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PROPEDEUTIC OF INTERNAL MEDICINE
LECTURE: GENERAL ISPECTION OF THE PATIENT
PLAN OF THE LECTURE
1. ROLE OF INSPECTION IN DIAGNOSTIC PROCESS 2. GENERAL INSPECTION OF THE BODY 2.1. Rules of inspection 2.2. Maine parameters of inspection 3. INSPECTION OF SEPARATE PART OF THE BODY 3.1. The head 3.2. The skin 3.3. The face 3.4. The neck 3.5. The chest 3.6. The abdomen 3.7. The hands 3.8. The legs
ROLE OF INSPECTION IN DIAGNOSTIC ROLE OF INSPECTION IN DIAGNOSTIC PROCESSPROCESS
Overview of
the patient
allows to
choose tactic
further
treatment.
Overview of the Overview of the patient allows to patient allows to estimate the acute estimate the acute problem of the problem of the patient.patient.
Effectiveness of Effectiveness of review review determined by determined by doctor erudition. doctor erudition. You can only see You can only see what you know.what you know.
Inspection is Inspection is carried out in carried out in daylight in daylight in warm roomwarm room
The physical The physical examination starts examination starts as soon as you see as soon as you see
the patient.the patient.
Often your general Often your general observations point to observations point to a specific diagnosis a specific diagnosis
or to the system or to the system causing problems.causing problems.
GENERAL CONDITION
Satisfactory ModerateSevere Very severe
The general condition of the patient includes the following indicators: state of consciousness,
position in bed, motor activity. Depending on these parameters is determined by the priority of the
diagnostic and therapeutic manipulations.
Incorrect evaluation of the general
condition is not only professional but
also a legal problem
State of consciousness
Clear consciousness: the patient is oriented in time, space and person
Stupor: partial loss of consciousness with preservation of verbal contact. Moderate sleepiness, slowed commands are executed
Sopor: loss of consciousness and lack of verbal contact. Saved response to pain
State of consciousness
Coma: loss of consciousness with total loss of perception of the environment and himself. With severe systemic and neurological disorders
Delirium: severe disturbance of consciousness with disorientation in the environment and the person. There is alcoholism, diabetic coma, as well as metastatic tumors in the brain.
State of consciousness
Twilight disorders of consciousness it appears disorientation, appearance horrific hallucinations, anger, fear, agitation with aggression. Occurs in patients with schizophrenia
Talking of the patient
Changed talking most often occurs when palsy.
In multiple sclerosis conversation becomes a chopped up into individual words or parts of words
Hoarseness indicates recurrent nerve paresis. The resulting inflammation or cancer of the mediastinum, aortic aneurysm, myxedema
Gait (walking) of the patient
Unsteadiness of gait - lesions of the cerebellum, significant hypertension, aortic defect, severe anemia, fever
Slow, tired gait when the patient barely pulls his legs, and head and shoulders lowered, indicating physical fatigue
Duck Walk indicate congenital dislocation of the hip
Gait of the patient
Hemiplegia - the patient drags up or assigns it to the side, describing a semicircle on the ground. After brain stroke.
Posture proud man - with ascites
Posture of the petitioner - when the disease Byehtyeryeva
Gait of the patient
Posture clodhopper at
arthritis
Provisions in bed.
Active. Passive. Involuntary: active
and passive
Attack of dispnea
Paine in right hypochondria
Type figure. Constitutional type
ASTENIC
NORMOSTENIC
HYPERSTENICThin man, epigastric angle less than 90
A man of average build,
epigastric 90
A man with a broad chest,
epigastric angle of more than 90
Type figure. Constitutional type
Rfdcvghnnn n m,mhjm v mk
Definition of epigastric
angle
Pathological forms of chest
a - emphysematous;b - paralytic;c - rachitic;d - funnel;e - scaphoid;f - kyphoscoliosis.
a b
cd
ef
Leonardo da Vinci. The ideal human body
The skin
Wrinkled and dry skin occurs in severe chronic diseases of the cardiovascular system, respiratory, endocrine diseases.
Pale skin is often observed in diseases of the cardiovascular system, kidney disease, anemia. Cyanosis - bluish, gray-blue, dark blue or blue-red color of the skin and mucous membranes due to enrichment of reduced hemoglobin levels.
• Redness of the skin is observed in a significant increase hemoglobin level and number of red blood cells (polycythemia), but such phenomena are rare. Often redness (hyperemia) of the skin is limited and temporary. Redness of the face observed in fever, limited congestion occurs in inflammatory processes (abscess, erysipelas, dermatitis). One of the cutaneous manifestations of systemic lupus is the appearance of red spots on the face that is shaped like butterfly wings is placed on the cheeks, and the body - the back of the nose
• Based jaundice color of skin and visible mucous membranes (mouth, eye sclera) in clinical practice diagnosed with jaundice. Jaundice - a symptom that occurs in various diseases due to excessive accumulation of bilirubin in the blood
• On examination, the patient's skin can detect areas of hyperpigmentation or depigmentation, commonly observed in endocrine disorders
• On examination, the patient's skin can detect scarring, the presence of which indicates postponed surgery, trauma, purulent skin and subcutaneous tissue, which in some cases can help in the diagnosis of internal diseases
Swelling
Swelling called excessive accumulation of fluid in the tissues, the extracellular space. Edema may be obvious, detected by palpation or hidden. At the press of a finger in the area of edema appears fossa, which then slowly turns. Water retention in the body accompanied by an increase in body weight of the patient, reducing the volume of daily urine output. Swelling observed in severe diseases of the heart and kidneys. The degree of severity varies - from mild swelling under the eyes in the morning after waking up to anasarca (swelling of the body). In severe cases fluid accumulates in the pleural cavity (hydrothorax) in the pericardial cavity (hydropericardium) and so on.
Swelling
In severe debilitating diseases, protein deficiency, malignant tumors arising swelling.
Slight swelling in both legs appear when hormonal fluctuations associated with the menstrual cycle, pregnancy, treatment of sex hormones or hormones of the adrenal cortex.
It should also be remembered that after a long stay on his feet in both feet or legs at the end of the day formed static edema (mainly in people who are overweight).
The head - pay attention to its shape, facial expression of the
patient, his eyes, nose shape. Facial expression is the mirror of the physical and mental condition of the patient. For example, suffering facial expression indicates the severity of the disease. In agonizing patients and in patients with inflammation of the peritoneum (peritonitis) observed the so-called Hippocratic face, characterized by pale skin, deep, sunken eyes, sharp facial features. The skin of the patient is cold with sticky sweat
The head
Cyanotic rosy cheeks, bluish color of the mucous lips and nose, lehkozhovtushni sclera stenosis of the left atrioventricular opening (facies mitralis).
Abnormal facial expressions
Features Diagnosis Poverty of expression Parkinsonism Startled expression Hyperthyroidism Apathy, with poverty Depression of expression and poor eye contact Apathy, with pale and Hypothyroidismpuffy skin Lugubrious expression Myotonic dystrophywith bilateral ptosis
The face
The face is the most revealing area of the body, showing the features of its physical and psychological well-being and disease. In no other part of the body can one find so many signs of clinical disorders. Face-to-face contact is often the first interaction with the patient and thus forms an essential part of the clinical examination.
Abnormal faciesThe face may show one or
more of the many characteristic
features associated with diseases
The face
acromegaly
Hypothyroidism:Note a
noncommunicativeaffect
Lipodystrophy:prominent muscular
contours due todeficient
subcutaneous fat
Cushing's syndromeMoon face
The face and eyes
Upper lid retraction
Acropachy
Graves' disease=Bazedow’s disease=Hyperthyroidism Pretibial myxoedema
The face and eyes
Hypothyroidism: hair lossClinical features of
hypothyroidism
The eyes are not shining,
noncommunicativeaffect
Hypothyroidism
The mouth It is possible to detect signs of inflammation of the mucosa
(stomatitis), rash - enantema that appears when measles, hemorrhagic diathesis. Pale mucous membranes of the mouth occurs with anemia and ochrodermia palate - with jaundice. During the inspection of the oral cavity should pay attention to the tongue of the patient, which can be coated in feverish conditions, diseases of the digestive tract. In some diseases can detect color changes and atrophy of tongue papillae. For example, in scarlet fever tongue is crimson, liver cirrhosis - red, looks like patent leather, at vit. B-12 deficiency anemia is marked atrophy of the mucosa with inflammatory hyperemia tip and edges of the tongue (Hanter’s glossitis).
The neck
On examination, the patient's neck draw attention to the condition of the thyroid gland, lymph nodes, pulsation of vessels. Increased thyroid observed in thyrotoxicosis, endemic goitre.
The neck
Cervical lymph nodes may increase in acute lymphadenitis, tuberculosis, syphilis, infectious mononucleosis, measles, lymphosarcoma, leukemia
At hypertension, aortic aneurysm, aortic insufficiency, thyrotoxicosis even at rest possible dancing cervical arteries. In patients with right ventricular heart failure can be detected swollen neck veins, indicating congestion in the superior vena cava
The abdomen
Inspection of the abdomen performed in the supine and standing positions of the patient. You determine the shape of the abdomen, the size, the mobility of the abdominal wall, the presence of abnormal protrusion. Normally, the stomach symmetrical, flat, depending on the constitution may be slightly protruding in hyperstenic and caught - in astenik.
The abdomen
The abdomen may increase in ascites, obesity, flatulence, the formation of large cysts in the abdominal cavity (cyst of the pancreas, ovaries). Shape of abdomen with ascites : in standing position fluid accumulates in lower abdomen,it has the shape of the bag. In the supine position – the expanding belly sides and flat in the middle part (the frog’s belly). When flatulence stomach is globular shape, with no bulging navel as in ascites.
The abdomen
In some parts of the abdomen (white line, navel, groin) hernia can be detected in a soft and rounded protrusion that better determined upright, scars of pregnancy.
Caput medusae
Musculoskeletal system
Bone changes are observed in fractures, bone tumors, osteomyelitis. During the inspection of joints pay attention to their shape, amplitude movements, skin’s condition over the joints
In severe chronic lung and heart disease, in patients can change terminal phalanges of fingers typing appearance drum sticks and nails - watch glass
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