物理诊断diagnosis白皮英文

Whatisdiagnosis?什么叫诊断？Diagnosisisinvestigationand 诊断就是诊察和判断Investigationisdatacollecting.诊察是收集疾病信息Judgmentissynthesisandyzedatatodeterminethenatureofillness. 判断是综合分析信息确定所患疾病Thediagnosisistakingaboutthemethodofdatacollectingandhowtomakeacorrectjudgment. StepsofDiagnosis诊断步骤Datacollectinghistoryintervewingphysicalexamination laboratoryexamination examinationDatayzingDeterminationof thenatureofthe ClassificationofClinicalDiagnosis临床诊断的分类Etiologicdiagnosishepatitis RheumaticheartdiseasePathological-anatomicdiagnosis AorticregurgitationLivercirrhosisPathophysiologicdiagnosis 病因诊 Inquiry问诊Inquiryisonemethodfromtheinterviewbetweendoctorandpatientorrelativefordiseasehistory,andmakingtheclinicaldeterminationbyyzinghistory.通过对患者或相关人员的询问获取病史资 经过综合分析ContentsofQuestioning问诊的内IdentifyinginformationSourceandreliabilityChiefcomplaintsPresentillnessPastmedicalhistoryalhistoryMaritalhistoryMenstrualandobstetrichistoryinwomenFamilyhistory患者个人信息叙述者和可信度主诉现病史既往史个人史史月经史史IdentifyingInformation患者个人信息NameSexandAgeNativeplaceBirthplaceNationalityMarriageAddressWorkplaceOccupation和籍贯出生地国籍或民族住址工作地点职OthersInformationChiefComplaint主 fortanditsMakesuretobe: persistingheadachefor3daysMakesuretoavoidusing: onsettimeofthedisease 书写注要简明扼要按时间先后持头痛3三不不要用起病时不要用诊断术PresentIllness现病Furtherdescriptionofthemaincomplaint,includingthewholediseaseprocessOnsetanddurationandPredisposingfactorsCharactersofthemainsymptom,progressionand symptomsManagementsandeffectsEffectsondailylife

PastMedicalHistory既往史PasthealthstatusPastillnessHistoryofinjuryHistoryofsurgeryHistoryofallergyHistoryofbloodtransfusionHistoryofvaccinationSystemicreview既往健康状况既往所患疾病既往外伤史 手术史 alHistory个人史Homeplace,inhabitationplace,epidemicdiseaseortravelexperiencetoepidemicareaSmokingandalcoholintakeWorkHousingconditionLifestyleSexhistory MaritalHistory史Marriageage 结婚Healthstatusofthespouse 爱人健康状况Maritalatta MenstrualandObstetricalHistory 史Formulaforrecording intermenstrualperiod(day)Menarcheage———menopauseage menstrualcycle LMPMenses:volume,color,leucorrhea,dysmenorrhealObstetrical:numberofpregnancyanddelivery,historyofoperativedelivery,difficultlabor,abortion 周期或绝经行经情况量颜色有无痛经孕产情况孕次产次有无手术产难FamilyHistoryHealthstatusofthreesequentialgenerationsCausesofdeathExistingthesamediseaseHereditarydiseasesInfectiousdiseases 父母兄妹(几男几女)原因BasicExaminationTechniques基本检查法视诊inspection触palpation叩诊percussionauscultation嗅诊olfactory触诊Lightpalpation浅部触诊法Deeppalpation深部触诊法Deepslippalpation滑行触诊法Bimanualpalpation双手触诊法Deeppresspalpation深压触诊法Ballottement冲击触诊法PercussionNotes叩诊音Tympany:gasHyperresonance:increasedgasinlungtissueResonance:lungtissueDullness:gasandtissueFlatness:essentialorganorfluid鼓音:气体过清音: 清音:肺组织浊音:气体与组织实音: GeneralExamination一般检查Vitalsigns生命体征Development发育Habitus体型Nutritionalstatus营养Consciousness意识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体温正常(腋窝)体温:36~37℃发热:T>37℃体温不升脉搏脉率:60~100/min节律:整齐呼吸频率:16~18/minDisturbanceofConsciousness意 Somnolence嗜睡意识模糊Stupor昏睡 Delirium谵FacialFeaturesandExpression面容与表情mitralface二尖瓣面Acutediseaseexpression急容Chronicdisease慢容Specialface 特殊面容GravesDisease甲亢面容MoonedFaceInducedbyCushing’s库兴氏满月脸HippocraticFaciesMyxedema粘液水肿Acromegaly肢端肥大PositionRelaxedposition自主Positivepositionindepletionorunconsciouspatient极度衰竭意识丧失Compulsiveposition强迫torelieve fort减轻痛苦被迫采取的Git步态l:clmditiesAbnolligitenniticitsitigitgertpitsissitteitetcliissicesis正常::蹒跚步态醉酒步态共济失调步态慌张步态跨阈步态剪刀步态间歇SubcutaneousHemorrhage皮下Winecolorandwon’tfadewhenpressed暗红色压之不褪色Petechia:<2mm瘀点<2mmPurpura:3~5mm紫癜:3~5mmEcchymosis:>5mm瘀斑:>5mmHematoma: 血肿:片状伴皮肤隆起SpiderAngioma蜘蛛痣Highlybranchedslatearteriallesionswhichpulsateandblanchonpressure.Distributedcommonlyonface,neck,orchest.Maybeassociatedwithpregnancy,chronicliverdisease,orestrogentherapy,ormaybenormal.定义:小动脉末端分支性扩张特点:受压血管机制:雌激素增多部位:上腔静脉区域面部颈部和胸部病因:妊娠慢性肝脏病变雌激素治疗Recordcontent记录内容Normalnode: 2~5mm,soft,smooth,notendernessandadhesion.Recordifenlarged:location,size,number,hardness,tender,mobility,adhesion,superficialskin.正常淋2~5mm质软光滑无压痛无粘连肿大时记录部位大小数目硬度压痛活动度粘连Pupil瞳孔大小Normal:3~4mmDilation: atropinizationContraction:organophosphoruspoisoning,drugreaction,narcotictakingPlatycoria:dying正常:3~4mm扩大:青光眼阿托品缩小: 有机磷药物反应过量双侧散大: 濒死状态CompareBothPupil比较双侧瞳孔Normal:SymmetryAnisocoria:Pathologyanywherefromthereceptionoflightthroughtheopticnervestothebrainstem,thethirdcranialnerve,sympathetic,orparasympatheticpathwaysCerebralhernia正常:等大等圆不等大视神经至脑干病变动眼神经受压交感神经受压副交感神经受压脑疝表面皮肤情况Sinuses鼻窦Location部位frontalsinuses额窦ethmoidsinuses筛窦maxillarysinus上颌窦Sphenoidsinusestenderness&percussionpain:sinusitis鼻窦区压痛叩击痛:TongueSize舌体Enlarged:inflammation,myxedema,tumor,acromegaly舌体肿大:炎症 肿瘤肢端肥大症Shrinked:severedehydration舌体干小:严重脱水AppearanceofTongue舌象Geographicandwrinkledorfissuredtongue:riboflavindeficiencyStrawberrytongue:longfeverBeefytongue:niacindeficiencySmoothtongue:ironorVitB12deficiencyBlackhairytongue:fungusinfection地图舌和裂纹舌: 提示核黄素缺乏草莓舌:舌肿胀 期发热牛肉舌:舌面绛红 菸酸缺乏镜面舌:光滑红色铁或维生素B12缺乏黑毛舌:黑黄褐色毛真菌PharynxandTonsil咽和扁桃体Pharynx咽 Turkeyredpaniedbyswelling:Acute 红肿:急性咽 paniedby Chronic暗红滤泡:慢性咽炎Tonsil扁桃 degreeoftonsil

Ⅰ°不超过腭咽弓Ⅱ°超过腭咽弓未达中线Ⅲ°达到超过咽后壁中线purulent化脓性扁桃体炎PalpationoftheTrachea触摸气管位置Indicatethelocationofmediastinum指示纵隔位置Location:normallyinthemiddle正常居中Shiftingtothehealth:largepleuraleffusion,pothorax移向健侧:大量胸腔积液气胸Shiftingtothedisaster:emphysema移向患侧:肺不张TheDegreeofThyroidGlandSwelling甲状腺肿大的分度Ⅰ:invisiblebutpalpable 不能看到能触到Ⅱ:visibleandpalpable能看到又能触到Ⅲ:exceedingtheoutmarginofsterno-mastoid AbnormalIntercostalSpace肋间隙改变Recessedornarroweddepressedwheninspirating:airwayobstruction depression:aeis,pleuraladhesionWideorswellinggeneralintensewhenexpirating:emphysema,bronchialasthmaone-sideintense:pleuraleffusion,pothorax 吸气时凹陷:大气道阻塞一侧变窄凹陷: 肺不张胸膜粘连膨隆或增宽(容积增大) 肺气肿支气管哮喘一侧增宽膨隆:胸腔积液气胸AbnormalLungBorder肺界异常Kronig’isthmus:Widening:emphysemaNarrowing(unilateral):tuberculosis,tumorInferiorborder:Lowered:emphysemaRised:aeis,increasedintra-abdominalpressureUndetectable:Pleuraleffusion,肺上界增宽:肺气肿变窄:肺结 肺下界下降:肺气肿升高:肺不张腹压增高叩不出:胸腔积 AbnormalDiaphragmaticExcursion肺下界移动范围异常<4cm减弱:<4cmUnilateral:ataleis,pleuraladhension单侧:肺不张膜粘连Bilateral:emphysema,lungfibrosis双侧:肺气肿肺纤维化AbnormalIntercostalSpace肋间隙改变Recessedornarroweddepressedwheninspirating:airwayobstruction depression:aeis,pleuraladhesionWideorswellinggeneralintensewhenexpirating:emphysema,bronchialasthmaone-sideintense:pleuraleffusion,pothorax凹陷或变窄(容积缩小)吸气时凹陷:大气道阻塞一侧变窄凹陷: 气肿支气管哮喘一侧增宽膨隆: 胸腔积液气胸Chestshape胸廓形态Normal:Ap:T=1:1.5Abnormal:FlatchestandBarrelchestRachiticchest Pigeonchest RachiticrosaryFunnelchest HarrisongrooveRegionaltransfigurationThorax-vertebrae-malformation-induced胸廓正常形态前后径:横径1:1.5胸廓形态异常扁平胸和桶状胸佝偻病胸鸡胸串珠胸漏斗胸肋膈沟局部变形胸椎严重畸形PathologicalConditions异常改变Weakenordisappear:Obstructiveae is,emphysema,Pleuraleffusion,p subcutaneousemphysemaEnhanced: Consolidationoflungtissue:lobarp onia,pulmonaryinfarction. Largeinthelung,esp.nearthepleura:lungabscess,cavernouspulmonarytuberculosis.减弱或阻塞性肺不张 肺气肿胸腔积液 肺实变:大叶肺梗死 ClinicalSignificanceLocalizedcrackles:regionaldiseasesBilateralcracklesinlowerfieldofthelungswithrhonchi:bronchitiswithlunginfectionCracklesinbilateralbasesofthelungs:pulmonarycongestioncausedbyheartfailureGeneralizedcoarsecracklesinbilaterallungfields:acutepulmonary局部: 并两肺底对称性: 左心功能不全两肺满布:Emphysema肺气肿Pathology: airtrapinthelungInspection:barrelchestPalpation:decreaseddynamiceventsofrespirationandtactilefremitusPercussion:hyperresonce;Down-shiftingoftheinferiorborderofthelungAuscultation:decreasedbreathsoundsandvocal机制 双肺含气增多视诊 桶状胸触诊 呼吸动度减弱语颤减弱叩诊过清音肺下界下移听诊呼吸音减 语音弱Aeis肺不张Pathology:theairwayisobstructedandthelungholdsnoairInspection:theaffectedchestwallisflattenedPalpation:decreaseddynamiceventsofrespirationandtactilefremitus;ThetracheaisshiftedtotheaffectedsidePercussion:dullnessorflatnessAuscultation:breathsoundsandvocalresonancedisappear.机制气道阻塞肺不含气视诊患侧胸廓凹陷触诊患侧呼吸动度减弱语颤减弱气管移向患侧叩诊患侧浊音或实音听诊患侧呼吸音、语音LobarP 性实变Pathology:toomuchfluidinalveoliInspection:normalchestPalpation:decreaseddynamiceventsofrespiration,increasedtactilefremitus.Percussion:dullnessorflatnessAuscultation:tubularbreathsound,crackles,increasedvocalresonance机制气道通畅 肺泡腔充满液体视诊患侧呼吸运动减弱触诊患侧呼吸动度减弱 强叩诊病变区浊音或实音听诊管状呼吸 语音增强 othorax气胸Pathology:airistrappedinpleuralInspection:over-inflationoftheaffectedsidePalpation:decreaseddynamiceventsofrespirationandtactilefremitus;the tympanyAuscultation:breathsoundsandvocalresonancedisappear机制胸腔气体存积视诊患侧饱满触诊患侧呼吸动度减弱 气管移向健侧叩诊患侧鼓音听诊患侧呼吸音语音PleuralEffusion胸腔积液Pathology:fluidistrappedinpleuralInspection:over-inflationoftheaffectedsidePalpation:decreaseddynamiceventsofrespirationandtactilefremitus;thetracheaisshiftedtotheunaffectedsidePercussion:dullnessflatnessAuscultation:breathsoundsandvocalresonance机制胸腔液体存积视诊患侧饱满触诊患侧呼吸动度减弱 气管移向健侧叩诊患处浊音或实音听诊患处呼吸音语音AbnormalLungBorder肺界异常Kronig’isthmus:Widening:emphysemaNarrowing(unilateral):tuberculosis,tumorInferiorborder:Lowered:emphysemaRised:aeis,increasedintra-abdominalpressureUndetectable:Pleuraleffusion,pothorax肺上界增宽:肺气肿变窄:肺结 肺肿瘤肺下界下降:肺气肿升高:肺

腹压增高叩不出:胸腔积气胸AbnormalDiaphragmaticExcursion肺下界移动范围异常Decreased:<4cm减弱:<4cmUnilateral:ataleis,pleuraladhension单侧:肺不张胸膜粘连Bilateral:emphysema,lungfibrosis双侧:肺气肿肺纤维化ClassifyofBreathSound呼吸音分类Normalandabnormal正常和异常呼吸音Bronchialbreathsounds支气管呼吸音Vesicularbreathsounds 肺泡呼吸音BronchovesicularbreathsoundsInspectionoftheHeart心脏视诊precordiumshape normalapicalimpulse 正常心尖搏动abnormalapicalimpulse异常心尖搏动precordialabnormalimpulse PrecordiumShape心前区外形Precordialbulge心前区隆起Features:bonybulge特点:骨骼突起Clinicalimportance:Congenitalheartdiseasewithventricularenlargement 大Precordialsatiety心前区饱满Features:intercostalregionsticking 特点:肋间软组织外突Clinicalimportance:massofpericardialeffusion提示:大量心包积液NormalApicalImpulse正常心尖搏动Location:0.5~1cmtotheleftmidclavicularlineatthe5thICSoutsideLSB.Range:2~2.5cmDirection:outwardwhenventricularsystolebegins位置:5肋间左锁骨中线内0.5~1cm范围2~2.5cm方向:收缩时向外搏动意义:提示心尖位置代表收缩期提示心脏大小AbnormalDullnessHeartBorder(1)heartvariation心脏改变L.Venlargement:boot-shapedheart左室扩大:靴形L.Aenlargement:pear-shapedheart 左房扩大:梨形心B.Venlargement:generalenlargedheart 双室扩大:普大心R.Venlargement:corpulmonal右室扩大:先心肺心Pericardialeffusion:flask-shapedheart心包积液:烧瓶心、AbnormalDullnessHeartBorder心界叩诊异常(2)chestandlungdiseases胸肺疾病Pleuraleffusionorlungconsolidation:dullnessborderundetectable 胸腔积液或肺实变:叩不出Emphysema:“shrinked”dullnessborder肺气肿:心浊音界缩小abdominaldisorders腹部疾病Diaphragmelevation:acrossingheart膈升高:Boot-shapedHeart靴形心Mechanism:L.VenlargementFeatures:theleftborderextendstotheinferiorleft,waistoftheheartisdeepened.Causes:aorticinsufficiency,hypertensiveheartdisease机制:左室扩大特点 心左界向左下扩 心腰加深病因 Pear-shapedHeart梨形心Mechanism:L.AenlargementanddistensionofpulmonaryarteryFeatures:dullnessheartborderinthe2nd,3rdICSontheLSBextendsoutside,waistoftheheartbulgesoutCauses:mitralstenosis机制: 左房扩大肺动脉扩大特 胸骨左缘2,3肋间心浊音界向外扩大心腰饱 GeneralEnlargedHeart普大心Mechanism:bothleftandrightventricleareenlargedFeatures:thedullnessborderextendstobothsides,theleftborderextendstoinferiorleftCauses:cardiomyopathy,myocarditis,wholeheartfailure机制:左右 心浊音界向双侧扩大左界向下扩大病因扩张型心肌病克山病重症心肌炎全心衰竭Flask-shapedHeart烧瓶心Mechanism:pericardialeffusionFeatures:Sittingposition:triangulardullnessborderSupine:wideneddullnessborderofthebase机制:心包积液特点:坐位时心浊音界呈三角形仰卧位心底部浊音区增宽随心界改变FirstHeartSound,S1第一心音SignalingthebeginningofIthascharactersoflowpitch,longduration. Itcanbeheardbestintheapexarea.在心尖部听诊最清楚SecondHeartSound,S2第二心音Signalingthebeginningofdiastole.提示舒张期开始Itishigh-pitched,low-intensity,shorterandbrisker.高调低强度时间短轻脆“嗒”Itcanbeauscultatedbestatthebaseoftheheart.在心底部听诊最清楚S1第一心音S2第二心音Pitch音调Low低High高Intensity强度High强Low弱Quality音质Blunter低钝Brisker清脆Duration持续时间Long长Short短Interval两者间隔S1-S2长<S2-S1短Apicalimpulse 心尖搏动itant 一致Post之后Bestsite最响部位Apex心尖Base心底ChangesofQuality心音性质改变ChangesofS1quality:S1sameasS2(blankness) 第二心音相同(单调)Diastolicphaseshorten:sameassystolic(single (单律)Characteristic:pendularrhythm,embryocardia 钟摆律胎心律Clinicalmeaning:myocardialdamageseverely,asacutemyocardialinfarction,severemyocarditis,. 提示:心肌严重受损如急性心肌梗塞重症心肌炎WideSplitting顺Typicalattheendofinspiration 明显Physiologicsplitting:deep 生理:气相回右心血量增加GeneralsplittingDelayedP2:pulmonaryhypertension,mitralstenosis,pulmonicstenosis,rightbundlebranchblock. 肺动脉瓣关闭延迟:肺动脉高压 二尖瓣狭窄肺动脉瓣狭窄右束支阻滞EarlyA2:mitralinsufficiency,IVSD主动脉瓣关闭提前:二尖瓣关闭不全室间隔缺损FixedSplitting固定Splittingisunaffectedbyrespiration不受呼吸影响Mechanism:delayedclosureofthepulmonicvalve(outputoftherightventricleisgreaterthanthatoftheleft)机制:肺动脉瓣关闭延迟Bloodflowfromleftatriumtotherightpassingthroughseptaldefectsamortizedaffectionofrespiration.房间隔缺损处血液左向右分流缓冲呼吸影响Commondiseases:largeatrialseptaldefectsandrightventricularfailure. 病因:大的房间隔缺损并右心功能不全ReversedSplitting逆Typicalattheendofexpiration 呼气末明显ParadoxicalSplitting:P2occursfirstly,followedbyA2 反常:肺动脉瓣第二音出现在主动脉瓣第二音之前Mechanism:closureoftheaorticvalveisdelayed 机制:主动脉瓣关闭明显延迟Commondiseases:Leftbundlebranchblock,Aortic 病因:左束支传导阻滞主动脉瓣狭窄ExtraHeartSoundssystolicextraheartsounds收缩期额外心音diastolicextraheartsounds舒张期额外心音ExtraHeartSounds额外心音SystolicEarlysystole:ejectionsoundsMid-/Latesystole:clickDiastolicEarlydiastole:openingsnap,pericardialknockMid-diastole:thirdheartsoundLatediastole:fourthheartsoundgalloprhythm收缩早期喷射音中晚期喀喇音舒张早期开瓣音心Gallop奔马律Mechanism:decreasedcomplianceoftheventriclecausedbyseveremyocardialdamage机制:心肌严重受损致

壁顺应性差Classification:分类Protodiastolicgallop(Ventriculargallop,S3gallop) 舒张早期奔马律(室性奔马律第三心音奔马律)Latediastolicgallop(atrialgallop,S4gallop) (房性奔马律第四心音奔马律)Quadruplerhythmandsummation 四音律和奔马律PhysicalS3&PathologicalS3生理性与病理性第三心音的区分QuadrupleRhythmandSummation四音律和奔马律Mechanism:pathologicalS3&S4. Duringtachycardia,thediastolicfillingtimeshortensandtheS3andS4moveclosertogether.心率加速时舒张期缩短四心音Theysoundsuperimposedinmid-diastole,andoneloud,prolonged,summatedsoundcanbeheardoftenlouderthaneitherS1orS2.特点:舒张中期较长响亮心音强于第一或第二心音CharacterizationofMurmurs杂音听诊要点LocationDurationPitchandQualityIntensityandTimingTransmissionorradiationEffectmurmursoffactor杂音的部位杂音的时期杂音的性质杂音的强度杂音的传导影响杂音的因素Location杂音部位Apicalarea:mitralvalveAorticarea:aorticvalvePulmonicarea: pulmonicvalveInferior tricuspidvalve3rd,4thICS,LSB:ventricularseptaldefect2nd,3rdICS,LSB: patentductusarteriosus杂音出现和最响部位与病变部位血流方向传导介质相关心尖部:二尖瓣主动脉瓣听诊区:主动脉瓣肺动脉瓣听诊区:肺动脉瓣胸骨下端:胸骨左缘34肋间:室间隔胸骨左缘23肋间:动脉tin 杂音时期tic (Hlslclitlicteitic (MHditliclMiitice(eti)ts收缩期杂音全收缩期收缩早期收缩中期收缩晚期舒张期杂音全舒张期舒早舒中舒晚连性音DistinguishDuration时期的区分systolicmurmur收缩期杂音appearbetweenS1andS2,sameasapicalimpulse 与第二心音之间出现与心尖搏动一致diastolicmurmur舒张期杂音appearbetweenS2andS1,nonsameasapicalimpulse在第2心音与第1心音之间出现 IntensityofSystolicMurmur收缩期杂音强度GradeⅠ:barelyaudibleinquietroom 1级:仔细听方可听到GradeⅡ:quietbutclearlyaudible 2级:容易听到但不响亮GradeⅢ:moderay 3级:较响亮GradeⅣ:loud,associatedwith4级:粗糙且响亮伴传导震颤GradeⅤ:veryloud,thrilleasily 5级:震耳GradeⅥ:veryloud,audiblewithstethoscopenotincontactwithchest,thrillpalpableandvisible6级:离开胸壁亦可闻及FunctionalandOrganicMurmurs收缩期杂音的鉴别Functional功能性Organic器质性AgeYoung儿童青少年Unlimited不定Location部位Pulmonic/apical 肺动脉瓣或心尖部Anyarea各部位Character性质Soft,smooth柔和Coarse,highpitch粗糙高调Duration时间Short短Long(wholesystole)（全收缩期）Intensity强度<3/6>or=3/6Thrill震颤no无Yes有Transmission传导Localized局限extensive传导Systolicmurmurinleftsternumintercostal3~4: septaldefect 胸骨左缘34肋间收缩期杂音:室间隔缺损Continuousmachine-likeinleftsternumintercostal2: ductusarteriosus 胸骨左缘第2肋间连续型杂音:动脉导管末PeripheralVascularSign周围血管征Vascularsign:征象Water-hammerPulse水冲脉Carotidarteryimpulse颈动脉搏动Noddingspasm点头运动 Capillarypulsation毛细血管搏动征Pistolshotsound枪击音Duroziezdoublemurmur杜氏双重杂音Clinicalmeaning:aorticinsufficiency,hypertension,Hyperthyroidism提示:主动脉瓣关闭不全高血压甲状腺机能亢进HeartDisease心脏疾病mitralstenosis 二尖瓣狭窄aortic 主动脉瓣关闭不全MitralStenosis二尖瓣狭窄(1)L.AenlargementPulmonaryarterydilationR.Venlargement 增大→肺动脉扩张→右室增大Inspection:Mitralface(malarflush),apicalimpulseleft 视诊:二尖瓣面容心尖搏左移位Palpation:diastolicthrillattheapexarea 触诊:心尖部舒张期震颤Percussion:pear-shapedheart 叩诊:梨型心MitralStenosisAuscultation二尖瓣狭窄(2)Apexarea:心尖部Heartsounds:AccentuationofS1 第一心音亢进Extrasound:openingsnaps开瓣音Murmurs:mid-orlate-diastolicrumblinginquality,decrescendo-crescendo,usuallylocalized,heardmoreclearlywiththepatientrecumbentoronhisleftsideoraftermoderateexercise.Pulmonicarea:肺动脉瓣区Heartsounds:AccentuationandsplittingofS2 第二心音亢进Murmur:Graham-steellG-S杂音AorticInsufficiency主动脉瓣关闭不全(1)Inspection:Apicalimpulsetoleftinferior 视诊:心尖搏左下移位carotidartery 颈动脉搏动Palpation:liftingapicalimpulse 诊:抬举性心尖搏动water-hammerpulse 脉Percussion:boot-shapedheart叩诊:靴型心AorticInsufficiencyAuscultation主动脉瓣关闭不全听诊(2)Aorticarea:主动脉瓣区Heartsounds:S2↓第二心音减弱Murmur:earlydiastolic,highpitch,blowing,radiatingtotheapex舒张期递减型叹气样杂音Apexarea:心尖部Heartsounds:S1↓第一心音减弱Murmurs:Austin-FlintA-F杂音Distension腹部膨隆Abdominalwalldisorders腹壁改变Tumor:appearedclearlyinforce 肿物:腹部用力时肿物明显Incrassation:hilumdepressedsuchasobesity 增厚:脐部凹陷如肥胖Abdominalincrease腹腔增大Fulldistension:normalpregnancyandabnormal 全腹膨隆:正常妊娠和异常Localdistension局部膨隆Measuresurroundofabdomen测量腹围Aroundtheabdomenthroughhilumbysoftruler仰卧位用软尺绕脐CommonCausesofDistension常见膨隆原因Fat肥胖Fluid腹水Feces粪块Fetus妊娠Flatus胃肠胀气Fibroids平滑肌瘤Fataltumor .Remember:5FContour:ProtuberantAbdomen全腹膨隆Ascites:frogshapeofabdomen, hilumhernia. 腹水:蛙状腹常伴脐疝causes:hepatocirrhosis,seriousheartfailure,pericarditis,renaldiseasesyndrome,peirto 病因:肝硬化严重心衰缩窄性心包炎肾病综合征腹膜癌Gasesdistentionoftheintestines:sphericityofabdomen 肠胀气:球形腹causes:ileus,intestinalparalysis. 病因:肠梗阻肠麻痹Organomegaly:enormousovarycystandteratoma. 肿瘤:巨大囊肿畸LocalDirectionoftheBloodflow血流方向检查Usetwofingersonappearedvein用两手指并拢压在静脉上Twofingerspressanddispart 两手指加压分开Loosensuperiorfinger松开上端手指Fastershowbloodflowdownwards充盈快示血

向下Repeatabove 重复以动作Looseninferior 松开下端手Fastershowbloodflow ObstructionofVenaCava腔静脉阻塞Varicosityontheflanks曲张静脉在侧腹部Obstructionofsuperiorvenacava:bloodstreamto 上腔静脉回流受阻血流方向向下Obstructionofinferiorvenacava:bloodstreamtoupwards. ReboundTenderness(Blumbergsign)反跳痛Examinationmethod:pressdeeplyandslowly,letslipsuddenly. 检查方法:逐渐深压腹壁突然松开Positivefinding:painprickupinloose.阳性:松开时疼痛加剧Clinicalmeanings:inflammationintheparietalperito.提示:炎症波及壁层腹膜PeritonealIrritationSignThreesignsameappear:TendernessReboundtendernessGuarding三联征:跳痛腹肌紧张Clinicalmeaning:acuteperitonitis提示:急性腹膜MeasureofEnlargedSpleen肿大脾脏的测量Thefirstline:betweencostalmarginandlowedgeofspleeninleftmidclavicularline1线(甲乙线):左锁骨中线上肋缘至脾下缘Thesecondline:betweenthepointoftheleftmidclaviculcrosscostalmarginandthepointofspleenapoapsis. 2线(甲丙线):左锁骨中线肋缘点至脾最远点Thethirdline:betweenrightsideofspleenandmidline,expresswithpositiveornegative 3线(丁戊线):脾右缘至正中线以SpleenEnlargementDegrees脾脏肿大分度Mildenlargement:<2cmundertherib轻度肿大:肋下<2cmModerateenlargement:notexceedthelevelofumbilicus中度肿大:不过脐Severeenlargement:exceedthelevelofumbilicusormidline高度肿大:过脐或中线Murphy’sSign莫非氏征Technique:Holdyourfingersundertheliverborder.手指放于肝脏下缘Positivesign:Asthedescendingliverpushestheinflamedgallbladderontotheexamininghand,thefeelssharppainandabruptlystopsinspirationmidway. 阳性:吸气时肝脏和胆囊下移手指触及炎性胆囊时被检者CharacteristicsofPalpation触诊要点LocationrelationtoorgansSize:diameterinlong,wideandthickContour:shape,marginandsurfaceTexture:soft,firmandhardTenderness:inflammation,liverswellingPulsation:dilativeandconductiveMovability:shiftbyrespirationorhand部位:所在部位与该处脏器多相关连大小:纵长横宽深厚可用实物比喻轮廓:形状边缘表面质地:柔软中等硬度质硬压痛:炎症肝肿大搏动:膨胀性和传导性移动度:随呼吸移动用手推动FluidThrill液波震颤Technique:moveflankwallbyhand检查方法:用手推动一侧腹壁Positive:theotherhandfeelsliquidwave阳性征象:对侧手掌感到液体波动Meaning:largevolumeofascites,usually>3000ml临床意义:大量腹水在3~4升以上PercussionofAscites腹水叩诊Shiftingdullness:移动性浊音freefluidcausesair-containingguttofloatuptothemostsuperiorposition液体流动使含气脏器位于最置volumeofascitesusuallyexceeds1000mlif 腹水量在1000ml以上Puddlesign:水坑freefluidinthemostinferiorpositioninelbow-kneeposture 膝位腹水位于最低位awaytodetectsmallamountsoffluid 腹水和囊肿的鉴别Signs 征象Ascites 囊肿Dorsalposition仰卧位Umbilicus Percussionsound 叩诊音Shiftingdullness移动性浊音Rulerpressingtest尺压试验Sidedistension侧腹膨隆Extrude突出Middletympanysidedullness 中部鼓音两侧浊音 阳性Nojumpiness 无跳动Middledistension中腹膨隆Flat 平坦Middledullnessside 中部浊音两侧鼓音Negitive Rhythm AuscultationofAbdomen腹部听诊bowelsounds肠鸣音vascularsounds血管杂音frictionrub摩擦音scratchsound搔弹音splashingsound振水音ScratchSound搔弹音Mechanism:soundwaveconductivediversityindiffermediummadenoisealteration.Aidsinstaticborderdefinition机制:声波在不同介质中传导的差异致声响改变有助于确定实质脏器或液体边界Technique:putthestethoscopeincentralandthehandscratchtoit,whensoundsuddenlyincreasedindicatethe 方法:听诊器置于手边搔弹边向听诊器移动声响突然增强为其边界Meaning:confirminferiorborderoftheliverandascites(<120ml) 意义:确定肝脏下界和小量腹水范围CirrhosisofLiver肝硬化Smalllivertopercussionbutahardedgemaybepalpableunderthexiphoid剑突下触及边钝质硬缩小的肝脏Spleenpalpable 脾脏肋缘下可触及Varicosityandascites 周静脉曲张和腹水征palmarerythema,spiderangiomaand 肝掌蜘蛛痣 发育Gastrointestinal AscitesSign腹水征Inspection:frogshapeofabdomenindorsalposition,hypogastriumregiondistensionwithhilumherniainstand.视诊:仰卧位蛙状腹直立位下腹膨隆脐突出Palpation:fluidthrill(asciteslargethan3000ml) 触诊:液波震颤(腹水量>3000ml)Percussion:shiftingdullness(asciteslargethan1000ml),puddlesign(smallamountsoffluid) 叩诊:移动性浊音(腹水 水坑征(少量腹水)Auscultation:umbilicusscratchsoundinelbow-kneeposture(ascites<120ml) 听诊:脐部搔弹音(腹水量<120ml)AcutePerforatedGastricorDuodenalUlcer急性胃十二指肠穿孔Suddenlyepigastricpain,forcedsupinepositionandtwinlowerlimbsflection突发上腹痛强迫仰卧位双下肢屈曲Acuteperitonitissigns,tendernessandreboundpaininepigastriumorroundumbilicus 急性腹膜炎征象压痛反跳痛位于上腹部和脐周Hepaticdullnessregiondecreaseordisappear 失shiftingdullnessinabdomen PhysicalExaminationPoint急性胃肠穿孔检体要点Gasin:dullnessareaofliverdisappear 腹腔气体:肝浊音区缩小Liquidinabdomen:shiftingdullness 腹腔液体:腹部移动性浊音Inflammationinabdomen:acuteperitonitissign,seriousinepigastricandumbilicalregion. 腹部炎症反应:急性弥漫性腹膜炎征 上腹部和脐周forepart:acuteacheface,compulsivesupineposition,lowerlimbsflection 早期:急性痛苦面容冷汗强迫仰卧位双下肢屈曲 anaphase:highfever,pulse 后期:高热失水精神萎靡面色灰白眼球凹

脉搏频AcutePeritonitisSigns急性腹膜炎征象Inspection:generaldepressioninabdomen,decreasedordisappearedabdominalrespiration 诊:腹部凹陷腹部呼吸运动减弱Palpation:tenderness,reboundtenderness,rigidabdominalwall 触诊:压痛和反跳痛腹壁呈板状硬Percussion:shiftingdullness 叩诊:可有移动性浊音Auscultation:decreasedorabsenceofbowelsounds 肠鸣音减弱IntestinalObstruction肠梗阻Symptom:bellyache,vomiting,nodefecateandanusexhaust 症状:腹痛无排便和排气Inspection:fulldistension,intestineformandperistalticwave视诊:腹部膨隆肠型可见肠蠕动波Palpation:rigidabdominalwall,tendernessandreboundpain 触诊:腹肌紧张压痛及反跳痛Percussion:tympanyregionincreased 叩诊:鼓音范围增大Auscultation:mechanicalileus paniedsharpbowelsoundanddecreasedorabsenceofbowelsoundsinparalysisileus听诊:机 麻痹性肠梗阻肠鸣音减弱或MusclePower肌力Forcebymusclecontractionproduced 收缩产生的力量Musclepowerdecreasingordisappearingcalledpartialorcompleteparalysis 肌力下降或称为不完全或完全瘫痪Paralysisdividedhemiparalysis,crossedparalysis,paraplegiaandsinglelimbparalysisbypathologicposition 分为偏瘫交叉瘫截瘫和单瘫Paralysisdividedcentralandperipheralbylocationofnervousinjury Thegradingofmusclestrength肌力分度Absent(0degree):nocontractiondetected. 0级(不动):完全瘫痪Trace(1degree):slightcontractiondetected.1级(肌动):肌肉可收缩不能产生运动Weak(2degree):movementwithgravityeliminated. 2级(平动):床面上可移动不能抬离Fair(3degree):movementagainst 3级(抬动):能抬离床面不能抗阻力Good(4degree):moveagainstgravitywithsome 4级(弱抗动):能抗阻力但较正常差Normal(5degree):movementagainstgravitywith 5级(正常):正常肌力Tremor震颤Statictremor:embitterinwhishtandmitigateinmovement,seeninparalysisagitans 静止性:静重动轻见于震颤麻痹Intentionaltremor:embitterinmovementandmitigateinwhisht,seenincerebeldisorders 意向性:动重静轻见于小脑疾患Seniletremor:noddedandhandtremble,seeninarteriosclerosis老年性:点头手抖见于动脉硬化Fluttertremor:flickerinwristandpalm,seeninhepaticcoma 扑翼样:腕掌扑动见于肝Tremoroffingers:fineseeninhyperthyroidism 颤:细小抖动见于甲状腺机能亢进症PhysicalReflex生理反射Superficialreflex:inducedbythestimulationofmucocutaneousreceptors 浅反射:刺激皮肤粘膜感受器引起反应Included:cornealreflex,abdominalreflex,cremastericreflex,plantarreflex 包括:角膜反射腹壁反射提睾反射跖反射Deepreflex:inducedbythestimulationofperiostealandtendon 深反射:刺激骨膜肌腱感受器引起反应Included:bicepsreflex,tricepsreflex,brachioradialisreflex,palarreflex,achillestendonreflex包括:肱二头肌反射肱三头肌反射桡骨 膝(腱)反射跟腱反射PyramidalSign锥体束征Upperlimbspathologicalreflex:HoffmannSignusuallyseenincervicalregiondisordersofspinal 上病理反射:征多见于颈髓病变Lowerlimbspathologicalreflex:Babinskisign,Chaddocksign,Oppenheimsign,Gordonsing下肢病理反射