1. Methods and pysical examination

2. 1Inspection 2Palpation ▲ 3Percussion ▲ 4Auscultation ▲ 5Smell

3. 1inspection Definition:By observing the patients systemic and local features with eyes to draw a conclusion or presume a diagnosis. least mechanical,hardest to learn

4. General visual inspection — as a whole Contents: age,facial expression,skin type tone and pattern of speech,position posture ， gait, nutrition,deformity or asymmetry of face,limbs,trunk

5. Close visual inspection — a single anatomic region Contents ： mucous membrane,eyes,nose,mouth, tongue ， muscle,bones, joints (the closer you look,the more you see)

6. 2Palpation  intrduction  specific qualities elicited by palpation  methods of palpation  announcements

7. introduction  definition:the act of feeling using the sense of touch to judge.  structures:(every part of the body) external structures, structures accessible through the body orifices, bones,joints,muscles,superficial nerves, ligaments,tendon sheaths

8.  range:exclusive,important for abdomen  the most sensitive locus of the examiner: (1)finger pulp (2) palmar surface of the metacarpophalangeal joint is sensitive to vibration (3)skin of back hand is sensitive to temperature

9. specific qualities elicited by palpation  Textur  Moisture  Skin temperature  Characteristics of masses  Precordial cardiac thrust  Crepitus  tenderness  thrills  vocal fremitus

10. Methods of palpation Light palpation Deep palpation Bimanual palpation

11. Light palpation Suitable for: joints,soft tissue,superficial arteries,vein and nerve Depth: 1 cm Method:gently slide fingertips over skin surface,then use cooperatiing action of metacarpophalangeal joint and wrist joint to rotate and glide. Notices:lightly touch

12. Deep palpation Suitable for:celiac change and neck,breasts,large muscle masses depth :2 cm Methods:deep slipping palpation deep press palpation ballottement

13. Bimanual palpation  Suitable for: liver, spleen,kidney,  Methods:put left palm on the back of the organ,then hold to the right hand to make the organ betwwen two hands.

14. Notice  Inform motive to patients  Warm and gentle  Proper position （ lie on one side ）  Urinate if palpate inferior belly  Do and think

15. 3percussion Definition:the act of striking the surface of the body to elicit a sound. Method of percussion ： direct percussion inderect percussion Most commonly used

16. Direct percussion Definition:striking the body surface directly with fingers,hand,reflex hammer Method:move intermedial tridactylism of right hand to each other,then slap the site Suitable for:exclusive change of chest and abdomen(pneumothorax ， generous pleural fluid)

17. indirect percussion Methods (1)press the palmar surface of the left long finger firmly onto the body surface as a pleximeter,only the distal phalanx should touch the wall,other fingers slightly uplift. the tip of the right long finger strike a sharp blow on the distal interphalangeal joint of the pleximeter as a plexor.

18. corecctwrong pose of indirect percussion

19. (2)The examiner holds the plexor finger flexed and rigid and delivers the blow by bending only the wrist; the elbow and shoulder should not move. (3)After the stroke,the plexor rebound quickly from the pleximeter (4)Struck two or three staccato blows in one place.

20. Suitable for: thorax, abdomen Notices:environment is quiet proper position compare symmetrical site change of percussion sound proper strength

21. percussion sound Resonance: airfilled lung(normal lung) Dullness:percussion over the heart when it is covered by lung Tympany:percussion the gastric air bubble Flatness:percussion the thigh muscles Hyperresonance:emphysematous lung

22. 4Auscultation Direct auscultation Inderect auscultation:through stethoscope

23. Inderect auscultation Lung:breath souds,whispers,voice sounds, crackles,friction Heart:normal heart sounds,gallops,murmurs rhythm disturbances,pericardial rubs and knocks Vessels of neck:murmurs in the thyroid, carotid,subclavian arteries,venous hums

24. Abdomen:bowel sounds,murmurs from aneurysms and stenotic arteries Skull:bruit of an arteriovenous fistula Joints,tendon sheaths,muscles for crepitus

25. stethoscope Vibrating air column:connect the body wall to the ears. Chestpiece:combines the bell and diaphragm Earpiece:connected by a spring

26. earpieces chestpiece diaphragm Air column

27. earpieces diaphragm chestpiece bell

28. Using the stethoscope,one shoud pay attention: earpiece without air leakage,pain,discomfort diaphragm pressed tightly against the wall eliminate the extraneous noises practice

29. 5smell Definition:the act by judging the relationship between abnormal smell and disease. Source of smell:breath,sputum,vomitus feces,urine,pus