The Principles and Methods of Physical DiagnosisPDF电子书下载

CHAPTER Ⅰ ROUTINE DATA 1

METHODS OF PHYSICAL DIAGNOSIS 1

Temperature 1

Oral Temperature 1

Rectal Temperature 2

Pathogenesis of Fever 2

Effect of Ovulation on Temperature 2

Types of Fever 3

Subnormal Temperature 4

The Pulse 4

Pulse Rate 4

Pulse Tension 5

Respiration 6

Types of Breathing 6

Blood Pressure 9

Blood Pressure Technic and Equipment 9

Height and Weight 10

Race 10

Childhood Nutrition 11

Climatic Factors 11

General Evolution 11

Effects of Disease on Height 11

Achondroplasia 11

Heart Disease 12

Renal Disease 12

Progeria 12

Ateliotic Dwarfs 12

Gigantism 13

Hypogonadism 13

Hypergonadism 13

Ovarian Insufficiency 13

Weight 14

Habitus 14

Male and Female Body Types 16

REFERENCES 16

CHAPTER Ⅱ EXAMINATION OF THE HEAD 17

THE CRANIUM 17

Size and Shape 17

Microcephalus 17

Hydrocephalus 17

The Acromegalic Head 18

Paget＇s Disease(Osteitis Deformans) 19

Craniostoses 19

The Rachitic Head 21

THE HAIR AND SCALP 21

Alopecia 21

Hirsutism(Hypertrichosis) 22

THE FACE 24

Dehydration of the Face 24

Edema of the Face 24

Color of the Face 27

Anemia 27

Polycythemia 28

Cyanosis of the Face 29

Malar Flush 29

Pigmentation of the Face 30

Jaundice 30

Argyria 30

Mask of Pregnancy(Chloasma Gravidarum) 30

Hemochromatosis 30

Addison＇s Disease 31

Albinism(Congenital Achromodermia) 32

Vitiligo 32

Chrysiasis 32

Local and Systemic Diseases Manifested in the Face 32

Nevi(Birthmarks) 32

Acne Vulgaris(Common Acne) 33

Collagen Diseases 34

Periarteritis Nodosa 34

Disseminated Lupus Erythematosus 35

Scleroderma 35

The Facies of Diseases of the Endocrine Glands 37

Cretinism 37

Mongolian Idiocy 38

Myxedema(Mucus Edema) 38

Hyperthyroidism 39

THE EYES 39

The Eyelids 43

The Conjunctiva 44

Subconjunctival Hemorrhage 45

The Cornea 46

Corneal Sensitivity 46

Keratitis 46

Herpetic Lesions 47

Arcus Senilis 47

The Sclera 48

Osteogenesis Imperfecta(Fragilitas Ossium) 48

Intraocular Tension 48

The Pupils 48

Horner＇s Syndrome 49

The Palpebral Fissures 50

Exophthalmos 50

Strabismus(Squint) 52

Nystagmus 54

The Visual Field 54

THE EARS 54

Color 54

Contour 54

Auricles 54

The Auditory Canal 55

Tympanic Membrane 55

Mastoid Region 56

Tests for Hearing 56

THE NOSE 56

Play of the Alae Nasi 58

Intranasal Examination 58

THE LIPS 59

THE BUCCAL CAVITY 62

Eruptions 62

Pigmentation 62

THE TONGUE 62

Monilial Infections 64

Leukoplakia(White Plaque) 66

Syphilitic Lesions 66

Tuberculosis of the Tongue 67

Carcinoma of the Tongue 67

THE TEETH AND GUMS 68

Hutchinson＇s Teeth 69

Hypertrophy of the Gums 70

Gingivitis 70

Lead Line 72

THE BREATH 72

THE TONSILS 73

THE PHARYNX 74

THE PALATE AND UVULA 74

THE LARYNX 75

Tuberculosis of the Larynx 76

Tumors of the Larynx 76

Paralysis of the Vocal Cords 76

REFERENCES 76

CHAPTER Ⅲ EXAMINATION OF THE NECK 78

CERVICAL LYMPHADENOPATHY 80

INFECTIONS 81

Acute Regional Infections 81

Acute Systemic Infections 81

Chronic Systemic Infections 82

Tuberculosis 82

Sarcoidosis 83

ALLERGIC REACTIONS 83

Serum Sickness 83

PRIMARY LYMPH NODE DISEASES 83

Leukemia 86

Metastatic Lymphadenopathy 86

THE SALIVARY GLANDS 86

Tumors of the Salivary Glands 87

THE THYROID GLAND 87

Anomalies of the Thyroid 87

Intrathoracic(Substernal)Goiter 88

Simple Goiter(Colloid Goiter) 88

Toxic Goiter 90

Nodular Goiters 91

Thyroid Malignancy 91

Acute Thyroiditis 91

VASCULAR PULSATIONS IN THE NECK 92

DISTENTION OF THE VEINS OF THE NECK 93

REFERENCES 93

CHAPTER Ⅳ EXAMINATION OF THE MUSCULOSKELETAL SYSTEM 95

EXAMINATION OF THE MUSCLES 95

EXAMINATION OF THE JOINTS 107

The Shoulder Joint 108

Motions 108

Lesions 109

The Elbow Joint 111

The Wrist Joint 113

Lesions 113

The Hip Joint 115

Motions 116

Lesions 117

The Knee Joint 120

Lesions 121

The Ankle Joint 123

Lesions 123

The Foot 124

Deformities 125

The Back 128

Spinal Curvature 128

Scoliosis 129

Low Back Pain 131

REFERENCES 133

CHAPTER Ⅴ EXAMINATION OF THE BREASTS 134

SELF-EXAMINATION 134

PHYSICAL EXAMINATION 135

Carcinoma 138

Gynecomastia 142

Tuberculosis of the Breast 142

REFERENCES 143

CHAPTER Ⅵ SOUNDS FROM THE THORAX：ACOUSTIC PRINCIPLES＆by S．Reid Warren，Jr Sc．D．in E．E 144

SOUNDS PRODUCED IN THE THORAX 145

Percussion 145

Auscultation 145

Electrical Pickups 146

Preliminary Conclusions 148

PRODUCTION AND PROPAGATION OF SOUND 148

What Sound Is 148

Kinds of Sounds 149

Sounds in Media Other than Air 151

Attenuation，Absorption and Reflection 151

Reflection and Viscosity 151

Attenuation and the Stethoscope 152

Thoracic Sounds：Frequency Range 152

Sensations of Sounds 153

Loudness 153

Intensity 153

Physical Aspects of Hearing 155

Audibility of Sounds 156

Ambient Sounds 157

Pitch of Sounds 157

Loudness of Sounds 157

Timbre 157

Location of Sounds 157

SOURCES OF SOUND IN THE THORAX 158

Circulatory System：Loudness and Frequency Range 158

Respiratory System：Loudness and Frequency Range 158

Vocal Sounds 158

Percussion 158

Interpretation 159

CONCLUSIONS 159

REFERENCES 160

CHAPTER Ⅶ EXAMINATION OF THE CHEST 161

ROENTGENOLOGIC VERSUS PHYSICAL EXAMINATION 163

INSPECTION OF THE CHEST 165

Beside Inspection 166

Conformation of the Normal Chest 166

Size and Development of the Chest 169

Asymmetry of the Chest 170

Shape and Movement of the Subcostal Angle 173

Local Bulging and Pulsations of the Thorax 173

Abnormal Thoracic Conformation 176

The Rachitic Chest 176

The Long Flat Chest(Pterygoid Chest，Alar Chest) 178

The Emphysematous(Barrel-Shaped)Chest 179

REFERENCES 181

CHAPTER Ⅷ PALPATION OF THE CHEST 182

TECHNIC OF PALPATION 182

VOCAL FREMITUS 183

Voice Production 184

Production of Fremitus 184

Tactile Vibrations 186

REFERENCE 186

CHAPTER Ⅸ PERCUSSION OF THE CHEST 187

TECHNIC OF PERCUSSION 188

Diaphragmatic Excursion 189

PERCUSSION SOUNDS 189

Tympany 189

Modified Tympany 190

Metallic Ring 190

Bell Tympany 191

Cracked-Pot Sound 191

Resonance 192

Hyperresonance 192

Dullness 192

Flatness 192

PERCUSSION RESISTANCE 192

OTHER PERCUSSION METHODS 192

Orthopercussion 193

Auscultatory Percussion 193

MOVABLE OR SHIFTING DULLNESS 195

REFERENCES 195

CHAPTER Ⅹ AUSCULTATION OF THE CHEST 196

Effect of Posture 197

The Stethoscope 197

NORMAL BREATH SOUNDS 197

Laryngeal or Bronchial Element of the Breath Sounds 197

Vesicular Element of the Breath Sounds 198

Vesicular Breath Sounds 199

ABNORMAL BREATH SOUNDS 200

Absent Breath Sounds 200

Decreased Breath Sounds 200

Exaggerated Breathing 200

Bronchial Breathing 200

Bronchovesicular Breathing 201

Cavernous Breathing 201

Amphoric Breathing 201

ADVENTITIOUS SOUNDS 202

Rales 202

Musical Rales 202

Crepitant(Consonating)Rales 202

Subcrepitant(Crackling)Rales 202

Bubbling(Gurgling)Rales 203

Marginal(Atelectatic)Rales 203

Production of Rales 203

Friction Sounds 204

Succussion Splash 204

Metallic Tinkle 204

VOICE SOUNDS 205

Vocal Resonance 205

Bronchophony 205

Pectoriloquy 205

Egophony 206

REFERENCES 206

CHAPTER Ⅺ PHYSICAL SIGNS IN CERTAIN DISEASES OF THE LUNGS AND PLEURA：CORRELATIVE DATA 207

DISEASES OF THE LUNGS 207

Pulmonary Tuberculosis 207

Lobar Pneumonia 207

Auscultation 209

Physical Signs 209

Bronchiectasis 209

Bronchial Asthma 210

Interstitial Emphysema 211

Massive Collapse of the Lung 212

Physical Signs 212

Inspection 212

Palpation 212

Percussion 212

Auscultation 213

Pulmonary Embolism 213

Physical Signs 213

Pulmonary(Venous)Air Embolism 213

Arterial Air Embolism 217

DISEASES OF THE PLEURA 218

Dry Pleurisy 218

Inspection 218

Palpation 218

Percussion 219

Auscultation 219

Diaphragmatic Pleurisy 219

Epidemic Pleurodynia(Bornholm Disease，Devil＇s Grip) 219

Pleural Effusion 220

Inspection 220

Palpation 220

Percussion 220

Auscultation 223

Loculated Pleural Fluid 224

REFERENCES 227

CHAPTER Ⅻ EXAMINATION OF THE CIRCULATORY SYSTEM 228

BLOOD PRESSURE 228

Normal Arterial Blood Pressure 228

High Blood Pressure(Arterial Hypertension) 229

Low Blood Pressure(Vascular Hypotension) 229

Pulse Pressure 230

Venous Blood Pressure 230

THE HEART 230

The Valves 231

Inspection 234

Palpation 236

Normal Position of the Cardiac Impulse 239

Displacement of the Cardiac Impulse 239

Thrills 240

Percussion 240

Heart Size 240

Method 242

Cardiac Dullness 245

Significance of Cardiac Dullness 246

Percussion versus Roentgenology 247

Auscultation 251

Valve Areas 251

Heart Sounds 252

Origin and Characteristics of Heart Sounds 252

The First Sound 252

The Second Sound 253

The Third Sound 253

Increased Intensity of the First Sound 253

Decreased Intensity of the First Sound 253

Increased Intensity of the Second Sound 254

Splitting or Reduplication of Heart Sounds 254

Gallop Rhythm 254

Heart Murmurs 255

Intensity 256

Cardiac Arrhythmias 257

Sinus Arrhythmia 258

Sinus Pauses 258

Auricular and Ventricular Premature Beats 258

Paroxysmal Auricular Tachycardia 259

Auricular Flutter 259

Auricular Fibrillation 259

Paroxysmal Ventricular Tachycardia 260

Ventricular Fibrillation 260

Heart Block 261

First Degree Heart Block 261

Second Degree Block(Partial Block) 261

Third Degree Block(Complete Block) 261

Pulsus Alternans 262

REFERENCES 262

CHAPTER ⅩⅢ PHYSICAL SIGNS IN CERTAIN DISEASES OF THE HEART AND GREAT VESSELS：CORRELATIVE DATA 264

VALVULAR DISEASES 264

Mitral Regurgitation(Insufficiency) 264

Mitral Stenosis 264

Aortic Insufficiency 267

Physical Signs 268

Inspection 268

Palpation 269

Percussion 271

Auscultation 271

Interpretation 272

Aortic Stenosis 272

Physical Signs 273

Inspection and Percussion 273

Palpation 274

Auscultation 274

Tricuspid Insufficiency 275

Physical Signs 275

Inspection 275

Palpation 275

Percussion 276

Auscultation 276

Tricuspid Stenosis 277

Pulmonary Insufficiency 277

Pulmonary Stenosis 277

Transmission of Murmurs 277

The Continuous Murmur 278

CONGENITAL CARDIAC AND VASCULAR DEFECTS 279

Patent Ductus Arteriosus 279

Coarctation of the Aorta 279

Aberrant Right Subclavian Artery 280

Interventricular Septal Defect(Roger＇s Disease) 283

Eisenmenger＇s Complex 283

Tetralogy of Fallot 284

Patent Foramen Ovale 285

MISCELLANEOUS CONDITIONS 286

Pericardial Effusion 286

Physical Signs 286

Inspection 286

Palpation 288

Percussion 290

Auscultation 291

Cor Pulmonale 291

Ayerza＇s Disease 292

Xiphosternal Crunch 293

REFERENCES 294

CHAPTER ⅩⅣ EXAMINATION OF THE ABDOMEN 295

Position of the Patient 295

Regions of Abdomen 295

Surface Markings 296

INSPECTION OF THE ABDOMEN 296

Visible Peristalsis 296

Bodily Movements 296

The Skin 297

Rashes 297

Contour 297

Enlarged and Tortuous Veins 298

Hirsutism and Hair Distribution 298

Abdominal Pulsations 298

Respiratory Movements of the Abdomen 299

Abdominal Asymmetry 299

Examination of the Umbilicus 300

Abdominal Hernias 300

Ventral Hernia 300

Umbilical Hernia 301

Inguinal Hernia 301

Femoral Hernia 302

Diaphragmatic Hernia 302

PALPATION OF THE ABDOMEN 302

Muscular Rigidity 303

Tenderness 303

Parietal Pain 303

Intercostal Neuralgia 304

Fluctuation 304

Ascites 304

Tumors 305

Palpation of the Liver 306

Technic 307

Palpation of the Spleen 307

Technic 308

Palpation of the Kidneys 309

PERCUSSION OF THE ABDOMEN 310

AUSCULTATION OF THE ABDOMEN 310

REFERENCES 310

CHAPTER ⅩⅤ THE GYNECOLOGIC EXAMINATION 311

EXAMINATION OF THE PATIENT 311

Position of the Patient 311

Position of the Examiner 314

Technic 314

EXTERNAL GENITALIA 314

Mons Veneris 315

Clitoris 315

Labia Majora 315

Labia Minora 315

Vulva 315

Bartholin＇s Glands 315

Perineal Body 316

Vestibule 316

Urethral Meatus 317

Skene＇s Ducts 317

Hymen 317

VAGINA AND ITS CONTENTS 318

Speculum Examination 318

Technic 318

Cervix 320

Vagina 323

Vaginitis 323

Vaginal Walls 323

Descensus Uteri 325

Palpation 325

Bimanual Examination 327

Uterus 328

Position 328

Size，Shape and Consistency 328

Motion 329

Adnexa 330

Hydrosalpinx 330

Ectopic Pregnancy 330

Tumors 330

Endometriosis 331

Parovarian Cyst 332

Parametrium 332

Special Tests 332

Papanicolaou Smears 332

Rubin Test 332

Hysterosalping-ography 332

Cervical Biopsy 333

Sperm Analysis 333

Huhner Test 333

Hanging Drop Preparations 333

Tests for Gonococci 333

REFERENCES 333

CHAPTER ⅩⅥ EXAMINATION OF THE MALE GENITALIA，AND OF THE ANUS，RECTUM AND RECTOSIGMOID COLON 334

MALE GENITALIA 334

Size and Development 334

Hypogonadism 334

Hypergonadism 334

Congenital Anomalies 335

Hypospadias 335

Epispadias 335

Incomplete Descent of One or Both Testes 335

Congenital Hydrocele 335

Lesions of the Penis 335

Phimosis 335

Chancre 335

Chancroid 335

Lymphopathia Venereum(Lymphogranuloma Inguinale) 337

The Testes and Scrotum 338

Hydrocele 339

Varicocele 339

Prostate and Seminal Vesicles 339

ANUS，RECTUM AND RECTOSIGMOID COLON 339

Digital Examination 339

Preparation 339

Position 339

Equipment 339

Anus and Rectum 340

Inspection and Palpation 340

Prostate and Seminal Vesicles 342

Prostate 342

Carcinoma of the Prostate 343

Seminal Vesicles 343

Proctosigmoidoscopy 344

Preparation 344

Position 344

Equipment 345

Conduct of the Examination 345

Anoscopy 347

REFERENCES 347

CHAPTER ⅩⅦ EXAMINATION OF THE EXTREMITIES 348

NUTRITIONAL，METABOLIC AND ENDOCRINE DISORDERS MANIFESTED IN THE EXTREMITIES 348

Rickets 348

Pellagra 349

Scurvy 349

Acromegaly 349

Paget＇s Disease(Osteitis Deformans) 349

Gout 350

THE EXTREMITIES IN CERTAIN SYSTEMIC INFECTIONS AND DEGENERATIVE STATES 351

Rheumatic Fever 351

Subacute Bacterial Endocarditis 352

Gonococcal Arthritis 352

Rheumatoid Arthritis 353

(Arthritis Deformans) 353

Hypertrophic Arthritis(Osteoarthritis，Senile Arthritis) 353

Tuberculous Arthritis 354

Tuberculous Osteomyelitis 354

Syphilis 354

Charcot＇s Joint 355

CLUBBING OF THE FINGERS AND TOES AND HYPERTROPHIC PULMONARY OSTEOARTHROPATHY 355

Symmetrical Clubbing 356

Pulmonary Diseases 356

Cardiac Diseases 358

Hepatic and Gastrointestinal Diseases 359

Unilateral Clubbing 359

Unidigital Clubbing 359

MISCELLANEOUS CONDITIONS 359

Tetany 359

Dupuytren＇s Contracture 360

Volkmann＇s Ischemic Contracture 360

Ganglia of the Wrist 360

Carphologia 360

Edema of the Extremities 360

Acute Lymphangitis 362

THE PERIPHERAL ARTERIES 362

Palpation 362

Peripheral Arteriosclerosis 363

Thromboangiitis Obliterans(Buerger＇s Disease) 363

Arterial Embolism 363

Exposure to Cold 364

Raynaud＇s Disease 364

Raynaud＇s Phenomenon 365

PERIPHERAL VEINS 365

Varicose Veins 365

Thrombophlebitis 365

Phlebothrombosis 366

REFERENCES 366

CHAPTER ⅩⅧ NEUROLOGIC EXAMINATION 367

ANATOMIC AND PHYSIOLOGIC CONSIDERATIONS 367

Voluntary Motor System 367

Voluntary Motor Control 367

Tone 368

Sensory System 368

Coordination 369

Special Senses 369

Gnostic Functions 369

Psychologic Component 370

PRACTICAL METHODS OF EXAMINATION AND INTERPRETATIONS OF INDIVIDUAL FINDINGS 370

Involuntary Movements 370

Fibrillations(Fasciculations) 370

Tremors 370

Choreiform Movements 371

Athetoid Movements 371

Dystonic Movements 371

Spasms 371

Tics(Habit Spasms) 372

Convulsive Seizures 372

Posture，Gait and Station 372

Posture 372

Gait 372

Station 373

Meningeal Irritation 374

The Head 374

The Cranial Nerves 374

First Nerve 374

Second，Third，Fourth and Sixth Nerves 375

Fifth Nerve 375

Seventh Nerve 376

Eighth Nerve 378

Ninth Nerve 380

Tenth Nerve 380

Eleventh Nerve 380

Twelfth Nerve 381

The Neck 381

The Back and Trunk 382

The Extremities 383

Upper Extremities 383

Coordination 383

Palpation of Muscles 384

Atrophy of Muscles 384

Muscle Strength 384

Nerve Lesions 384

Muscle Tone 385

Reflexes 385

Sensory Determination 386

Lower Extremities 387

Reflexes 390

Coordination 391

Sensory Determination 392

NEUROLOGIC EVALUATION 392

REFERENCES 393

CHAPTER ⅩⅨ PSYCHIATRIC SURVEY 394

MENTAL STATUS 394

General Attitude of the Patient 395

Memory 395

Orientation 396

Stream of Thought 396

Disturbances of Perception 397

Association of Ideas 397

Judgment 398

Mood 398

Anxiety 399

Apathy 399

Depression 399

Elation 400

Other Moods 400

Special Preoccupations 400

Phobias，Obsessions and Compulsions 400

Insight 401

REFERENCES 402

CHAPTER ⅩⅩ THE HISTORY 403

Physician-Patient Rapport 403

Use of Understandable Words 404

Patient Personalities 404

TECHNIC OF HISTORY TAKING 404

History of Present Illness 405

Systemic Review 405

Past Medical History 406

Occupational History 406

Social History 407

Family History 407

REFERENCES 407

INDEX 409