時(shí)間先后持頭痛3三不不要用起病時(shí)不要用診斷術(shù)PresentIllness現(xiàn)病Furtherdescriptionofthemaincomplaint,includingthewholediseaseprocessOnsetanddurationandPredisposingfactorsCharactersofthemainsymptom,progressionand symptomsManagementsandeffectsEffectsondailylife

PastMedicalHistory既往史PasthealthstatusPastillnessHistoryofinjuryHistoryofsurgeryHistoryofallergyHistoryofbloodtransfusionHistoryofvaccinationSystemicreview既往健康狀況既往所患疾病既往外傷史 手術(shù)史 alHistory個(gè)人史Homeplace,inhabitationplace,epidemicdiseaseortravelexperiencetoepidemicareaSmokingandalcoholintakeWorkHousingconditionLifestyleSexhistory MaritalHistory史Marriageage 結(jié)婚Healthstatusofthespouse 愛人健康狀況Maritalatta MenstrualandObstetricalHistory 史Formulaforrecording intermenstrualperiod(day)Menarcheage———menopauseage menstrualcycle LMPMenses:volume,color,leucorrhea,dysmenorrhealObstetrical:numberofpregnancyanddelivery,historyofoperativedelivery,difficultlabor,abortion 周期或絕經(jīng)行經(jīng)情況量顏色有無(wú)痛經(jīng)孕產(chǎn)情況孕次產(chǎn)次有無(wú)手術(shù)產(chǎn)難FamilyHistoryHealthstatusofthreesequentialgenerationsCausesofdeathExistingthesamediseaseHereditarydiseasesInfectiousdiseases 父母兄妹(幾男幾女)原因BasicExaminationTechniques基本檢查法視診inspection觸palpation叩診percussionauscultation嗅診olfactory觸診Lightpalpation淺部觸診法Deeppalpation深部觸診法Deepslippalpation滑行觸診法Bimanualpalpation雙手觸診法Deeppresspalpation深壓觸診法Ballottement沖擊觸診法PercussionNotes叩診音Tympany:gasHyperresonance:increasedgasinlungtissueResonance:lungtissueDullness:gasandtissueFlatness:essentialorganorfluid鼓音:氣體過(guò)清音: 清音:肺組織濁音:氣體與組織實(shí)音: GeneralExamination一般檢查Vitalsigns生命體征Development發(fā)育Habitus體型Nutritionalstatus營(yíng)養(yǎng)Consciousness意識(shí)Facialfeaturesandexpressions面容和表情VitalSign(T,P,R)生命征TemperatureNormalaxillaryT:36~37℃Fever:T>37℃Hypothermia:T<35℃Pulse 60~100/minRhythm:RegularRespirationNormal:16~18/min體溫正常(腋窩)體溫:36~37℃發(fā)熱:T>37℃體溫不升脈搏脈率:60~100/min節(jié)律:整齊呼吸頻率:16~18/minDisturbanceofConsciousness意 Somnolence嗜睡意識(shí)模糊Stupor昏睡 Delirium譫FacialFeaturesandExpression面容與表情mitralface二尖瓣面Acutediseaseexpression急容Chronicdisease慢容Specialface 特殊面容GravesDisease甲亢面容MoonedFaceInducedbyCushing’s庫(kù)興氏滿月臉HippocraticFaciesMyxedema粘液水腫Acromegaly肢端肥大PositionRelaxedposition自主Positivepositionindepletionorunconsciouspatient極度衰竭意識(shí)喪失Compulsiveposition強(qiáng)迫torelieve fort減輕痛苦被迫采取的Git步態(tài)l:clmditiesAbnolligitenniticitsitigitgertpitsissitteitetcliissicesis正常::蹣跚步態(tài)醉酒步態(tài)共濟(jì)失調(diào)步態(tài)慌張步態(tài)跨閾步態(tài)剪刀步態(tài)間歇SubcutaneousHemorrhage皮下Winecolorandwon’tfadewhenpressed暗紅色壓之不褪色Petechia:<2mm瘀點(diǎn)<2mmPurpura:3~5mm紫癜:3~5mmEcchymosis:>5mm瘀斑:>5mmHematoma: 血腫:片狀伴皮膚隆起SpiderAngioma蜘蛛痣Highlybranchedslatearteriallesionswhichpulsateandblanchonpressure.Distributedcommonlyonface,neck,orchest.Maybeassociatedwithpregnancy,chronicliverdisease,orestrogentherapy,ormaybenormal.定義:小動(dòng)脈末端分支性擴(kuò)張?zhí)攸c(diǎn):受壓血管機(jī)制:雌激素增多部位:上腔靜脈區(qū)域面部頸部和胸部病因:妊娠慢性肝臟病變雌激素治療Recordcontent記錄內(nèi)容Normalnode: 2~5mm,soft,smooth,notendernessandadhesion.Recordifenlarged:location,size,number,hardness,tender,mobility,adhesion,superficialskin.正常淋2~5mm質(zhì)軟光滑無(wú)壓痛無(wú)粘連腫大時(shí)記錄部位大小數(shù)目硬度壓痛活動(dòng)度粘連Pupil瞳孔大小Normal:3~4mmDilation: atropinizationContraction:organophosphoruspoisoning,drugreaction,narcotictakingPlatycoria:dying正常:3~4mm擴(kuò)大:青光眼阿托品縮小: 有機(jī)磷藥物反應(yīng)過(guò)量雙側(cè)散大: 瀕死狀態(tài)CompareBothPupil比較雙側(cè)瞳孔Normal:SymmetryAnisocoria:Pathologyanywherefromthereceptionoflightthroughtheopticnervestothebrainstem,thethirdcranialnerve,sympathetic,orparasympatheticpathwaysCerebralhernia正常:等大等圓不等大視神經(jīng)至腦干病變動(dòng)眼神經(jīng)受壓交感神經(jīng)受壓副交感神經(jīng)受壓腦疝表面皮膚情況Sinuses鼻竇Location部位frontalsinuses額竇ethmoidsinuses篩竇maxillarysinus上頜竇Sphenoidsinusestenderness&percussionpain:sinusitis鼻竇區(qū)壓痛叩擊痛:TongueSize舌體Enlarged:inflammation,myxedema,tumor,acromegaly舌體腫大:炎癥 腫瘤肢端肥大癥Shrinked:severedehydration舌體干小:嚴(yán)重脫水AppearanceofTongue舌象Geographicandwrinkledorfissuredtongue:riboflavindeficiencyStrawberrytongue:longfeverBeefytongue:niacindeficiencySmoothtongue:ironorVitB12deficiencyBlackhairytongue:fungusinfection地圖舌和裂紋舌: 提示核黃素缺乏草莓舌:舌腫脹 期發(fā)熱牛肉舌:舌面絳紅 菸酸缺乏鏡面舌:光滑紅色鐵或維生素B12缺乏黑毛舌:黑黃褐色毛真菌PharynxandTonsil咽和扁桃體Pharynx咽 Turkeyredpaniedbyswelling:Acute 紅腫:急性咽 paniedby Chronic暗紅濾泡:慢性咽炎Tonsil扁桃 degreeoftonsil

Ⅰ°不超過(guò)腭咽弓Ⅱ°超過(guò)腭咽弓未達(dá)中線Ⅲ°達(dá)到超過(guò)咽后壁中線purulent化膿性扁桃體炎PalpationoftheTrachea觸摸氣管位置Indicatethelocationofmediastinum指示縱隔位置Location:normallyinthemiddle正常居中Shiftingtothehealth:largepleuraleffusion,pothorax移向健側(cè):大量胸腔積液氣胸Shiftingtothedisaster:emphysema移向患側(cè):肺不張TheDegreeofThyroidGlandSwelling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-mastoid AbnormalIntercostalSpace肋間隙改變Recessedornarroweddepressedwheninspirating:airwayobstruction depression:aeis,pleuraladhesionWideorswellinggeneralintensewhenexpirating:emphysema,bronchialasthmaone-sideintense:pleuraleffusion,pothorax 吸氣時(shí)凹陷:大氣道阻塞一側(cè)變窄凹陷: 肺不張胸膜粘連膨隆或增寬(容積增大) 肺氣腫支氣管哮喘一側(cè)增寬膨隆:胸腔積液氣胸AbnormalLungBorder肺界異常Kronig’isthmus:Widening:emphysemaNarrowing(unilateral):tuberculosis,tumorInferiorborder:Lowered:emphysemaRised:aeis,increasedintra-abdominalpressureUndetectable:Pleuraleffusion,肺上界增寬:肺氣腫變窄:肺結(jié) 肺下界下降:肺氣腫升高:肺不張腹壓增高叩不出:胸腔積 AbnormalDiaphragmaticExcursion肺下界移動(dòng)范圍異常<4cm減弱:<4cmUnilateral:ataleis,pleuraladhension單側(cè):肺不張膜粘連Bilateral:emphysema,lungfibrosis雙側(cè):肺氣腫肺纖維化AbnormalIntercostalSpace肋間隙改變Recessedornarroweddepressedwheninspirating:airwayobstruction depression:aeis,pleuraladhesionWideorswellinggeneralintensewhenexpirating:emphysema,bronchialasthmaone-sideintense:pleuraleffusion,pothorax凹陷或變窄(容積縮小)吸氣時(shí)凹陷:大氣道阻塞一側(cè)變窄凹陷: 氣腫支氣管哮喘一側(cè)增寬膨隆: 胸腔積液氣胸Chestshape胸廓形態(tài)Normal:Ap:T=1:1.5Abnormal:FlatchestandBarrelchestRachiticchest Pigeonchest RachiticrosaryFunnelchest HarrisongrooveRegionaltransfigurationThorax-vertebrae-malformation-induced胸廓正常形態(tài)前后徑:橫徑1:1.5胸廓形態(tài)異常扁平胸和桶狀胸佝僂病胸雞胸串珠胸漏斗胸肋膈溝局部變形胸椎嚴(yán)重畸形PathologicalConditions異常改變Weakenordisappear:Obstructiveae is,emphysema,Pleuraleffusion,p subcutaneousemphysemaEnhanced: Consolidationoflungtissue:lobarp onia,pulmonaryinfarction. Largeinthelung,esp.nearthepleura:lungabscess,cavernouspulmonarytuberculosis.減弱或阻塞性肺不張 肺氣腫胸腔積液 肺實(shí)變:大葉肺梗死 ClinicalSignificanceLocalizedcrackles:regionaldiseasesBilateralcracklesinlowerfieldofthelungswithrhonchi:bronchitiswithlunginfectionCracklesinbilateralbasesofthelungs:pulmonarycongestioncausedbyheartfailureGeneralizedcoarsecracklesinbilaterallungfields:acutepulmonary局部: 并兩肺底對(duì)稱性: 左心功能不全兩肺滿布:Emphysema肺氣腫Pathology: airtrapinthelungInspection:barrelchestPalpation:decreaseddynamiceventsofrespirationandtactilefremitusPercussion:hyperresonce;Down-shiftingoftheinferiorborderofthelungAuscultation:decreasedbreathsoundsandvocal機(jī)制 雙肺含氣增多視診 桶狀胸觸診 呼吸動(dòng)度減弱語(yǔ)顫減弱叩診過(guò)清音肺下界下移聽診呼吸音減 語(yǔ)音弱Aeis肺不張Pathology:theairwayisobstructedandthelungholdsnoairInspection:theaffectedchestwallisflattenedPalpation:decreaseddynamiceventsofrespirationandtactilefremitus;ThetracheaisshiftedtotheaffectedsidePercussion:dullnessorflatnessAuscultation:breathsoundsandvocalresonancedisappear.機(jī)制氣道阻塞肺不含氣視診患側(cè)胸廓凹陷觸診患側(cè)呼吸動(dòng)度減弱語(yǔ)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、語(yǔ)音LobarP 性實(shí)變Pathology:toomuchfluidinalveoliInspection:normalchestPalpation:decreaseddynamiceventsofrespiration,increasedtactilefremitus.Percussion:dullnessorflatnessAuscultation:tubularbreathsound,crackles,increasedvocalresonance機(jī)制氣道通暢 肺泡腔充滿液體視診患側(cè)呼吸運(yùn)動(dòng)減弱觸診患側(cè)呼吸動(dòng)度減弱 強(qiáng)叩診病變區(qū)濁音或?qū)嵰袈犜\管狀呼吸 語(yǔ)音增強(qiáng) othorax氣胸Pathology:airistrappedinpleuralInspection:over-inflationoftheaffectedsidePalpation:decreaseddynamiceventsofrespirationandtactilefremitus;the tympanyAuscultation:breathsoundsandvocalresonancedisappear機(jī)制胸腔氣體存積視診患側(cè)飽滿觸診患側(cè)呼吸動(dòng)度減弱 氣管移向健側(cè)叩診患側(cè)鼓音聽診患側(cè)呼吸音語(yǔ)音PleuralEffusion胸腔積液Pathology:fluidistrappedinpleuralInspection:over-inflationoftheaffectedsidePalpation:decreaseddynamiceventsofrespirationandtactilefremitus;thetracheaisshiftedtotheunaffectedsidePercussion:dullnessflatnessAuscultation:breathsoundsandvocalresonance機(jī)制胸腔液體存積視診患側(cè)飽滿觸診患側(cè)呼吸動(dòng)度減弱 氣管移向健側(cè)叩診患處濁音或?qū)嵰袈犜\患處呼吸音語(yǔ)音AbnormalLungBorder肺界異常Kronig’isthmus:Widening:emphysemaNarrowing(unilateral):tuberculosis,tumorInferiorborder:Lowered:emphysemaRised:aeis,increasedintra-abdominalpressureUndetectable:Pleuraleffusion,pothorax肺上界增寬:肺氣腫變窄:肺結(jié) 肺腫瘤肺下界下降:肺氣腫升高:肺

腹壓增高叩不出:胸腔積氣胸AbnormalDiaphragmaticExcursion肺下界移動(dòng)范圍異常Decreased:<4cm減弱:<4cmUnilateral:ataleis,pleuraladhension單側(cè):肺不張胸膜粘連Bilateral:emphysema,lungfibrosis雙側(cè):肺氣腫肺纖維化ClassifyofBreathSound呼吸音分類Normalandabnormal正常和異常呼吸音Bronchialbreathsounds支氣管呼吸音Vesicularbreathsounds 肺泡呼吸音BronchovesicularbreathsoundsInspectionoftheHeart心臟視診precordiumshape normalapicalimpulse 正常心尖搏動(dòng)abnormalapicalimpulse異常心尖搏動(dòng)precordialabnormalimpulse PrecordiumShape心前區(qū)外形Precordialbulge心前區(qū)隆起Features:bonybulge特點(diǎn):骨骼突起Clinicalimportance:Congenitalheartdiseasewithventricularenlargement 大Precordialsatiety心前區(qū)飽滿Features:intercostalregionsticking 特點(diǎn):肋間軟組織外突Clinicalimportance:massofpericardialeffusion提示:大量心包積液NormalApicalImpulse正常心尖搏動(dòng)Location:0.5~1cmtotheleftmidclavicularlineatthe5thICSoutsideLSB.Range:2~2.5cmDirection:outwardwhenventricularsystolebegins位置:5肋間左鎖骨中線內(nèi)0.5~1cm范圍2~2.5cm方向:收縮時(shí)向外搏動(dòng)意義:提示心尖位置代表收縮期提示心臟大小AbnormalDullnessHeartBorder(1)heartvariation心臟改變L.Venlargement:boot-shapedheart左室擴(kuò)大:靴形L.Aenlargement:pear-shapedheart 左房擴(kuò)大:梨形心B.Venlargement:generalenlargedheart 雙室擴(kuò)大:普大心R.Venlargement:corpulmonal右室擴(kuò)大:先心肺心Pericardialeffusion:flask-shapedheart心包積液:燒瓶心、AbnormalDullnessHeartBorder心界叩診異常(2)chestandlungdiseases胸肺疾病Pleuraleffusionorlungconsolidation:dullnessborderundetectable 胸腔積液或肺實(shí)變:叩不出Emphysema:“shrinked”dullnessborder肺氣腫:心濁音界縮小abdominaldisorders腹部疾病Diaphragmelevation:acrossingheart膈升高:Boot-shapedHeart靴形心Mechanism:L.VenlargementFeatures:theleftborderextendstotheinferiorleft,waistoftheheartisdeepened.Causes:aorticinsufficiency,hypertensiveheartdisease機(jī)制:左室擴(kuò)大特點(diǎn) 心左界向左下擴(kuò) 心腰加深病因 Pear-shapedHeart梨形心Mechanism:L.AenlargementanddistensionofpulmonaryarteryFeatures:dullnessheartborderinthe2nd,3rdICSontheLSBextendsoutside,waistoftheheartbulgesoutCauses:mitralstenosis機(jī)制: 左房擴(kuò)大肺動(dòng)脈擴(kuò)大特 胸骨左緣2,3肋間心濁音界向外擴(kuò)大心腰飽 GeneralEnlargedHeart普大心Mechanism:bothleftandrightventricleareenlargedFeatures:thedullnessborderextendstobothsides,theleftborderextendstoinferiorleftCauses:cardiomyopathy,myocarditis,wholeheartfailure機(jī)制:左右 心濁音界向雙側(cè)擴(kuò)大左界向下擴(kuò)大病因擴(kuò)張型心肌病克山病重癥心肌炎全心衰竭Flask-shapedHeart燒瓶心Mechanism:pericardialeffusionFeatures:Sittingposition:triangulardullnessborderSupine:wideneddullnessborderofthebase機(jī)制:心包積液特點(diǎn):坐位時(shí)心濁音界呈三角形仰臥位心底部濁音區(qū)增寬隨心界改變FirstHeartSound,S1第一心音SignalingthebeginningofIthascharactersoflowpitch,longduration. Itcanbeheardbestintheapexarea.在心尖部聽診最清楚SecondHeartSound,S2第二心音Signalingthebeginningofdiastole.提示舒張期開始Itishigh-pitched,low-intensity,shorterandbrisker.高調(diào)低強(qiáng)度時(shí)間短輕脆“嗒”Itcanbeauscultatedbestatthebaseoftheheart.在心底部聽診最清楚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(zhǎng)Short短Interval兩者間隔S1-S2長(zhǎng)<S2-S1短Apicalimpulse 心尖搏動(dòng)itant 一致Post之后Bestsite最響部位Apex心尖Base心底ChangesofQuality心音性質(zhì)改變ChangesofS1quality:S1sameasS2(blankness) 第二心音相同(單調(diào))Diastolicphaseshorten:sameassystolic(single (單律)Characteristic:pendularrhythm,embryocardia 鐘擺律胎心律Clinicalmeaning:myocardialdamageseverely,asacutemyocardialinfarction,severemyocarditis,. 提示:心肌嚴(yán)重受損如急性心肌梗塞重癥心肌炎WideSplitting順Typicalattheendofinspiration 明顯Physiologicsplitting:deep 生理:氣相回右心血量增加GeneralsplittingDelayedP2:pulmonaryhypertension,mitralstenosis,pulmonicstenosis,rightbundlebranchblock. 肺動(dòng)脈瓣關(guān)閉延遲:肺動(dòng)脈高壓 二尖瓣狹窄肺動(dòng)脈瓣狹窄右束支阻滯EarlyA2:mitralinsufficiency,IVSD主動(dòng)脈瓣關(guān)閉提前:二尖瓣關(guān)閉不全室間隔缺損FixedSplitting固定Splittingisunaffectedbyrespiration不受呼吸影響Mechanism:delayedclosureofthepulmonicvalve(outputoftherightventricleisgreaterthanthatoftheleft)機(jī)制:肺動(dòng)脈瓣關(guān)閉延遲Bloodflowfromleftatriumtotherightpassingthroughseptaldefectsamortizedaffectionofrespiration.房間隔缺損處血液左向右分流緩沖呼吸影響Commondiseases:largeatrialseptaldefectsandrightventricularfailure. 病因:大的房間隔缺損并右心功能不全ReversedSplitting逆Typicalattheendofexpiration 呼氣末明顯ParadoxicalSplitting:P2occursfirstly,followedbyA2 反常:肺動(dòng)脈瓣第二音出現(xiàn)在主動(dòng)脈瓣第二音之前Mechanism:closureoftheaorticvalveisdelayed 機(jī)制:主動(dòng)脈瓣關(guān)閉明顯延遲Commondiseases:Leftbundlebranchblock,Aortic 病因:左束支傳導(dǎo)阻滯主動(dòng)脈瓣狹窄ExtraHeartSoundssystolicextraheartsounds收縮期額外心音diastolicextraheartsounds舒張期額外心音ExtraHeartSounds額外心音SystolicEarlysystole:ejectionsoundsMid-/Latesystole:clickDiastolicEarlydiastole:openingsnap,pericardialknockMid-diastole:thirdheartsoundLatediastole:fourthheartsoundgalloprhythm收縮早期噴射音中晚期喀喇音舒張?jiān)缙陂_瓣音心Gallop奔馬律Mechanism:decreasedcomplianceoftheventriclecausedbyseveremyocardialdamage機(jī)制:心肌嚴(yán)重受損致

壁順應(yīng)性差Classification:分類Protodiastolicgallop(Ventriculargallop,S3gallop) 舒張?jiān)缙诒捡R律(室性奔馬律第三心音奔馬律)Latediastolicgallop(atrialgallop,S4gallop) (房性奔馬律第四心音奔馬律)Quadruplerhythmandsummation 四音律和奔馬律PhysicalS3&PathologicalS3生理性與病理性第三心音的區(qū)分QuadrupleRhythmandSummation四音律和奔馬律Mechanism:pathologicalS3&S4. Duringtachycardia,thediastolicfillingtimeshortensandtheS3andS4moveclosertogether.心率加速時(shí)舒張期縮短四心音Theysoundsuperimposedinmid-diastole,andoneloud,prolonged,summatedsoundcanbeheardoftenlouderthaneitherS1orS2.特點(diǎn):舒張中期較長(zhǎng)響亮心音強(qiáng)于第一或第二心音CharacterizationofMurmurs雜音聽診要點(diǎn)LocationDurationPitchandQualityIntensityandTimingTransmissionorradiationEffectmurmursoffactor雜音的部位雜音的時(shí)期雜音的性質(zhì)雜音的強(qiáng)度雜音的傳導(dǎo)影響雜音的因素Location雜音部位Apicalarea:mitralvalveAorticarea:aorticvalvePulmonicarea: pulmonicvalveInferior tricuspidvalve3rd,4thICS,LSB:ventricularseptaldefect2nd,3rdICS,LSB: patentductusarteriosus雜音出現(xiàn)和最響部位與病變部位血流方向傳導(dǎo)介質(zhì)相關(guān)心尖部:二尖瓣主動(dòng)脈瓣聽診區(qū):主動(dòng)脈瓣肺動(dòng)脈瓣聽診區(qū):肺動(dòng)脈瓣胸骨下端:胸骨左緣34肋間:室間隔胸骨左緣23肋間:動(dòng)脈tin 雜音時(shí)期tic (Hlslclitlicteitic (MHditliclMiitice(eti)ts收縮期雜音全收縮期收縮早期收縮中期收縮晚期舒張期雜音全舒張期舒早舒中舒晚連性音DistinguishDuration時(shí)期的區(qū)分systolicmurmur收縮期雜音appearbetweenS1andS2,sameasapicalimpulse 與第二心音之間出現(xiàn)與心尖搏動(dòng)一致diastolicmurmur舒張期雜音appearbetweenS2andS1,nonsameasapicalimpulse在第2心音與第1心音之間出現(xiàn) IntensityofSystolicMurmur收縮期雜音強(qiáng)度GradeⅠ:barelyaudibleinquietroom 1級(jí):仔細(xì)聽方可聽到GradeⅡ:quietbutclearlyaudible 2級(jí):容易聽到但不響亮GradeⅢ:moderay 3級(jí):較響亮GradeⅣ:loud,associatedwith4級(jí):粗糙且響亮伴傳導(dǎo)震顫GradeⅤ:veryloud,thrilleasily 5級(jí):震耳GradeⅥ:veryloud,audiblewithstethoscopenotincontactwithchest,thrillpalpableandvisible6級(jí):離開胸壁亦可聞及FunctionalandOrganicMurmurs收縮期雜音的鑒別Functional功能性O(shè)rganic器質(zhì)性AgeYoung兒童青少年Unlimited不定Location部位Pulmonic/apical 肺動(dòng)脈瓣或心尖部Anyarea各部位Character性質(zhì)Soft,smooth柔和Coarse,highpitch粗糙高調(diào)Duration時(shí)間Short短Long(wholesystole)（全收縮期）Intensity強(qiáng)度<3/6>or=3/6Thrill震顫no無(wú)Yes有Transmission傳導(dǎo)Localized局限extensive傳導(dǎo)Systolicmurmurinleftsternumintercostal3~4: septaldefect 胸骨左緣34肋間收縮期雜音:室間隔缺損Continuousmachine-likeinleftsternumintercostal2: ductusarteriosus 胸骨左緣第2肋間連續(xù)型雜音:動(dòng)脈導(dǎo)管末PeripheralVascularSign周圍血管征Vascularsign:征象Water-hammerPulse水沖脈Carotidarteryimpulse頸動(dòng)脈搏動(dòng)Noddingspasm點(diǎn)頭運(yùn)動(dòng) Capillarypulsation毛細(xì)血管搏動(dòng)征Pistolshotsound槍擊音Duroziezdoublemurmur杜氏雙重雜音Clinicalmeaning:aorticinsufficiency,hypertension,Hyperthyroidism提示:主動(dòng)脈瓣關(guān)閉不全高血壓甲狀腺機(jī)能亢進(jìn)HeartDisease心臟疾病mitralstenosis 二尖瓣狹窄aortic 主動(dòng)脈瓣關(guān)閉不全MitralStenosis二尖瓣狹窄(1)L.AenlargementPulmonaryarterydilationR.Venlargement 增大→肺動(dòng)脈擴(kuò)張→右室增大Inspection:Mitralface(malarflush),apicalimpulseleft 視診:二尖瓣面容心尖搏左移位Palpation:diastolicthrillattheapexarea 觸診:心尖部舒張期震顫Percussion:pear-shapedheart 叩診:梨型心MitralStenosisAuscultation二尖瓣狹窄(2)Apexarea:心尖部Heartsounds:AccentuationofS1 第一心音亢進(jìn)Extrasound:openingsnaps開瓣音Murmurs:mid-orlate-diastolicrumblinginquality,decrescendo-crescendo,usuallylocalized,heardmoreclearlywiththepatientrecumbentoronhisleftsideoraftermoderateexercise.Pulmonicarea:肺動(dòng)脈瓣區(qū)Heartsounds:AccentuationandsplittingofS2 第二心音亢進(jìn)Murmur:Graham-steellG-S雜音AorticInsufficiency主動(dòng)脈瓣關(guān)閉不全(1)Inspection:Apicalimpulsetoleftinferior 視診:心尖搏左下移位carotidartery 頸動(dòng)脈搏動(dòng)Palpation:liftingapicalimpulse 診:抬舉性心尖搏動(dòng)water-hammerpulse 脈Percussion:boot-shapedheart叩診:靴型心AorticInsufficiencyAuscultation主動(dòng)脈瓣關(guān)閉不全聽診(2)Aorticarea:主動(dòng)脈瓣區(qū)Heartsounds:S2↓第二心音減弱Murmur:earlydiastolic,highpitch,blowing,radiatingtotheapex舒張期遞減型嘆氣樣雜音Apexarea:心尖部Heartsounds:S1↓第一心音減弱Murmurs:Austin-FlintA-F雜音Distension腹部膨隆Abdominalwalldisorders腹壁改變Tumor:appearedclearlyinforce 腫物:腹部用力時(shí)腫物明顯Incrassation:hilumdepressedsuchasobesity 增厚:臍部凹陷如肥胖Abdominalincrease腹腔增大Fulldistension:normalpregnancyandabnormal 全腹膨隆:正常妊娠和異常Localdistension局部膨隆Measuresurroundofabdomen測(cè)量腹圍Aroundtheabdomenthroughhilumbysoftruler仰臥位用軟尺繞臍CommonCausesofDistension常見膨隆原因Fat肥胖Fluid腹水Feces糞塊Fetus妊娠Flatus胃腸脹氣Fibroids平滑肌瘤Fataltumor .Remember:5FContour:ProtuberantAbdomen全腹膨隆Ascites:frogshapeofabdomen, hilumhernia. 腹水:蛙狀腹常伴臍疝causes:hepatocirrhosis,seriousheartfailure,pericarditis,renaldiseasesyndrome,peirto 病因:肝硬化嚴(yán)重心衰縮窄性心包炎腎病綜合征腹膜癌Gasesdistentionoftheintestines:sphericityofabdomen 腸脹氣:球形腹causes:ileus,intestinalparalysis. 病因:腸梗阻腸麻痹O(shè)rganomegaly:enormousovarycystandteratoma. 腫瘤:巨大囊腫畸LocalDirectionoftheBloodflow血流方向檢查Usetwofingersonappearedvein用兩手指并攏壓在靜脈上Twofingerspressanddispart 兩手指加壓分開Loosensuperiorfinger松開上端手指Fastershowbloodflowdownwards充盈快示血

向下Repeatabove 重復(fù)以動(dòng)作Looseninferior 松開下端手Fastershowbloodflow ObstructionofVenaCava腔靜脈阻塞Varicosityontheflanks曲張靜脈在側(cè)腹部Obstructionofsuperiorvenacava:bloodstreamto 上腔靜脈回流受阻血流方向向下Obstructionofinferiorvenacava:bloodstreamtoupwards. ReboundTenderness(Blumbergsign)反跳痛Examinationmethod:pressdeeplyandslowly,letslipsuddenly. 檢查方法:逐漸深壓腹壁突然松開Positivefinding:painprickupinloose.陽(yáng)性:松開時(shí)疼痛加劇Clinicalmeanings:inflammationintheparietalperito.提示:炎癥波及壁層腹膜PeritonealIrritationSignThreesignsameappear:TendernessReboundtendernessGuarding三聯(lián)征:跳痛腹肌緊張Clinicalmeaning:acuteperitonitis提示:急性腹膜MeasureofEnlargedSpleen腫大脾臟的測(cè)量Thefirstline:betweencostalmarginandlowedgeofspleeninleftmidclavicularline1線(甲乙線):左鎖骨中線上肋緣至脾下緣Thesecondline:betweenthepointoftheleftmidclaviculcrosscostalmarginandthepointofspleenapoapsis. 2線(甲丙線):左鎖骨中線肋緣點(diǎn)至脾最遠(yuǎn)點(diǎn)Thethirdline:betweenrightsideofspleenandmidline,expresswithpositiveornegative 3線(丁戊線):脾右緣至正中線以SpleenEnlargementDegrees脾臟腫大分度Mildenlargement:<2cmundertherib輕度腫大:肋下<2cmModerateenlargement:notexceedthelevelofumbilicus中度腫大:不過(guò)臍Severeenlargement:exceedthelevelofumbilicusormidline高度腫大:過(guò)臍或中線Murphy’sSign莫非氏征Technique:Holdyourfingersundertheliverborder.手指放于肝臟下緣Positivesign:Asthedescendingliverpushestheinflamedgallbladderontotheexamininghand,thefeelssharppainandabruptlystopsinspirationmidway. 陽(yáng)性:吸氣時(shí)肝臟和膽囊下移手指觸及炎性膽囊時(shí)被檢者CharacteristicsofPalpation觸診要點(diǎn)LocationrelationtoorgansSize:diameterinlong,wideandthickContour:shape,marginandsurfaceTexture:soft,firmandhardTenderness:inflammation,liverswellingPulsation:dilativeandconductiveMovability:shiftbyrespirationorhand部位:所在部位與該處臟器多相關(guān)連大小:縱長(zhǎng)橫寬深厚可用實(shí)物比喻輪廓:形狀邊緣表面質(zhì)地:柔軟中等硬度質(zhì)硬壓痛:炎癥肝腫大搏動(dòng):膨脹性和傳導(dǎo)性移動(dòng)度:隨呼吸移動(dòng)用手推動(dòng)FluidThrill液波震顫Technique:moveflankwallbyhand檢查方法:用手推動(dòng)一側(cè)腹壁Positive:theotherhandfeelsliquidwave陽(yáng)性征象:對(duì)側(cè)手掌感到液體波動(dòng)Meaning:largevolumeofascites,usually>3000ml臨床意義:大量腹水在3~4升以上PercussionofAscites腹水叩診Shiftingdullness:移動(dòng)性濁音freefluidcausesair-containingguttofloatuptothemostsuperiorposition液體流動(dòng)使含氣臟器位于最置volumeofascitesusuallyexceeds1000mlif 腹水量在1000ml以上Puddlesign:水坑freefluidinthemostinferiorpositioninelbow-kneeposture 膝位腹水位于最低位awaytodetectsmallamountsoffluid 腹水和囊腫的鑒別Signs 征象Ascites 囊腫Dorsalposition仰臥位Umbilicus 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 陽(yáng)性Nojumpiness 無(wú)跳動(dòng)Middledistension中腹膨隆Flat 平坦Middledullnessside 中部濁音兩側(cè)鼓音Negitive Rhythm AuscultationofAbdomen腹部聽診bowelsounds腸鳴音vascularsounds血管雜音frictionrub摩擦音scratchsound搔彈音splashingsound振水音ScratchSound搔彈音Mechanism:soundwaveconductivediversityindiffermediummadenoisealteration.Aidsinstaticborderdefinition機(jī)制:聲波在不同介質(zhì)中傳導(dǎo)的差異致聲響改變有助于確定實(shí)質(zhì)臟器或液體邊界Technique:putthestethoscopeincentralandthehandscratchtoit,whensoundsuddenlyincreasedindicatethe 方法:聽診器置于手邊搔彈邊向聽診器移動(dòng)聲響突然增強(qiáng)為其邊界Meaning:confirminferiorborderoftheliverandascites(<120ml) 意義:確定肝臟下界和小量腹水范圍CirrhosisofLiver肝硬化Smalllivertopercussionbutahardedgemaybepalpableunderthexiphoid劍突下觸及邊鈍質(zhì)硬縮小的肝臟Spleenpalpable 脾臟肋緣下可觸及Varicosityandascites 周靜脈曲張和腹水征palmarerythema,spiderangiomaand 肝掌蜘蛛痣 發(fā)育Gastrointestinal AscitesSign腹水征Inspection:frogshapeofabdomenindorsalposition,hypogastriumregiondistensionwithhilumherniainstand.視診:仰臥位蛙狀腹直立位下腹膨隆臍突出Palpation:fluidthrill(asciteslargethan3000ml) 觸診:液波震顫(腹水量>3000ml)Percussion:shiftingdullness(asciteslargethan1000ml),puddlesign(smallamountsoffluid) 叩診:移動(dòng)性濁音(腹水 水坑征(少量腹水)Auscultation:umbilicusscratchsoundinelbow-kneeposture(ascites<120ml) 聽診:臍部搔彈音(腹水量<120ml)AcutePerforatedGastricorDuodenalUlcer急性胃十二指腸穿孔Suddenlyepigastricpain,forcedsupinepositionandtwinlowerlimbsflection突發(fā)上腹痛強(qiáng)迫仰臥位雙下肢屈曲Acuteperitonitissigns,tendernessandreboundpaininepigastriumorroundumbilicus 急性腹膜炎征象壓痛反跳痛位于上腹部和臍周Hepaticdullnessregiondecreaseordisappear 失shiftingdullnessinabdomen PhysicalExaminationPoint急性胃腸穿孔檢體要點(diǎn)Gasin:dullnessareaofliverdisappear 腹腔氣體:肝濁音區(qū)縮小Liquidinabdomen:shiftingdullness 腹腔液體:腹部移動(dòng)性濁音Inflammationinabdomen:acuteperitonitissign,seriousinepigastricandumbilicalregion. 腹部炎癥反應(yīng):急性彌漫性腹膜炎征 上腹部和臍周forepart:acuteacheface,compulsivesupineposition,lowerlimbsflection 早期:急性痛苦面容冷汗強(qiáng)迫仰臥位雙下肢屈曲 anaphase:highfever,pulse 后期:高熱失水精神萎靡面色灰白眼球凹

脈搏頻AcutePeritonitisSigns急性腹膜炎征象Inspection:generaldepressioninabdomen,decreasedordisappearedabdominalrespiration 診:腹部凹陷腹部呼吸運(yùn)動(dòng)減弱Palpation:tenderness,reboundtenderness,rigidabdominalwall 觸診:壓痛和反跳痛腹壁呈板狀硬Percussion:shiftingdullness 叩診:可有移動(dòng)性濁音Auscultation:decreasedorabsenceofbowelsounds 腸鳴音減弱IntestinalObstruction腸梗阻Symptom:bellyache,vomiting,nodefecateandanusexhaust 癥狀:腹痛無(wú)排便和排氣Inspection:fulldistension,intestineformandperistalticwave視診:腹部膨隆腸型可見腸蠕動(dòng)波Palpation:rigidabdominalwall,tendernessandreboundpain 觸診:腹肌緊張壓痛及反跳痛Percussion:tympanyregionincreased 叩診:鼓音范圍增大Auscultation:mechanicalileus paniedsharpbowelsoundanddecreasedorabsenceofbowelsoundsinparalysisileus聽診:機(jī) 麻痹性腸梗阻腸鳴音減弱或MusclePower肌力Forcebymusclecontractionproduced 收縮產(chǎn)生的力量Musclepowerdecreasingordisappearingcalledpartialorcompleteparalysis 肌力下降或稱為不完全或完全癱瘓Paralysisdividedhemiparalysis,crossedparalysis,paraplegiaandsinglelimbparalysisbypathologicposition 分為偏癱交叉癱截癱和單癱Paralysisdividedcentralandperipheralbylocationofnervousinjury Thegradingofmusclestrength肌力分度Absent(0degree):nocontractiondetected. 0級(jí)(不動(dòng)):完全癱瘓Trace(1degree):slightcontractiondetected.1級(jí)(肌動(dòng)):肌肉可收縮不能產(chǎn)生運(yùn)動(dòng)Weak(2degree):movementwithgravityeliminated. 2級(jí)(平動(dòng)):床面上可移動(dòng)不能抬離Fair(3degree):movementagainst 3級(jí)(抬動(dòng)):能抬離床面不能抗阻力Good(4degree):moveagainstgravitywithsome 4級(jí)(弱抗動(dòng)):能抗阻力但較正常差Normal(5degree):movementagainstgravitywith 5級(jí)(正常):正常肌力Tremor震顫Statictremor:embitterinwhishtandmitigateinmovement,seeninparalysisagitans 靜止性:靜重動(dòng)輕見于震顫麻痹Intentionaltremor:embitterinmovementandmitigateinwhisht,seenincerebeldisorders 意向性:動(dòng)重靜輕見于小腦疾患Seniletremor:noddedandhandtremble,seeninarteriosclerosis老年性:點(diǎn)頭手抖見于動(dòng)脈硬化Fluttertremor:flickerinwristandpalm,seeninhepaticcoma 撲翼樣:腕掌撲動(dòng)見于肝Tremoroffingers:fineseeninhyperthyroidism 顫:細(xì)小抖動(dòng)見于甲狀腺機(jī)能亢進(jìn)癥PhysicalReflex生理反射Superficialreflex:inducedbythestimulationofmucocutaneousreceptors 淺反射:刺激皮膚粘膜感受器引起反應(yīng)Included:cornealreflex,abdominalreflex,cremastericreflex,plantarreflex 包括:角膜反射腹壁反射提睪反射跖反射Deepreflex:inducedbythestimulationofperiostealandtendon 深反射:刺激骨膜肌腱感受器引起反應(yīng)Included:bicepsreflex,tricepsreflex,brachioradialisreflex,palarreflex,achillestendonreflex包括:肱二頭肌反射肱三頭肌反射橈骨 膝(腱)反射跟腱反射PyramidalSign錐體束征Upperlimbspathologicalreflex:HoffmannSignusuallyseenincervicalregiondisordersofspinal 上病理反射:征多見于頸髓病變Lowerlimbspathologicalreflex:Babinskisign,Chaddocksign,Oppenheimsign,Gordonsing下肢病理反射