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MindMap Gallery Medicine - physical examination diagnostics physical examination
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Medicine - physical examination diagnostics physical examination
An article about the physical examination mind map of Huke Dental College, including general examination, head examination, neck examination, chest examination, lung and pleural examination, etc.
Edited at 2023-12-07 10:07:38
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Medicine - physical examination diagnostics physical examination
- Valentine's Day marketing campaign
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- Outline
Physical examination
ordinary inspection
vital signs
T body temperature 36-37.2
BP blood pressure 90-139/60-89
R breathing 15-20 times/min
P pulse 60-100
Reflects the metabolic state of the body
age
child
Susceptible to exanthematous infectious diseases: such as scarlet fever and measles
idiopathic thrombocytopenia
minimal change nephropathy
Adolescents: rheumatic fever, tuberculosis, pneumonia
Middle-aged and elderly people: cardiovascular and cerebrovascular diseases, solid tumors, COPD
Development and body shape
Chest circumference = 1/2 height; distance between hands = height; sitting height = length of lower limbs
Nutritional status
The difference in fat distribution on the flexor side of the forearm or the lower 1/3 of the dorsal side of the upper arm is the smallest - the best way to judge the degree of fat enrichment
Malnutrition
10% below the standard weight BMI＜18.5kg/m2
Overnutrition
20% over standard body weight
BMI＞28kg/m2
secondary obesity
Hypothalamic Pituitary Disease Cushing's Syndrome Hypothyroidism Hypogonadism
face
Acute illness
Flushing complexion, excitement and restlessness, flaring nose, sores on lips, and painful expression
More common in acute infectious diseases, such as pneumococcal pneumonia, malaria, and meningococcal meningitis
Chronic disease appearance
Gaunt face, dull or pale complexion, dull eyes
Seen in chronic wasting diseases, such as malignant tumors, cirrhosis, and severe tuberculosis
anemic face
Pale complexion, pale lips and tongue, tired expression
Anemia caused by various causes
liver disease face
Dark complexion, brown pigmentation on forehead, back of nose, and cheeks
kidney disease face
Pale complexion, swollen face with double eyelids, pale tongue, and tooth marks on the edge of the tongue
Hyperthyroidism face
The face is shocked, the eye fissures are widened, the eyeballs are bulging and the eyes are bright, excited and restless, irritable and irritable
Myxedema face
Pale complexion, swollen face, slow reaction, sparse hair, pale and enlarged tongue
Seen in hypothyroidism
Acromegaly face
The head is enlarged, the face is elongated, the eyebrow arch and zygomatic protrusions are protruding, the lips and tongue are thickened, and the ears and nose are enlarged.
wry smile face
Trismus, facial muscle spasm, and a forced smile
tetanus
Typhoid face
Indifferent expression, slow reaction, and lack of desire
Enterotyphoid, cerebrospinal meningitis, encephalitis and other high fever exhaustion diseases
full moon face
Face as round as a full moon, red skin with acne and moustache
Cushing's syndrome long-term use of hormones
Mitral valve face
Dull complexion, purple cheeks, and mild cyanosis of the lips
Seen in rheumatic valvular heart disease Mitral stenosis
mask face
dull face
shaking paralysis encephalitis
body position
autonomous position
passive position
Extreme exhaustion or loss of consciousness
forced position
forced supine position
acute peritonitis
forced prone position
spinal disease
forced lateral decubitus position
Pleurisy on one side, massive pleural effusion
forced sitting position
Cardiopulmonary insufficiency
Decreased blood return to the heart
Forced squatting position
Cyanotic congenital heart disease
Increased blood return to the heart
forced stance
Angina pectoris
tossing and turning
Cholelithiasis Biliary ascariasis Renal colic
opisthotonus
Tetanus Meningitis in children
gait
drunken gait
Cerebellar diseases Alcoholism, barbiturate poisoning
waddling gait (duck)
Rickets, osteoarthropathy, muscular dystrophy, hip dislocation
ataxic gait
spinal cord disease
Lifting too high, taking long strides, landing hard
Panic gait (little mouse)
Parkinson's Disease
threshold crossing gait
common peroneal nerve palsy
scissor gait
Cerebral palsy and paraplegia patients
intermittent claudication
hypertension arteriosclerosis
Lymph nodes 0.2-0.5cm
Sliding palpation with the head slightly lowered or tilted to the examination side
local swelling
nonspecific lymphadenitis
Acute and chronic inflammation of the drainage area
Tenderness, no adhesion, flexibility
simple lymphadenitis
Inflammation of the lymph nodes themselves
Tenderness usually occurs in cervical lymph nodes
lymph node tuberculosis
Often located on the neck in a bead-like distribution
Slightly hard texture around the blood vessels in the neck, adhesion, and fluctuating sensation after cheese necrosis
malignant tumor metastasis
Lung cancer metastasizes to right supraclavicular lymph node Gastric cancer Esophageal cancer metastasized to left supraclavicular lymph node
Hard, rubbery, adhesions, no tenderness
swollen lymph nodes throughout the body
Infectious Diseases Connective Tissue Disorders (SLE SSSS) Leukemia Lymphoma
skin
color
pale
Anemia, capillary insufficiency-cold, collapse, aortic insufficiency
Acral pallor only - Raynaud's disease Thromboarteritis obliterans
redness
Febrile Diseases - Big Lung, Tuberculosis, Scarlet Fever, Atropine Co Poisoning
Persistent redness - Cushing's erythrocytosis
yellow dye
jaundice
Sclera jaundice first, then skin jaundice, severe at far and light at near.
Increased bilirubin
Increased carotene
Palms, soles, forehead, sclera, oral mucosa, no jaundice
Long-term use of yellow pigment medicine
Skin jaundice first, then sclera jaundice, near severe and far mild
Bilirubin is not high
rash
macula
Local skin redness not prominent on the skin surface
Typhus, erysipelas, erythema multiforme
Roseola
bright red round rash
Rash characteristic of typhoid and paratyphoid fever
Papules
Local color change, lesions protruding from the skin surface
drug rash, measles, eczema
Urticaria
Pale localized edema slightly raised on the skin surface
Various allergic reactions
maculopapular rash
There is a red base of skin around the pimples
Rubella, scarlet fever, drug eruption
herpes
Those with pus in the cavity are called pustules
Chickenpox, burns, diabetic foot
Desquamation
Rice bran-like measles
Flaky-Scarlet Fever
subcutaneous bleeding
Petechiae: diameter <2mm, fades under pressure
Purpura: diameter 3-5mm
Identifying rashes: The rash fades under pressure
Ecchymosis: diameter>5mm
Hematoma: Large bleeding above the skin
spider nevus
Vascular nevus formed by branching dilation of terminal arterioles in the skin
upper chest
subcutaneous nodules
rheumatic nodules
Joint near bony prominence No tenderness Varying in size
metacercarial nodules
Subcutaneous on trunk and limbs, pushable, no adhesion
gouty nodules
Auricle Metacarpal joint
Osler's nodes (infectious endocarditis)
Head examination
eye examination
Eyebrows: sparse and falling off; the outer 1/3 is sparse or falling off (hypothyroidism)
eyelids
Entropion-trachoma
Ptosis: bilateral muscle weakness, unilateral oculomotor nerve palsy
Eyelid closure disorder: bilateral hyperthyroidism, unilateral facial nerve palsy
Eyelid edema: Nephritis Chronic liver disease Malnutrition Anemia
conjunctiva
Redness of the mucous membrane during congestion shows engorged blood vessels - conjunctivitis keratitis
Granules and Follicles-Trachoma
Scattered bleeding spots - infective endocarditis
Scattered bleeding spots with congestion and discharge - acute conjunctivitis
Large subconjunctival hemorrhage-hypertension arteriosclerosis
Except for trachoma and spring catarrhal conjunctivitis, the lower eyelid is more obvious than the upper eyelid.
cornea
Normal: Transparent (sclera is opaque)
abnormal
Peripheral vascular proliferation-severe trachoma
Corneal softening-infant malnutrition Vitamin A deficiency
White turbid ring-senile ring Lipoid deposition
Tan ring-KF ring Hepatolenticular degeneration
Pupil 3-4mm
Pathological shrinkage
Iritis, organophosphate poisoning, morphine, pilocarpine, chlorpromazine
pathological enlargement
Trauma, cervical sympathetic nerve stimulation, atropine, cocaine, glaucoma
Pupils of different sizes
Various sizes - brain trauma, brain tumors, brain herniation
Varying in size and variable - central nervous system disorders
Different sizes and reduced light reflex - damage to midbrain function
eyeball
protrude
Unilateral - localized inflammation or space-occupying lesion
Bilateral-Hyperthyroidism
Eye signs of hyperthyroidism
Stellwag-blink reduction
Graefe - upper eyelid does not turn downward accordingly
Mobius - Collection Movement Disorders
Joffroy-No forehead lines when viewed from above
sunken eyeballs
Horner syndrome orbital apex fracture
eye movement
Problems with cranial motor nerves
fundus
Hypertension, diabetes, chronic nephritis, eclampsia, and leukemia can all cause fundus changes.
cranial examination
size
Newborn 34cm, 18 years old up to 53cm
Fontanelle usually closes at 12-18 months
Most seams ossify in 6 months
small skull
Premature closure of fontanels, accompanied by intellectual developmental disabilities
giant skull
Sunset phenomenon seen in hydrocephalus
Long head
Acromegaly Marfan syndrome
form
square skull
Rickets in children, congenital syphilis
Pointed skull
Apical syndactyly (Apert syndrome)
Deformed skull
Osteitis deformans (Paget's disease)
sports
Abnormalities: Cervical Spondylosis, Paralysis Tremors, Musset's Disease (Aortic Valve Insufficiency)
Nose examination
shape
Frog nose-nasal polyps Saddle nose-nasal bone destruction
sinus tenderness
Maxillary sinus: left and right zygomatic areas
Frontal sinus: medial to the upper edge of the orbit
Ethmoid sinus: between the root of the nose and the medial canthus of the eye
Sphenoid sinus: located deep and cannot be examined superficially
Bloody secretions on one side of the nasopharynx, tinnitus, deafness - early nasopharyngeal cancer
oral examination
lips
Pallor - collapse, aortic regurgitation and anemia
Cyanosis - heart failure and respiratory failure
Herpes-herpes simplex virus infection, associated with lobar pneumonia
Cleft lip - congenital developmental malformation
Erythema-telangiectasia hereditary
Hypertrophic-myxedema, acromegaly, cretinism
Dry and cracked - severe dehydration
Mucous membrane
Bleeding, ulcers, pigmentation, mucosal plaques, thrush (Bai Nian)
Koplik spots
Measles spots - white spots the size of a pinhead appear under the mucosa of the second molar
Blue-black pigmented patches - Addison's disease (hypocorticism)
gums
Lead wire (blue-gray) Mercury Arsenic (dark brown dotted line)
Tongue
geographical tongue
Riboflavin B2 deficiency
Beef tongue
Pellagra (niacin deficiency)
cracked tongue
Transverse fissure riboflavin deficiency Down syndrome
Longitudinal fissure syphilitic glossitis
strawberry tongue
Scarlet fever patients with long-term fever
mirror tongue
Iron deficiency anemia, chronic atrophic gastritis
Pharynx and tonsils
Pharynx: mucous membrane congestion and swelling, lymphoid follicle hyperplasia, tonsil enlargement
enlarged tonsils
I degree: between the lingual and palatine arches and the pharyngeal and palatine arches
Degree II: Beyond the pharyngeal and palatine arches
II degree: reaches the midline of the posterior pharyngeal wall
Tonsillitis-pseudomembrane is easy to peel off
parotid gland
The parotid gland opens between the maxillary second molar and the cheek mucosa
Earlobe pressure pain during mumps
neck examination
congenital torticollis
Sternocleidomastoid muscle bulge on the affected side
Blood vessel
①Jugular vein
normal
The jugular vein is not exposed in the standing or sitting position
If not apparent in supine position - hypovolemic state
Jugular vein filling
Right heart failure, pericardial effusion, constrictive pericarditis, superior vena cava obstruction syndrome
The amount of blood returned to the heart decreases
jugular venous pulse
Seen in tricuspid regurgitation
Right atrium blood return
②Carotid artery
normal
Not obvious when normal and quiet
Increased pulsation
Aortic insufficiency, hypertension, hyperthyroidism, severe anemia
High excretion disease (SV/HR)
thyroid
Palpation: size, texture, surface, shape, tenderness, tremor
degree of swelling
Degree I: Can be touched but not seen
Degree II: palpable and visible, within the sternocleidomastoid muscle
III degree: beyond the outer edge of the sternocleidomastoid muscle
Cause
Hyperthyroidism - vascular murmur palpable tremor
Thyroid cancer - nodular feeling, irregular, hard texture, and carotid artery pulse cannot be palpated
Chronic Lymphatic Thyroiditis - Common Carotid Artery Pulsation at the Posterior Border of the Gland
Identification: Whether the carotid artery is touched
trachea
normal
center
tracheal displacement
Bilateral to the healthy side: seen in pleural effusion, pneumatosis, mediastinal tumors, and unilateral thyroid enlargement
Biased to the affected side: seen in atelectasis, pulmonary sclerosis, and pleural adhesions
Olive's sign: aortic arch aneurysm. The aneurysm expands when the heart contracts and presses the trachea backwards. It touches the trachea and pulls it downwards as the heart beats.
Chest examination
body surface markers
skeleton sign
suprasternal notch
Located above the manubrium of the sternum
The trachea is located in the middle of the notch
sternal angle
Angle of Louis: The connection between the manubrium of the sternum and the body of the sternum protrudes forward.
Connected to the second costal cartilage, at the level of the 4th/5th thoracic vertebra
Bronchial branches, upper edge of atrium, junction of upper and lower mediastinum
upper abdominal corner
Substernal angle The angle formed by the confluence of the left and right costal arches at the lower end of the sternum
The fornix equivalent to the transverse septum, the left lobe of the liver, the stomach and the pancreas are located in the area
shoulder blade
Posterior chest wall between ribs 2 to 8
7th/8th rib level mark 8th thoracic vertebra
spinous process of spine
Posterior midline mark
The spinous process of the 7th cervical vertebra is the most prominent and serves as a marker for counting thoracic vertebrae.
Boundary between lungs and pleura
apex of lung
At the level of the first thoracic vertebra, 3cm from the upper edge of the clavicle
upper boundary of lung
Up to the level of the first thoracic vertebra, down to the junction of the middle 1/3 and inner 1/3 of the clavicle
lower boundary of lung
The anterior chest wall is at the level of the 6th intercostal space at the midclavicular line, the midaxillary line is at the level of the 8th intercostal space, and the posterior chest wall is at the level of the scapular line at the 10th intercostal space.
tracheal bifurcation
Bifurcation of left and right main bronchus and flat sternal angle
chest wall examination
vein
Superior vena cava obstruction/inferior vena cava obstruction
Blood returns to the heart from opposite veins
subcutaneous emphysema
Crepitus/snow gripping sensation - Respiratory system damage, gas escaping into the subcutaneous
chest wall tenderness
Localized tenderness - intercostal neuritis, costochondritis, rib fractures
Sternal tenderness and percussion pain - leukemia
intercostal space
Retraction of intercostal spaces during inspiration - airway obstruction
Widened intercostal spaces - pleural effusion, tension pneumothorax, emphysema
Intercostal space bulging-chest wall tumors, aortic aneurysms, cardiac malformations
Thoracic examination
1:1.5
flat chest
Slender build, chronic wasting disease (tuberculosis)
barrel chest
Severe copd, short and fat body type, old age
Rickets chest
Pectus excavatum, breast of chicken, rib septum, rickets beaded
Deformation of one side of the thorax
Bulging on one side - massive pleural effusion, pneumothorax, emphysema
Subsidence on one side - atelectasis, pulmonary fibrosis, pleural thickening and adhesions
Partial bulge of thorax
Significant enlargement of the heart, pericardial effusion, aortic aneurysm
Costochondritis - tenderness over costal cartilage protrusions
Rib fracture - squeezing the chest front and back, severe local pain, bone scraping sound
Breast examination
Nipple: Midclavicular line, 4 intercostal spaces
先左后右 外上象限顺时针
symmetry
Enlargement on one side is seen in congenital malformation cysts, forming inflammatory tumors. Bilateral enlargement Liver disease Decreased estrogen inactivation
Shrinkage seen in agenesis
Lymphedema
Breast cancer (orange peel-like changes in the skin) Mastitis (localized skin redness)
nipple retraction
Developmental abnormalities, breast cancer
Nipple bleeding
Benign intraductal papilloma (most common) Breast cancer Mastductitis
nipple discharge
chronic cystic mastitis
Lung and pleural examination
Inspection
breathing pattern
abdominal breathing
Normal men and children (diaphragm movement mainly
chest breathing
Normal women (mainly intercostal muscle movement
Abnormal breathing
Increased abdominal breathing - pneumonia, tuberculosis, pleurisy, intercostal neuralgia
Increased chest breathing - peritonitis, ascites, hepatosplenomegaly, intra-abdominal tumors
Reduced respiratory movement - emphysema pneumothorax
Reduced respiratory movements - acidosis, deep breathing
Difficulty breathing
Inspiratory dyspnea
Airway obstruction (partial obstruction of the upper respiratory tract
Triple concavity (suprasternal fossa, supraclavicular fossa, and intercostal space depression)
expiratory dyspnea
Bronchial asthma, COPD (lower respiratory tract obstruction
Dilation of intercostal spaces during expiration
body position
Orthopnea - heart failure (reduced blood volume required)
Supine breathing - portal hypertension, lobectomy (requires increased blood return)
Accompanying Symptoms-Textbook 126
Respiratory rate
Normal breathing--R12~20 times/min Newborn 44
Tachypnea--R>20 times/min
Fever, pain, anemia, hyperthyroidism, heart failure
Bradypnea--R<12 times/min
Overdose of narcotics, sedatives, increased intracranial pressure
Inhibited respiration (sudden interruption of breathing movements
rib fracture, acute pleurisy
Breathing type
tidal breathing
Respiratory movements are wavy, alternating with apneas
Decreased excitability of respiratory centers - brain damage at cortical level Certain intoxications
Intermittent Breathing Biots
Breathe regularly for a few times and then pause (repeatedly)
Decreased excitability of the respiratory center - increased intracranial pressure, brain damage at the medulla oblongata level, cerebral hemorrhage
Sighing breathing
Insert a deep breath into the normal breathing rhythm
neurasthenia, nervousness, depression
Mostly functional
kussmaul breathing
Breathe deeply and quickly
Diabetes, uremic acidosis
Palpation (lower front side of thorax)
Limited thoracic expansion
① Lung diseases: pneumonia, atelectasis, chronic fibrocavitary tuberculosis, lung tumors, pulmonary fibrosis and bullae, etc.
② Pleural lesions: various pleurisy, pleural effusion, pleural pneumothorax, pleural hypertrophy and adhesions, and pleural tumors.
③ Rib lesions: rib fractures, rib osteomyelitis, rib tuberculosis, rib tumors, rib arthritis and costal cartilage calcification, making the ribs fixed and immovable.
④ Chest wall soft tissue lesions
⑤Diaphragm disease: If one side of the diaphragm is paralyzed, the expansion of the chest corridor on the affected side will be weakened.
Voice tremor
Definition: The sound wave vibration generated by making a sound is transmitted to the chest wall along the trachea, bronchi and alveoli, and can be touched with the palm of the hand.
Influencing factors
Strong pronunciation, low pitch, thin chest wall, close distance between bronchi and chest wall, tremor↑
The scapular area and the 1 and 2 intercostal spaces near the left and right sternum are the strongest, and the lung base is the weakest.
The upper part of the chest, the upper part of the right chest is stronger
weaken
Too angry
Emphysema Pneumothorax Chest wall subcutaneous emphysema
The bronchus is blocked
obstructive atelectasis
Lungs not attached to chest wall
Significant thickening of chest wall and adhesions, massive pleural effusion
Enhance
Less angry
Consolidation stage of lobar pneumonia, large pulmonary infarction
Bronchus with holes
tuberculosis cavity lung abscess
Compression of lung tissue - above pleural effusion
Pleural friction sensation
acute pleurisy
Exuded fibrin is deposited in the visceral and parietal pleura (the effusion disappears)
percussion
Percussion of lung boundary
upper boundary of lung
Kronig's Gap refers to the width of the lung apex 4 to 6 cm (voiceless to percussion)
lesions
Narrowing - secondary tuberculosis, fibrosis, atrophy
widening_emphysema, pneumothorax
anterior border of lung
Equivalent to the absolute heart dullness realm
lesions
Enlargement - Cardiomegaly Pericardial effusion Aortic aneurysm
shrink - emphysema
lower boundary of lung
Sixty or eighty intercostal space (normal movement is 6 to 8 cm)
Movement range↓: COPD, atelectasis, pulmonary fibrosis, pneumonia, pulmonary edema
Cannot be seen: massive pleural effusion, pneumatosis, extensive pleural adhesions
Normal percussion sound-voiceless
The upper part of the chest is cloudier than the lower part. The upper part of the right lung is cloudier than the left lung. The back is cloudier than the front chest.
Influence on the liver under the right axillary. Presence of gastric alveoli under the left anterior axillary - tympanic sound.
Abnormal percussion sounds
voiced/solid
Decreased air content - pneumonia (dullness), atelectasis, tuberculosis, pulmonary infarction
Air-free - pulmonary edema, pulmonary sclerosis, lung tumors
Pleural lesions - pleural effusion (solid), pleural thickening
Too unvoiced
Increased air content in the lungs - emphysema
Drum sound
Cavity >3~4cm - cavitary tuberculosis, liquefied lung abscess, pneumothorax
Kongwengyin
Huge Hollow (Special Case of Drum Sound)
Voiced tympanic sound
Lack of breath and alveolar relaxation - atelectasis. Congestive phase of pneumonia. Resolving phase of pneumonia. Pulmonary edema
auscultation
Top down, cross left and right
breath sounds
normal breath sounds
bronchial breath sounds
Loud, high pitched, breathy 1:3
Bronchial-alveolar breath sounds
Medium pitch, breath 1:1
Alveolar breath sounds
Soft, low-pitched, breathing 3:1
abnormal breath sounds
Abnormal alveolar breath sounds
weaken/disappear
Reduced incoming air flow or reduced speed
Prolonged breath sounds
Partial obstruction of the lower respiratory tract - asthma bronchitis
Decreased elasticity of lung tissue-COPD
intermittent breath sounds
local stenosis blockage
Gear Breath Sounds - Tuberculosis Pneumonia
Abnormal bronchial breath sounds
Bronchial breath sounds are heard at the site of normal alveolar breath sounds
Lung tissue consolidation, large cavities in the lungs, and compressive atelectasis
Abnormal bronchoalveolar breath sounds
Bronchoalveolar breath sounds are heard at the site of normal alveolar breath sounds
Bronchopneumonia, tuberculosis, early stage of lobar pneumonia
rales
moist rales
Passing through secretions and resulting from rupture of blisters
吸气明显 不易变异 位置恒定
Rough and wet rales (big bubbling sounds)
Tracheal and bronchial cavities are more common in the early stages of inspiration
Comatose or dying patients Heart failure Pulmonary edema Bronchiectasis
Medium wet rales
Medium-sized bronchi, more common in mid-inspiration
pneumonia bronchitis
Thin wet rales (small bubbling sounds)
Small bronchi are more common in late inspiration
Pneumonia Bronchitis Pulmonary congestion Pulmonary infarction
Velcro rales-diffuse interstitial pulmonary fibrosis
Crepitus
Bronchioles and alveolar walls adhere to each other
The elderly and bedridden for a long time
Cranes that can occur in normal people
Bronchiolar and Alveolar Inflammation & Congestion
clinical significance
Lungs full of wet rales
Acute pulmonary edema, severe bronchitis
Wet rales at the lung base on both sides
Pulmonary congestion in heart failure, bronchopneumonia
localized rales
Pneumonia, tuberculosis, bronchiectasis
Tiny crackles
bronchial or bronchiolitis
Dry rales
Airway narrowing and vibration
呼气明显 易变异 位置不定
high pitched rales
whistle sound
smaller bronchi or bronchioles
Low-key dry rales
Snoring
trachea or main bronchi
wheeze
Occurs in main bronchus
clinical significance
bilateral
chronic bronchitis
Bronchial Asthma
cardiogenic asthma
Those with wet rales are of cardiogenic origin
limitation
endobronchial tuberculosis
tumor
Voice resonance
① Bronchial speech: The intensity and clarity of speech resonance are increased, often accompanied by increased speech tremor, percussion dullness, and auditory and pathological bronchial breath sounds.
② Chest speech: It is a stronger, higher-pitched ear speech.
③ Sheep rumble: often heard in the area of lung compression above a moderate amount of pleural effusion
④ Ear speech: When the lungs are consolidated, the enhancement can be heard clearly
Common in pulmonary consolidation
fricative sound
pleural friction rub
Anteroinferior chest wall (rarely heard at lung apex)
Stop after holding your breath
pericardial friction rub
The precordium or the third and fourth intercostal spaces on the left edge of the sternum
exist after breath holding
Common disease
Handout 596
heart checkup
Inspection
Precordial bulge
The lower part of the sternum and the left edge of the sternum at 345 intercostal areas are partially raised.
Quadruple of Fallot Pulmonary stenosis-Right ventricular hypertrophy
Rheumatoid bistenosis in children-right ventricular hypertrophy and pericarditis with effusion
Partial bulge in the second intercostal space on the right edge of the sternum
aortic arch aneurysm
Apical beat
Definition: 0.5~1cm medial to the left midclavicular line of the fifth intercostal space, pulsation range 2-2.5cm
beat displacement
Shift left and down
left ventricular enlargement
aortic valve insufficiency
Shift to the left
Right ventricular enlargement
mitral stenosis
Left lower displacement, heart boundary enlarged on both sides
Dilated cardiomyopathy
Emphysema-vertical position Obesity Pregnancy Ascites-transverse position
Beat range
Increased pulsation - strenuous exercise, high fever, anemia, hyperthyroidism, left ventricular hypertrophy
Decreased pulsation - cardiodilation, myocardial infarction, effusion, constrictive pericarditis, emphysema, pneumothorax
Negative pulsatility-adhesive pericarditis Severe right ventricular hypertrophy
Precordial beat
Right heart related
Pulsation in the 3rd and 4th intercostal space on the left sternal border
right ventricular hypertrophy
Second intercostal pulse on the left sternal border (pulmonary valve area)
Pulmonary hypertension/normal physical activity or mood swings in young adults
Second intercostal pulse on the right edge of the sternum (aortic valve area)
Aortic arch aneurysm dilatation of ascending aorta
Subxiphoid pulse
Right ventricular hypertrophy/abdominal aortic aneurysm
Increased during inspiration - right heart hypertrophy Decreased - abdominal aortic aneurysm
palpation
Apical beat and precordial beat
Left ventricular hypertrophy-apical lifting pulses (aortic stenosis)
Right ventricular hypertrophy - systolic lifting pulses at the lower left sternal border (precordium) (ventricular septal defect)
Tremor (cat panting)
Small vibrations when palpated with fingers
Congenital vascular disease, valvular disease, and rarely tremor
Any tremor that is palpable can be considered to have organic disease in the heart.
Palpation is sensitive to low-frequency vibrations Auscultation is sensitive to high-frequency vibrations
pericardial friction sensation
Palpation site - precordium or the third and fourth intercostal spaces on the left edge of the sternum
Comparison of pleural friction sensation - lower and anterior part of the thorax
Acute pericarditis caused by fibrinous exudation - friction disappears as the exudate increases
percussion
Bottom up, outside in
The relative dullness boundary of the heart reflects the size of the heart (the absolute dullness boundary is the anterior pulmonary boundary)
normal voiced area
Heart dullness/external factors
Displacement of the heart boundary to the healthy side
Large amount of pleural effusion and pneumothorax on one side
Displacement of the heart border to the affected side
Pleural adhesions on one side, pleural thickening, and atelectasis
The heart boundary increases to the left
A large amount of ascites and a huge tumor in the abdominal cavity
Heart dullness area narrowed
Emphysema
Heart dullness world/heart itself
Left ventricular enlargement (boot heart)
aortic valve insufficiency
Right ventricular enlargement (enlargement of left and right ventricles)
Cor pulmonale, atrial deficiency
Bichamber enlargement (general large heart)
Dilated cardiomyopathy
Enlargement of the left atrium (pyriform heart)
mitral stenosis
Pericardial effusion (flask-like heart)
Pericardial effusion
Heart auscultation
auscultation site
M: Mitral valve auscultation area - 0.5-1cm within the fifth intercostal space/left midclavicular line
P: Pulmonary valve auscultation area-the second intercostal space on the left sternal border
A: Aortic valve auscultation area-the second intercostal space on the right edge of the sternum
E: The second auscultation area of the aortic valve - the third intercostal space on the left sternal border
T: Tricuspid valve auscultation area-the 4th and 5th intercostal space on the left sternal edge
Sequence: M P A E T (starting from the apex, counterclockwise)
heart rate/rhythm
Heart rate: 60 to 100 beats per minute
Infant >150 times/minute tachycardia
Heart rhythm: the rhythm of the heart’s beating
sinus arrhythmia
Increase when inhaling, slow down when exhaling
Seen in some young people, no clinical significance
preterm contraction
The first heart sound is significantly enhanced and the second heart sound is mostly weakened
Digraph Trigram
An electrocardiogram is required to confirm the source.
atrial fibrillation
Absolutely irregular heart rhythm, variable first heart sound, short pulse
Bistenosis, coronary heart disease, hypertension, hyperthyroidism
heart sounds
Classification
first heart sound
Mitral and tricuspid valves close and leaflets vibrate
ventricular contraction begins
Simultaneous apical/cervical A beats
Low pitch, long duration, loudest at the apex
S1 S2 spacing <S2 to next S1
Enhance
Preload reduction
Second stenosis, tachycardia, pr cycle contraction (poor blood)
Thickened leaflets, stiffness, weakened posterior S1
Increased contractility - high fever, anemia, hyperthyroidism
weaken
Increased preload - secondary closure, primary closure, increased pr phase (excessive blood)
Decreased contractility-myocarditis, cardiomyopathy, myocardial infarction, heart failure
Strong and weak
Atrial fibrillation, third degree atrioventricular block (cannon sound)
second heart sound
Only 2 is heard at the bottom of the heart / the other is the apex
Main and pulmonary valves close and leaflets vibrate
ventricular diastole begins
High pitch, short time limit, loudest from the bottom of my heart
Teenagers P2>A2 and the opposite for the elderly
Enhance
Increased main A pressure - hypertension, atherosclerosis
Increased pulmonary A pressure
Cor pulmonale, bistenosis with pulmonary hypertension
Atrial defect Ventricular defect Patent duct A (left to right shunt)
weaken
Decreased main A pulse pressure - main stenosis hypotension
Decreased pulse pressure in lung A - pulmonary stenosis
third heart sound
Rapidly filling blood in the ventricles, impacting the ventricular walls
Early ventricular diastole/audible in some children and adolescents
fourth heart sound
Vibration of ventricular and ventricular valves and related structures during atrial contraction
Pathological!
S1, S2 split and S4 have nothing to do with body position. S3 is best seen in the supine position.
Changes in the nature of heart sounds
monophonic
S1 is significantly weakened, and S1 and S2 are very similar to severe cardiomyopathy.
pendulum law
The heart rate increases based on the monophonic rhythm, and the systolic and diastolic phases are almost equal.
fetal heart rhythm
Pendulum rhythm > 120 beats/min Large area myocardial infarction, severe myocarditis
Split heart sounds
S1 split
Inconsistent valve closure >0.03s
Tricuspid valve closes significantly later than mitral valve
Delayed electrical activity-complete right bundle branch block
Delayed mechanical activity - pulmonary hypertension
S2 split
Inconsistent ventricular ejection
肺动脉瓣区最明显
Physiological dissociation: take a deep breath
The amount of blood returned to the heart increases and right ventricular ejection is slower than left ventricular ejection.
usually split
Prolonged right heart ejection
Pulmonary valve stenosis Mitral valve stenosis
Shortened left heart ejection
Ventricular septal defect Mitral regurgitation
fixed split
Unaffected by inspiration-atrial septal defect
Abnormal division
Left bundle branch block, severe hypertension, main stenosis
extra heart sounds
diastole
galloping law
A rhythm composed of pathological S3 or S4 and the original S1 S2, when the heart rate is > 100 beats/min
Classification
early diastolic gallop
Essence: Pathological S3
Diastolic overload Severe organic heart disease
Heart failure, acute myocardial infarction, severe myocarditis, cardiomyopathy
late diastolic gallop
Essence: Enhanced S4 presystolic, atrial gallop
Resistance overload Heart disease causing ventricular hypertrophy
Hypertensive heart disease, hypertrophic cardiomyopathy, aortic stenosis
overlapping gallop
4 heart sounds Cardiomyopathy or heart failure
Features of Shuzao Galloping Rhythm
The distance between S2 and S3 is similar to that of S1 and S2. The pitch is low and the intensity is weak.
Normal S3
It is easy to detect when the heart rate is not fast
S2 S3 distance＜S1 S2
Lying on the left side and exhaling are obvious and disappear when sitting or standing.
The left ventricular gallop is loudest when exhaling. The right ventricular gallop is loudest when inhaling.
open sound
Mitral valve opening beat sound is located 0.05-0.06s after S2
Mitral valve stenosis and still soft (a little narrow but can close)
Important reference conditions for indications for mitral valve separation surgery
pericardial percussion sound
Rapid ventricular filling, restricted ventricular diastole, and generation of ventricular wall vibration
Constrictive pericarditis pericardial calcification
The left edge of the sternum is easiest to hear
tumor flutter
Left atrial diastolic tumor blocking mitral valve orifice
Can change with body position
left atrial myxoma
systole
early rattle
Mechanism: Enlarged pulmonary artery. Aorta wall vibrates during ventricular ejection & valve leaflets are restricted in opening.
Hypertension, pulmonary hypertension, aortic stenosis, pulmonary stenosis
This ejection sound may disappear when the valve calcification activity weakens
Middle/late click sound
The mitral valve prolapses into the left atrium, and the leaflets suddenly tense and vibrate.
Mitral valve prolapse
Mitral valve prolapse: mid-to-late apical systolic click sound followed by diabetic SM
Mitral valve prolapse syndrome: late systolic click late systolic murmur
Rupture of chordae tendineae: seagull call or musical murmur
heart murmur
Specific long-lasting sounds other than heart sounds
mechanism
Accelerated blood flow, valve orifice stenosis, valve insufficiency, abnormal blood flow channels, abnormal heart structure, and large hemangioma-like dilation
Classification
AI murmur: occurs in early diastole
Aortic regurgitation Sighing (decreasing)
AS murmur: often mid-systolic murmur
Aortic stenosis jet (increasing and decreasing)
MS murmur: occurs in mid to late diastole
Mitral stenosis rumbling (increasing)
MI murmur: can occupy the entire systole and is called a holosystolic murmur
Mitral regurgitation blowing (consistent)
strength
Divided into 6 levels: > Level 4 has tremor; Level 3 is all organic noise > Level 2 can be heard by beginners
Effects of breathing and posture
①Body position:
Lying on the left side: diastolic murmur in MS is more pronounced
Sitting forward and leaning forward: the diastolic murmur of AI is more obvious
Supine position: The murmur of bicuspid, tricuspid, and pulmonary valve insufficiency is more obvious.
②Breathe
Any murmur from a right heart lesion enhances during deep inspiration - TS, Tl, PI, PS enhance
Any murmur from a left heart lesion enhances during deep breathing - MS, ML, AL, AS enhance
other
Continuous noise like machine rotation
Patent ductus arteriosus
G-S murmur/Guess murmur: Mitral stenosis with significant pulmonary hypertension-relative pulmonary artery insufficiency-diastolic murmur
Austin Flint murmur: moderate to severe aortic regurgitation - large left ventricular volume load - mitral valve semi-closing - relative stenosis
Diastolic murmur
Valsalva maneuver (inhale deeply and then close the glottis and exhale forcefully) - all valve murmurs are reduced and hypertrophic obstructive cardiomyopathy is enhanced.
Physiological murmur: limited to systole, no heart enlargement, soft murmur, blowing like, no tremor
Identification of organic and functional murmurs in each auscultation area
Textbook 157
pericardial friction rub
Precordium/Left sternum 3-4 intercostal space
double phase murmur
Pericarditis (tuberculous, nonspecific, rheumatic, purulent) may also occur in acute myocardial infarction, uremia, and SLE
Common disease
valvular heart disease
Handout 606
Pericardial effusion
Visual examination - jugular venous distension
Palpation - Pulsus paradoxus, positive hepatic jugular venous reflux
Percussion-cardiac dullness appears like a triangular flask, changing with body position
Auscultation - rapid heart rate, distant heart sounds, and occasional pericardial percussion sounds. Pericardial friction sounds can be heard when there is a small amount of pericardial effusion.
Ewart's sign - increased tremor in the left subscapular area, dullness to percussion, and bronchoalveolar breath sounds.
heart failure
left heart failure
right heart failure
Blood vessel
pulse
pulse rate
Influencing factors are similar to heart rate
pulse rhythm
Atrial fibrillation with short pulse
Pulse leakage may occur in 2nd degree atrioventricular block
Abnormal waveform
Shuichongmai
Pulse rises and falls suddenly
Hyperthyroidism, severe anemia, aortic occlusion, patent ductus arteriosus, arteriovenous fistula
Late pulse
Significantly reduced speed
aortic stenosis
alternating pulses
Normal rhythm, alternating between strong and weak rhythms
Left heart failure, high heart disease, acute myocardial infarction
Strange pulse
Pulse significantly weakens/disappears during calm inspiration
Right heart failure, massive pericardial effusion, constrictive pericarditis, bronchial asthma
Pulseless
Severe shock, Takayasu arteritis
blood pressure
Systolic blood pressure: reflects heart contractility
Diastolic blood pressure: degree of blood vessel filling
Mean arterial pressure = diastolic pressure 1/3 pulse pressure
Hypertension: BP＞=140/90mmHg at least 3 times on different days
Hypotension: BP＜90/60mmHg
Unequal blood pressure in both upper limbs: Takayasu arteritis, congenital arterial malformation (normal 5-10mmHg)
Unequal blood pressure in the upper and lower limbs: aortic coarctation, thoracoabdominal aortic Takayasu arteritis (normal 20-40mmHg)
Increased pulse pressure: aorta, hyperthyroidism, atherosclerosis
Decreased pulse pressure: main stenosis, pericardial effusion, severe heart failure
peripheral vascular sign
All refer to an increase in pulse pressure, often combined with water flushing pulse
Primary occlusion Hyperthyroidism Severe anemia Patent ductus arteriosus Arteriovenous fistula
Corrigan Vein Water Chong Vein
De Musset's sign - nodding sign - seen in main syndrome
Cap pulsation sign - alternating red and white nails when pressed
Traube's sign shooting sound-femoral artery shooting sound consistent with heartbeat
Duroziez's sign - a double-phase blowing murmur in the suprafemoral artery
Venous murmur
Jugular vein burping - caused by rapid backflow of jugular vein blood into the superior vena cava (harmless)
Liver cirrhosis - portal hypertension causes varicose veins in the abdominal wall, and venous squelching sounds can be heard in the upper abdomen around the umbilical cord.
Abdominal examination
Pay attention to the order
Body surface mark partition
Inspection
shape
Total abdominal distension
Ascites (frog belly)
Cirrhosis, portal hypertension, heart failure, peritoneal cancer metastasis
Pointed abdomen--peritonitis or tumor infiltration
Protruding umbilicus (umbilicus is sunken in obesity)
Air accumulation in the abdomen (spherical)
Intestinal obstruction Intestinal paralysis (not moving with body position)
huge intra-abdominal mass
Giant ovarian cyst, term pregnancy, teratoma
local swelling
Upper right - hepatomegaly Upper left - splenomegaly
Epigastric area - stomach pancreas umbilical area - small intestine lumbar kidneys
Lower right - ileocecal lower left - sigmoid colon Descending colon
Identify the abdominal wall/abdominal cavity - Lie on your back with your neck flexed and your shoulders raised
The mass is obvious on the abdominal wall The mass disappears in the abdominal cavity
Full abdominal depression
Significant depression at the level of the anterior abdominal wall when lying on your back - weight loss and dehydration
Scaphoid-cachexia (tuberculosis, malignancy
Abdominal depression during inhalation - diaphragm paralysis, upper respiratory tract obstruction
local depression
Abdominal wall scar shrinkage and incisional hernia after surgery
respiratory movements
Increased abdominal breathing - hysteria, massive pleural effusion
Decreased abdominal breathing - peritonitis, acute abdominal pain, pregnancy, ascites
Loss of abdominal breathing - acute peritonitis due to gastrointestinal perforation, diaphragmatic paralysis
abdominal wall vein
Portal hypertension - the blood flow direction of the abdominal wall varicose veins is centered on the umbilicus and radiates to all sides
Inferior vena cava obstruction-superficial venous blood flow direction from bottom to top
Superior vena cava obstruction-superficial venous blood flow direction from top to bottom
Gastrointestinal and peristaltic waves
Pyloric obstruction: peristaltic wave gastric type
Intestinal obstruction: peristaltic wave intestinal type
Intestinal paralysis: disappearance of peristaltic waves
other
rash
Congestive or hemorrhagic rash, purpura, urticaria
pigment
Brown pigmentation in skin folds - addison disease
Waist Quarter rib Lower abdomen Blue-Grey-Turner sign (severe acute pancreatitis/intestinal strangulation)
Blue color around the umbilicus or lower abdominal wall - Cullen's sign (severe acute pancreatitis/ruptured ectopic pregnancy)
Abdominal lines
Stria alba - splitting of the dermal connective tissue due to increased tension (obesity, multiparous women
Purple stria-glucocorticoid hyperlipidemia (lower abdomen, buttocks, lateral femoral
Stretch marks-distributed on the lower abdomen and iliac area
umbilicus
Discharge with serous purulent odor - omphalitis
The discharge is watery and smells like urine - patent urachus
Umbilical ulcer-suppurative inflammation, tuberculous inflammation
Hard and fixed bulge in umbilicus - cancer
hernia
Inguinal hernia, femoral hernia, umbilical hernia, incisional hernia
pulsating
Upper abdominal pulsation - thin people, abdominal aortic aneurysm, right ventricular enlargement, hepatic hemangioma
auscultation
D
Auscultation site: Periumbilical area: Right lower abdomen
physical signs
1. Normal bowel sounds: 4-5 times/min:
2. Active bowel sounds: >10 times/min, not high pitched
Acute gastroenteritis, massive gastrointestinal bleeding, taking certain drugs (laxatives, pituitaryin)
3. Hyperactive bowel sounds: more than 10 times/min, metallic sound or watery sound
mechanical intestinal obstruction
4. Bowel sounds are weakened: Bowel sounds are less than normal, or may be heard only once every few minutes.
Seen in hypokalemia, senile constipation, and low gastrointestinal motility
5. Bowel sounds disappear: no bowel sounds are heard after continuous auscultation for 3-5 minutes.
Seen in acute peritonitis, paralytic intestinal obstruction
vascular murmur
artery
Ejection murmur in mid-abdomen-abdominal aortic aneurysm abdominal aortic stenosis
Left and right upper quadrant systolic murmur-renal aortic stenosis
Systolic murmur on both sides of lower abdomen-iliac artery stenosis
vein
Periumbilical or epigastric continuous murmur - formation of collateral circulation of portal hypertension
fricative sound
Splenic infarction to perisplenic inflammation Perihepatitis Cholecystitis involving the peritoneum Peritoneal fibrous inflammation
Scratching experiment
When the lower edge of the liver is unclear to palpation, assist in measuring the lower edge of the liver
percussion
Most of it is drum sound area, no excessive voiceless sound
Hepatic dullness percussion
normal
Upper liver boundary (relative to the dullness boundary) right 5-7-10
Lower boundary of the liver: lower edge of the right ribs; upper and lower diameter of the liver: 9-11cm
expand
Liver cancer, liver abscess, viral hepatitis, liver congestion, polycystic liver disease
zoom out
Acute severe viral hepatitis, cirrhosis, flatulence
Move up
Fibrosis of the right lung, atelectasis of the right lower lung, pneumoperitoneum and tympanic bowel
move down
Emphysema, right tension pneumothorax
disappear
Acute gastrointestinal perforation, intraoperative after major abdominal surgery, intermediate colon
gastric tympanic area
Also known as Traube's area. Above the costal margin in the lower part of the left chest
Significant enlargement - gastric dilatation, pyloric obstruction
Significant reduction - seen in pericardial effusion, left pleural effusion, left liver lobe enlargement, splenomegaly
All dull sounds: overeating-acute gastric dilatation, drowning patients
Spleen percussion
Expansion of spleen dullness area - splenomegaly
Reduced spleen dullness area - left pneumothorax, gastric dilation, tympanic bowel
mobile voicedness
Shifting dullness: There is dullness on both sides when lying on the back, and a tympany in the middle abdomen. The dullness area changes when the body position is changed.
Positive: free ascites in the abdominal cavity >1000ml
Puddle sign in elbow and knee position: 120ml of ascites is enough
Palpation (left → right)
Technique
Superficial palpation (1cm)
Abdominal wall tone Superficial tenderness Masses Pulsations and abdominal wall masses
Deep palpation (>2cm)
Tenderness, rebound tenderness, intra-abdominal mass
Deep pressure palpation, sliding palpation, bimanual palpation (liver, spleen, kidney and intra-abdominal masses)
Floating and sinking palpation (examination of organs when there is a large amount of ascites) hook finger palpation (liver and spleen)
Increased abdominal wall tension
Total abdominal wall tension - abdominal distension, pneumoperitoneum, ascites
Slab-like abdomen - acute diffuse peritonitis (gastrointestinal perforation)
Abdominal wall flexibility-tuberculous peritonitis, peritoneal metastases
Tightness in the upper abdominal or left upper abdominal muscles - acute pancreatitis
Right upper abdominal muscle tightness - acute cholecystitis
Right lower abdominal muscle tightness - acute appendicitis, gastric perforation
Not obvious tension - old and frail, overweight, pelvic inflammatory disease
abdominal tenderness rebound tenderness
Tenderness - Abdominal wall or intra-abdominal organ disease
Appendiceal point: the junction of the middle and outer 1/3 of the line between the umbilicus and the right anterior superior iliac spine
Gallbladder point: the junction of the right midclavicular line and costal margin
Rebound tenderness - inflammation involving the peritoneal parietal layer (signature
Common signs
hepato-jugular sign
Right heart failure, liver congestion
hepatic dilation pulsation
tricuspid valve insufficiency
Unidirectional hepatic pulsation
conducts the pulse of the abdominal aorta
Liver tremors
hepatic echinococcosis
Murphy's sign
acute cholecystitis
Courvoisier's sign
pancreatic head cancer
liquid wave tremor
Large amount of fluid in abdominal cavity 3000-4000ml
Zhenshuiyin
Pyloric obstruction, gastric dilatation (retention of fluid and gas)
Liver palpation
In normal people, it cannot be palpated under the costal margin. When taking a deep breath, it is within 1cm below the costal margin. Under the xiphoid process, it does not exceed the middle and upper 1/3 junction from the xiphoid process to the umbilicus.
acute hepatitis
Mild swelling, smooth surface, slightly tough texture, tenderness
Liver stasis
The liver is obviously enlarged, with smooth surface, tough texture, tenderness, and liver neck sign.
Cirrhosis
Swells in the early stage and shrinks in the late stage. There are small nodules on the surface with sharp edges, hard texture and no tenderness.
liver cancer
The liver gradually enlarges, with nodules or lumps with irregular edges
The texture is as hard as a stone, and the tenderness is obvious upon percussion.
Palpation of spleen
Splenomegaly measurement
Measurement I: Line A and B - vertical
Measurement II: Line A and C - diagonally downward
Measurement III: Ding-Wu Line - Horizontal
Grading of splenomegaly
1. Mild: <2cm under the ribs. Acute and chronic hepatitis, typhoid fever, miliary tuberculosis, malaria, septicemia
2. Moderate: >2cm below the ribs, but above the level of the umbilicus. Cirrhosis, chronic lymphocytic
3. Height: exceeds the level of the umbilicus or the front midline. Chronic myelofibrosis, myelofibrosis
Kidney palpation
normal kidney
It is generally not palpable. In a thin person, the lower pole of the right kidney is palpable.
nephroptosis
More than 1/2 of the kidney is touched during deep inhalation
wandering kidney
Nephroptosis is obvious and can move in all directions in the abdominal cavity
enlarged kidneys
hydronephrosis or pyema, renal tumors, or polycystic kidney disease
abdominal mass
Normally accessible
Liver and kidneys Rectus abdominis muscle belly, tendinous division, lumbar vertebrae, sacral promontory, sigmoid colon, transverse colon, cecum
Normally inaccessible
Spleen Gallbladder Bladder Uterus
abnormal lump
Cord-like metamorphosis in a short period of time - roundworm mass or intussusception
An oval mass with smooth edges was palpated in the right upper quadrant - gallbladder effusion
Examination of limbs and spine
spine examination
Related concepts
The spine consists of 7 cervical vertebrae, 12 thoracic vertebrae, 5 lumbar vertebrae, 5 low vertebrae, and 4 coccygeal vertebrae.
body surface markers
The spinous process of the 7th cervical vertebra is particularly long, which is more obvious when the neck is bent forward.
The line connecting the inner ends of the two scapular spines passes through the spinous process of the third thoracic vertebra
The line connecting the lower angles of the two scapulae passes through the spinous process of the 7th thoracic vertebra
Spinal lesions may manifest as local pain, abnormal posture or form, and limited range of motion.
spinal curvature
①Inspection method
Observe the spine from the side for excessive lordosis and kyphosis, and from the back for scoliosis (squeeze your fingers along the spinous process of the spine from top to bottom)
②Physiological curvature
The four "S"-shaped physiological curvatures are cervical lordosis, thoracic kyphosis, lumbar lordosis, and sacral kyphosis.
③Pathological deformation
a. Kyphosis: hunchback, mostly occurs in the thoracic segment
Rickets (disappears when lying supine), spinal tuberculosis (angular deformity), ankylosing spondylitis
Others: poor posture during development, traumatic compression fracture, spinal osteochondritis
b. Lordosis: mostly occurs in the lumbar spine
Late pregnancy, abdominal effusion, horizontal sacral spine, hip tuberculosis
c. Scoliosis: occurs in the thoracic, lumbar or combined thoracic and lumbar segments
Postural - poor sitting posture Sciatica Post-poliomyelitis sequelae
Organic - spinal hypoplasia, muscle paralysis, malnutrition, chronic pleural hypertrophy, pleural adhesions
spinal mobility
Inspection method: The cervical and lumbar segments have the greatest range of motion
Restricted activities
Soft tissue injuries: myofibrositis of neck and psoas muscles, strain of neck and psoas muscles and ligaments, etc.
Bone hyperplasia: proliferative arthritis of cervical and lumbar vertebrae
Bone destruction: spinal tuberculosis or tumors
Vertebral fracture or dislocation: Avoid spinal activities due to trauma
Herniated disc: lumbar spine, limited movement in all directions
Spinal tenderness and percussion pain
①Spinal tenderness
Inspection method: Press the spinous process and paravertebral muscles of the spine one by one with the thumb of your right hand from top to bottom.
Clinical significance: It indicates that there may be pathology or damage to the spine or muscles at the tender site
clinical manifestations
Stiff neck - tenderness at midpoint of trapezius muscle
Cervical rib syndrome, anterior scalene syndrome--supraclavicular fossa and lateral cervical triangle
Cervical myofibrotitis - neck and shoulders
Thoracic spine lesions (tuberculosis, disc herniation, trauma, fractures) - corresponding spinal spinous processes
Low back myofibrositis or strain--paravertebral muscles
②Spine percussion pain
Examination method: Direct percussion method: Indirect percussion method (knocking on the skull)
Clinical significance: Normal people have no percussion pain in the spine
Spinal tuberculosis, spinal fractures, spinal tumors, intervertebral disc herniation
Special tests for spinal examination
Special examination of cervical spine
Jackson head test
Cervical spondylosis, cervical disc herniation
Forward flexion and neck rotation test (Fenz sign)
Degenerative disease of cervical facet joints
Neck compression test (Naffziger test)
Worsening of upper limb pain is seen in radicular cervical spondylosis
Worsening of lower limb pain seen in radicular sciatica
neck rotation test
Vertebral artery cervical spondylosis
Special examination of lumbosacral area
Swing test
Lumbosacral lesions
Pick up test
Lumbar disc herniation, psoas muscle trauma and inflammation
Straight leg pick-up test (Lasegue sign)
Lumbar disc herniation
simple sciatica
Neck flexion test (Linder test)
Root-shoulder lumbar disc herniation
Femoral nerve stretch test
High lumbar disc herniation
(L2-3 or L3-4)
Examination of limbs and joints
1. Abnormal shape
① Spoon-shaped onychomycosis: Also known as inverse onychomycosis, it is more common in iron deficiency anemia, altitude sickness, and occasionally in onychomycosis and rheumatic fever.
②Club-shaped fingers: Club-shaped fingers (toes) are hyperplasia, hypertrophy, and swelling at the ends of fingers or toes, which are called clubbing fingers.
Mechanism: Chronic hypoxia, metabolic disorder, toxic injury at the end of the limbs
③Finger joint deformation: Fusiform joint: Claw-shaped hand Others: Senile osteoarthritis
④Wrist joint deformation: synovitis: tendon cyst, others: such as fibrolipoma, soft tissue inflammation, trauma and fracture, etc.
⑥Knee varum, knee valgus: "0" shaped legs, "X" shaped legs. Genu varum or genu valgum is seen in rickets and Kashin-Beck disease
Genu varum or genu valgum is seen in rickets and Kashin-Beck disease
⑦Knee joint deformation: arthritis: joint effusion
⑧ Varus and eversion of the foot: Varus or eversion of the foot is more common in congenital malformations, post-poliomyelitis syndrome, etc.
⑨Acromegaly
2. Common diseases
Respiratory diseases: Bronchial lung cancer, bronchiectasis, lung abscess, empyema
Certain cardiovascular diseases: cyanotic congenital heart disease, infective myocarditis, subacute infective endocarditis.
Nutritional disorders: Malabsorption syndromes, Crohn's disease, ulcerative colitis, cirrhosis.
Subclavian artery aneurysms can cause ipsilateral unilateral clubbing.
3. Sports function
Under the coordination of nerves, muscles and tendons drive joint movement to complete
①Inspection method: active movement of joints in all directions; passive movement. Observe its range of motion and whether there is pain, etc.
②Joint mobility disorders: seen in fractures, dislocations, inflammation, tumors, joint degeneration and tendon and soft tissue injuries in corresponding parts.
neurological examination
Shallow reflection
Superficial skin irritation
① Corneal reflection
Method: The person being examined looks inward and upward, and uses a fine cotton swab to lightly touch the patient's cornea from the outer edge of the cornea, and the subject's eyelids close quickly.
Related concepts
Stimulation of one cornea → eyelid closing reaction on the opposite side → indirect corneal reflex
Reflex arc: ophthalmic branch of trigeminal nerve → pons → facial nerve nucleus → orbicularis oculi muscle
clinical response
Loss of both direct and indirect corneal reflexes - trigeminal neuropathy (afferentation disorder)
The direct reflex disappears and the indirect reflex exists - the stimulated lateral nerve is damaged (efferent disorder)
Direct reflex exists, indirect reflex disappears - the stimulated contralateral facial nerve is damaged (efferent disorder)
Complete disappearance of corneal reflex: seen in patients with deep coma
②Abdominal wall reflex
Method: The patient lies on his back, with both lower limbs slightly flexed, and the abdominal wall relaxed. Then use a matchstick to press the upper, middle, and lower parts of the abdominal wall skin and lightly scratch the abdominal wall muscles. Contraction of the abdominal wall muscles can be seen in the stimulated parts.
clinical response
The upper abdominal wall reflex disappears: the lesion is located in the 7th to 8th thoracic cord.
The middle abdominal wall reflex disappears: the lesion is located in thoracic cord segments 8 to 10
Loss of reflexes in the lower abdominal wall: The lesion is located in the 11th to 12th thoracic cord.
Location
Absence of upper, middle and lower abdominal wall reflexes: seen in coma or acute abdomen, obesity, the elderly, and multiparous women
Loss of reflexes in one side of the abdominal wall: seen in ipsilateral pyramidal tract lesions
③ cremasteric reflex
Method: Use a matchstick to gently scratch the skin above the medial thigh from bottom to top, which can cause the cremaster muscle on the same side to contract and lift the testicles.
clinical response
Bilateral loss of reflexes is seen in lesions of lumbar spinal cord segments 1 to 2
Reduction or disappearance of reflexes on one side is seen in pyramidal tract damage, the elderly and local lesions (inguinal hernia, scrotal edema, orchitis).
deep reflection
Caused by irritation of periosteum and tendons
Clinical significance: The weakening or disappearance of deep reflexes is mostly due to organic diseases, such as peripheral neuritis, radiculitis, and anterior horn poliomyelitis, which can damage the reflex arc.
①Biceps reflex
The doctor supports the patient's flexed elbow with his left hand, places his thumb on the biceps tendon, and then taps the thumb with a percussion hammer. The normal reaction is contraction of the biceps and rapid flexion of the forearm.
The reflex center is in the 5th to 6th cervical spinal cord.
②Triceps reflex
The doctor supports the patient's flexed elbow with his left hand, and then uses a percussion hammer to directly tap the triceps tendon above the olecranon process. The reaction is contraction of the triceps and a slight extension of the forearm.
The reflex center is in the 7th to 8th cervical spinal cord.
③radial periosteal reflection
The doctor gently supports the wrist with his left hand and makes the wrist joint droop naturally. Then he lightly taps the radial stem with a percussion hammer. The normal reaction is pronation of the forearm and flexion of the elbow.
The reflex center is located in cervical spinal cord segments 5 to 8
④ Knee reflex
During examination in the sitting position, the calf is completely relaxed and hanging naturally. When lying down, the doctor uses his left hand to hold up the two lower limbs at the fossa, slightly flexing the hip and knee joints, and uses the percussion hammer held in his right hand to tap the quadriceps tendon under the patella.
The normal response is calf extension and the reflex center is at L2-4.
⑤Achilles tendon reflex
Lying supine, with the hip and knee joints flexed, and the lower limbs externally rotated and abducted, the doctor uses his left hand to hold the patient's foot so that the foot is in a hyperextended position, and then taps the Achilles tendon with a percussion hammer. The response is contraction of the gastrocnemius and flexion of the foot toward the plantar surface.
pathological reflex
When the vertebral tract is damaged, the inhibitory function of the brainstem and spinal cord is lost and the reflex of dorsiflexion of the feet and toes is released. Infants <1 and a half years old may have the above reflex phenomenon due to the immature development of the pyramidal tract. In adults, it appears as a pathological reflex.
①Babinski levy
The patient lies supine, with the hip and knee joints straightened. The doctor holds the patient's ankle and uses a blunt bamboo stick to draw the outer sole of the foot from back to front.
②Oppenheim sign
Push the thumb and index finger firmly from top to bottom along the front edge of the patient's tibia
③Gordon sign
Place the thumb and other four fingers separately on the gastrocnemius muscle, and pinch the gastrocnemius muscle with moderate force.
A positive reaction is when the big toe slowly extends dorsally and the other four toes spread out in a fan shape.
Seen in pyramidal tract damage
④Hoffmann's sign
The doctor holds the patient's wrist in his left hand. Hold the patient's middle finger between the middle finger and index finger of your right hand, lift it slightly upward so that the wrist is in a slightly overextended position, and then quickly scrape the nail of the patient's middle finger with your thumb.
Slight palmar flexion reaction of the remaining four fingers due to traction on the flexor profundus of the middle finger
Upper limb pyramidal tract signs, often seen in cervical spinal cord lesions
meningeal irritation
Symptoms of meningeal irritation, encephalitis, meningeal hemorrhage, and signs that may occur when cerebrospinal fluid pressure increases.
①Neck stiffness
The patient lies on his back, and his hands support the patient's occiput to perform passive flexion movements to test the resistance of the cervical muscles.
Increased resistance: cervical spondylosis and fractures can also be positive
②Kernig’s sign
The patient lies on his back, first bend one hip joint to a right angle, and then raise the calf with his hands. A normal person can extend the knee joint to more than 135°.
Restricted knee extension, pain, and flexor spasm are positive
③Brudzinski sign
The patient lies on his back with his lower limbs naturally straightened. The doctor holds the patient's occiput with his left hand, puts his hand on the patient's chest, and then bends his head forward.
Flexion of knee joints and hip joints on both sides is positive
Lasegue sign (straight leg raise test)
Symptoms of nerve root irritation. Lying down, with both lower limbs straightened, the doctor places his left hand on the knee joint to keep the lower limbs straight, and lifts the lower limbs with the other hand. Normally, it can be raised to 70 degrees.
If it can only be raised 30 to 40 degrees, it is positive and is seen in sciatica.
floating theme