OM301 

Western Medicine Diagnosis Introduction

General data -Name, gender, age, phone, occupation, marital status

🞂Date and Time of History.

   The date is always important. You are strongly advised to routinely document the time you evaluate the patient, especially in urgent, emergent, or hospital settings.

1. Inspection

2. Palpation 
   1. Light palpation
   2. Deep palpation

3. Percussion
   1. direct percussion
   2. indirect percussion

4. Auscultation (stethophone/stethoscope) 

GENERAL EXAMINATION.

I. The General condition of the patient.

II. The skin and the subcutaneous cellular tissue.

III. lymph nodes

I. The General Condition of the Patient.

1. Vital sign: Blood Pressure, Pulse (HR), Respiration, Temperature
2. Development (Height, Build, Weight)
3. State of nutrition
4. Consciousness
5. Tone 
6. Facial Expression
7. The position in bed (Active position, Passive position, Compulsive position)
8. Posture and gait.

Vital sign:

1. BLOOD PRESSURE: blood pressure is considered to be between 90/60mmHg and 120/80mmHg. high blood pressure is considered to be 140/90mmHg or higher. low blood pressure is considered to be below 90/60mmHg.

2. HEART RATE AND RHYTHM: 

   The radial pulse is commonly used to assess the heart rate. If the rhythm is regular and the rate seems normal, count the rate for 15 seconds and multiply by 4. 

   Normally, adults heart rate is 60 - 100.

3. RESPIRATORY RATE AND RHYTHM:

   Observe the rate, rhythm, depth, and effort of breathing. 

   Count the number of respirations in 1 minute either by visual inspection or by subtly listening over the patient’s trachea with your stethoscope during your examination of the head and neck or chest. 

   Normally, adults take 14 to 20 breaths a minute in a quiet regular pattern.

4. TEMPERATURE:

The average oral temperature, at 37°C (98.6°F), In the early morning hours it may fall as low as 35.8°C (96.4°F), and in the late afternoon or evening it may rise as high as 37.3°C (99.1°F). 

Rectal temperatures are higher than oral temperatures by an average of 0.4 to 0.5°C (0.7 to 0.9°F).

Axillary temperatures are lower than oral temperatures by approximately 1 degree, but take 5 to 10 minutes to register and are generally considered less accurate than other measurements.)

Fever:

(Normal: 36～37℃)

Pathogeny:

1. infective fever

2. noninfective fever: absorption fever, immunological reaction, endocrine system illness, skin illness, nerve centre fever.

Degree: 

Low fever:         37.3～38℃

Middle fever:    38.1～39℃

High fever:        39.1～41℃

Extra high fever:   over 41℃

2. Development (Height, Build, Weight):

1. Height

2. Weight

3. State of nutrition:

The nutritional status of the patient based on height and weight is interpreted by the body mass index (BMI)

BMI = weight (pounds)/height (inches)2 × 703

BMI less than 18.5 kg/m2  underweight;

BMI between 18.5 and 25  healthy weight; 

BMI between 25.1 and 29.9  overweight; 

BMI of 30 or more is considered obese.

II The skin and the subcutaneous cellular tissue.

1. Skin color

2. Moisture

3. Elasticity

4. Skin eruption(Rashes) 

5. Subcutaneous hemorrhage (skin bruise)

6. Spider angioma 蜘蛛痣

7. Edema

8. Subcutaneous nodules

9. Scar 

10. Hair

III lymph nodes:

Normal: 0.2-0.5 cm, soft, not pain, smooth, not easy to find.

Looking for:

Location, size, number, soft or hard, pain, moving, red, swollen, scar,  Looking primary illness.

Reason of lymph nodes enlarge: 

1. Inflammation

2. Cancer

3. Blood System illness

Inspection

• Inspect the position of the head. Does the patient hold the head erect? 

• Is there any asymmetry of the facial structure? 

• Is the head in proportion to the rest of the body?

• Inspect the scalp for lesions. Describe the hair.

• Are any masses present? If so, describe their size, consistency, and symmetry.

Visual Fields

Assess Fields by Confrontation Testing

• The examiner stands or sits 3 feet in front of and at eye level with the patient. 

• The patient is asked to close the right eye while the examiner closes his or her own left eye, each fixating on the other’s nose. 

• The examiner holds up fists with the palms facing him or her. 

• The examiner then shows one or two fingers on each hand simultaneously and asks the patient how many fingers he or she sees. 

• The hands are moved from the upper to the lower quadrants, and the examination is repeated. The examination is then repeated, with the other eye of the patient and that of examiner. The fingers should be seen by both patient and examiner simultaneously.

CONVERGENCE

Ask the patient to follow your finger or pencil as you move it in toward the bridge of the nose. The converging eyes normally follow the object to within 5 cm to 8 cm of the nose.

Swinging Flashlight Test

• In dim room light, note the size of the pupils. 

• After asking the patient to gaze into the distance, swing the beam of a penlight back and forth from one pupil to the other, each time concentrating on the pupillary size and reaction in the eye that is lit.

sinuses

Palpate for sinus tenderness. Press up on the frontal sinuses from under the bony brows, avoiding pressure on the eyes. Then press up on the maxillary sinuses.

NECK EXAMINATION.

1. Skin and Nodules(mass), Neck stiffness

2. Blood Vessels – external  jugular vein

Sit or stand couldn’t see, lie down < 2/3 from clavicle to angle of the jaw

1. Thyroid
2. NECK EXAMINATION - Palpation
         Palpation confirms the information obtained by inspection. The patient’s head should be slightly flexed and cradled in the examiner’s hands. 
      Palpate the Thyroid Gland 
   There are two approaches to palpating the thyroid gland. 
   The posterior approach the examiner should stand behind the patient to palpate the thyroid by the posterior approach. In this approach, the examiner places two hands around the patient’s neck, which is slightly extended. The examiner uses the left hand to push thetrachea to the right. The patient is asked to swallow while the examiner’s right hand rolls over
   the thyroid cartilage. As the patient swallows, the examiner’s right hand feels for the thyroid gland against the right sternocleidomastoid muscle.
   Palpate for Supraclavicular Nodes
   • Palpation for supraclavicular nodes concludes the examination of the head and neck. The examiner stands behind the patient and places the fingers into the medial supraclavicular fossae, deep to the clavicle and adjacent to the sternocleidomastoid muscles. The patient is instructed to take a deep breath while the examiner presses deeply in and behind the clavicles.
   • Any supraclavicular nodes that are enlarged are palpated as the patient inspires.
     

   • Common or Concerning Symptoms

     •  Headache
     •  Change in vision
     •  Double vision
     •  Hearing loss, earache, tinnitus
     •  Vertigo
     •  Nosebleed, 
     •  Sore throat, hoarseness
     •  Swollen glands
     •  Goiter

Surface symbol:

suprasternal notch

sternal angle

infrasternal angle

supraclavicular fossa

suprascapular region

infrascapular region

costal spinal angle

INSPECTION

• Observe the shape of the patient’s chest and the movement of the chest wall.
  

•  Deformities or asymmetry

•  Abnormal retraction of the lower interspaces during inspiration

•  Local lag or impairment in respiratory movement

  PALPATION

  • Identification of tender areas

  •  Assessment of observed abnormalities

  •  Further assessment of chest expansion. Place your thumbs along each costal margin, your hands along the lateral rib cage. As you position your hands, slide them medially a bit to raise loose skin folds between your thumbs. Ask the patient to inhale deeply. Observe how far your thumbs diverge as the thorax expands, and feel for the extent and symmetry of respiratory movement. 

Examination of the Posterior Chest

   INSPECTION

• From a midline position behind the patient, note the shape of the chest and the way in which it moves, including: Deformities or asymmetry

• Abnormal retraction of the interspaces during inspiration. Retraction is most apparent in the lower interspaces. Supraclavicular retraction is often associated.

• Impaired respiratory movement on one or both sides or a unilateral lag (or delay) in movement.

  PALPATION

  • As you palpate the chest, focus on areas of tenderness and abnormalities in the overlying skin, respiratory expansion, and fremitus.

  • Identify tender areas. Carefully palpate any area where pain has been reported or where lesions or bruises are evident. 

    • Test chest expansion. Place your thumbs at about the level of the 10th ribs, with your fingers loosely grasping and parallel to the lateral rib cage. As you position your hands, slide them medially just enough to raise a loose fold of skin on each side between your thumb and the spine.

    • Ask the patient to inhale deeply. Watch the distance between your thumbs as they move apart during inspiration, and feel for the range and symmetry of the rib cage as it expands and contracts. 

      Feel for tactile fremitus. 

      • Fremitus refers to the palpable vibrations transmitted through the bronchopulmonary tree to the chest wall when the patient speaks. 

LUNG EXAMINATION

Inspection

1. respiratory movement

2. breathing rate

3. respiratory rhythm

Palpation

thoracic expansion

vocal fremitus 

Percussion

1. Normal lung ---Resonant

(upper bound 2-3cm over clavicle bone, lower bound in the 6th intercostal space in mid clavicle line)

2. Illness

1. Consolidation ---Dull 

2. Pneumothorax ---Hyper resonant

Auscultation

1. Normal breath sound

1. bronchial breath sound 

2. bronchovesicrllar breath sound

3. Vesicular

2. Adventitious sound

1. Crackles (moist rales)

2. Wheezes

3. Rhonchi

Percussion

1. Normal Percussion Figure of the Heart.

2. Enlargement of the Area of Heart-dullness (Hypertrophy and dilatation of the left ventricle, Fluid in the pericardium)

3. Diminution or Loss of Heart-dullness (emphysema of the lungs, pneumo-pericardium, 

4. Displacement (dislocation) of the Heart-dullness 

(chest flattened or pressed in, Emphysema of the lungs, pleurisy, Shrinking of the lungs)

Auscultation

1.Method

1.Aortic valve : 2d intercostal space, right of sternum.

2.Pulmonic valve : 2d intercostal space, left of sternum

3.Tricuspid valve :left sternal border, 4th intercostal space

4.Mitral valve : Apex

2. Normal Condition

The first and second heart-sounds

1st sound : Closure of the mitral and the tricuspid valves and ventricular contraction.

2d sound :  Closure of aortic  and pulmonary valve.

The Breasts 

The female breast lies against the anterior thoracic wall, extending from the clavicle and 2nd rib down to the 6th rib, and from the sternum across to the midaxillary line. The breast overlies the pectoralis major and at its inferior margin, the serratus anterior. The breast is hormonally sensitive tissue, responsive to the changes of monthly cycling and aging.

INSPECTION

Inspect the breasts and nipples with the patient in the sitting position A thorough examination of the breast includes careful inspection for skin changes, symmetry, contours(Shape), and retraction in four views— arms at sides, arms over head, arms pressed against hips, and leaning forward.

PALPATION

Palpation is best performed when the breast tissue is flattened. The patient should be supine. Plan to palpate a rectangular area extending from the clavicle to the inframammary fold or bra line, and from the midsternal line to the posterior axillary line and well into the axilla for the tail of the breast.

The Axillae 

INSPECTION 

Inspect the skin of each axilla, noting evidence of: Rash Infection Unusual pigmentation

PALPATION

To examine the left axilla, ask the patient to relax with the left arm down. Help by supporting the left wrist or hand with your left hand. Cup together the fingers of your right hand and reach as high as you can toward the apex of the axilla. Warn the patient that this may feel uncomfortable. Your fingers should lie directly behind the pectoral muscles, pointing toward the midclavicle.  Now press your fingers in toward the chest wall and slide them downward, trying to feel the central nodes against the chest wall.  Of the axillary nodes, these are the most often palpable. One or more soft, small (<1 cm), nontender nodes are frequently felt.

Breast Self Examination

Step 1: Look in the Mirror (Hands on Hips)
Stand in front of a mirror with your shoulders straight and hands on your hips.
Look for:

• Usual size, shape, and color

• Even shape with no swelling or changes

Tell your doctor if you see:

• Skin dimpling or puckering

• Nipple changes or pulling inward

• Redness, rash, or swelling

Step 2: Raise Your Arms and Look Again
Raise your arms and check for the same changes as above.

Step 3: Check for Nipple Discharge
Look for any fluid coming from one or both nipples (clear, milky, yellow, or bloody).

Step 4: Feel for Lumps Lying Down
Lie down and use your right hand to feel your left breast, then your left hand to feel your right.

• Use a circular motion with your finger pads

• Cover the whole breast from top to bottom and side to side

• Use light, medium, and firm pressure to feel all layers

Step 5: Feel for Lumps While Standing or Sitting
Check your breasts while standing or in the shower.

• Use the same circular motion

• Cover the entire breast area

1. Inspection

   1. Appearance
   2. Breathing movement
   3. Veins  
   4. Gastral or intestinal pattern and peristalsis

2. Palpation:

• Light Palpation. 

  • Feeling the abdomen gently is especially helpful in identifying abdominal tenderness, muscular resistance, and some superficial organs and masses. It also serves to reassure and relax the patient.

• Deep Palpation.

• This is usually required to delineate abdominal masses and enlarged organs.

• Identify any masses and note their location, size, shape, consistency, tenderness, pulsations, and any mobility with respiration or with the examining hand.

1. Abdominal guarding
2. Tenderness and Rebound tenderness
3. Organs : Liver, GB, Spleen, Kidney, 
4. Lumps
5. McBurney’s Point (Appenicitis):
   Pain in the right lower quadrant one third the distance from the anterior iliac crest to the umbilicus.
   Caused by the inflamed appendix
6. Murphy’s sign (Cholecystitis): Pain on inspiration during gentle palpation below the right subcostal arch.As the patient breathes in, the liver moves down exposing the gallbladder to pressure from the examiners hand. Murpy’s sign may also be present with hepatitis.

3. Percussion

1. Liver

2. Stomach

3. Spleen  

4. Kidney: Assessing Kidney Tenderness.

5. Shifting dullness

4. Auscultation:  

Place the diaphragm of your stethoscope gently on the abdomen. Listen for bowel sounds and note their frequency and character. Listen to the abdomen before performing percussion or palpation, since these maneuvers may alter the frequency of bowel sounds.

1. Bowel sound normal  4-5/mins

a. Bowel sound active >10/mins

b. Hypoactive bowel sounds: < 1/ 2-5 mins

2. Vascular accentuated

3. Fetal heart sounds when pregnancy over 5 months 130-160/mins

Nerve Systems

• Important Areas of Examination
•  Mental status: appearance and behavior, speech and language, mood, thoughts and perceptions, cognition
•  Cranial Nerves I through XII
• 
  
  • I Smell
  • II Visual acuity, visual fields
  • III Pupillary reactions
  • III, IV, VI Extraocular movements
  • V Corneal reflexes, facial sensation, and jaw movements
  • VII Facial movements
  • VIII Hearing
  • IX, X Swallowing and rise of the palate
  • V, VII, X, XII Voice and speech
  • XI Shoulder and neck movements
  • XII Tongue symmetry and position
•  Motor system: muscle bulk, tone, and strength; coordination, gait, and stance
  1. Motor function
     1. muscle strength
     2. muscular tension
     3. Involuntary movements
        1. Tremor 
        2. Choreic movement (舞蹈病)
        3. Athetosis (手足徐动症)
•  Sensory system: pain and temperature, position and vibration, light touch, discrimination
  2. Sensory function
  1. Superficial sensibility 
     1. Pain sensation
     2. Touch sensation
     3. temperature sense
• 
  
  2. Deep sensibility
     1. Movement sense
     2. Position sense
     3. Vibration sense
•  Deep tendon, abdominal, and plantar reflexes
  3. Neural reflex
  1. Superficial reflexes
     1. Abdominal reflex
     2. plantar reflex---Babinski
  2. Deep Reflexes
     1. biceps tendon reflex
     2. triceps tendon reflex
     3. patellar tendon reflex
     4. achilles tendon reflex
  3. Pathologic reflex:  Babinski (central nerve damaged)
     

Common or Concerning Symptoms

• Pain in the arms or legs
•  Intermittent claudication (跛行)
•  Cold, numbness, pale in the arm, or legs, body hair loss
•  Color change in fingertips or toes in cold weather
•  Swelling in calves, legs, or feet
•  Swelling with redness or tenderness
• 
  
  • Important Areas of Examination
  • The Arms  Size, symmetry, skin color, Radial pulse, brachial pulse
  • TECHNIQUES OF EXAMINATION
  • Assessment of the peripheral vascular system relies primarily on inspection of the arms and legs, palpation of the pulses, and a search for edema. 

  • Arms

  • Inspect both arms from the fingertips to the shoulders. Note:  Their size, symmetry, and any swelling  The venous pattern  The color of the skin and nail beds and the texture of the skin 
  • Palpate the radial pulse with the pads of your fingers on the flexor surface of the wrist laterally. Partially flexing the patient’s wrist may help you feel this pulse. Compare the pulses in both arms. 

  • The Legs

  •  Size, symmetry, skin color  Femoral pulse and inguinal lymph nodes
  •  Popliteal, dorsalis pedis, and posterior tibial pulses
  •  Peripheral edema 

    If edema is present, look for possible causes in the peripheral vascular system.

    These include 

    1. recent deep venous thrombosis, 

    2. chronic venous insufficiency due to previous deep venous thrombosis or to incompetence of the venous valves, and 

    3. lymphedema.

• Important Areas of Examination for Each of the Major Joints
• Inspection for joint symmetry, alignment, bony deformities
• Inspection and palpation of surrounding tissues for skin changes, nodules, muscle atrophy,
• Range of motion and maneuvers to test joint function and stability,
• integrity of ligaments, tendons, bursae, especially if pain or trauma
• Assessment of inflammation or arthritis, especially swelling, warmth, tenderness, redness

The Temporomandibular Joint (TMJ)

To locate and palpate the joint, place the tips of your index fingers just in front of the tragus of each ear and ask the patient to open his or her mouth. The fingertips should drop into the joint spaces as the mouth opens. Check for smooth range of motion; note any swelling or tenderness.

The Shoulder

The Elbow

• Support the patient’s forearm with your opposite hand so the elbow is flexed to about 70°. 
• Palpate the olecranon process and press on the epicondyles for tenderness.
• Note any displacement of the olecranon.

The Wrist and Hand

Palpate the eight carpal bones lying distal to the wrist joint, and then each

of the five metacarpals and the proximal, middle, and distal phalanges.

Palpate any other area where you suspect an abnormality.

SPINE

1. Inspection
   1. Spine curvature
   2. Spinal mobility
2. Palpation ---Tenderness 
3. Percussion---Percussion pain

ANATOMY AND PHYSIOLOGY CHANFGS

During pregnancy, there are changes in the thyroid gland, breasts, abdomen, and pelvis. You may also detect minor skin changes such as the mask of pregnancy and abdominal striae. • During pregnancy, the thyroid gland and the breasts undergo moderate enlargement due to hormonal stimulation and increased vascularity and hyperplasia of glandular tissue. There may be tenderness and tingling in the breasts that makes them more sensitive during examination.

By the third month of gestation, the breasts become more nodular, requiring careful palpation to avoid discomfort as you examine for any breast masses. • The nipples become larger and more erectile. From mid to late pregnancy, colostrum, a thick, yellowish secretion rich in nutrients, may be expressed from the nipples. The areolae darken, and Montgomery’s glands are more prominent. The venous pattern over the breasts becomes increasingly visible as pregnancy progresses

The abdomen’s most notable change is distention, primarily from the increasing size of the growing uterus and fetus. • Early distention from fluid retention and relaxation of abdominal muscles may be noted before the uterus becomes an abdominal organ (12–14 weeks of pregnancy).

As the skin stretches to accommodate the growth of the fetus, purplish striae may appear. • The linea nigra(黑线), a brownish black pigmented line following the midline of the abdomen, may become evident. • Muscle tone is diminished as pregnancy advances, and separation of the rectus muscles at the midline of the abdomen, may be noticeable in the later trimesters of pregnancy.

TECHNIQUES OF EXAMINATION

Positioning.

• Positioning is important when examining the abdomen of a pregnant woman given the added time and attention needed to palpate the uterus and listen to the fetal heart. The semi-sitting position with the knees bent, affords the greatest comfort, as well as protection from the negative effects of the weight of the gravid uterus on abdominal organs and vessels.

Vital Signs and Weight

Take the blood pressure. A baseline reading helps to determine the woman’s usual range. In midpregnancy, blood pressure is normally lower than in the nonpregnant state. • Measure the weight. First-trimester weight loss related to nausea and vomiting is common but should not exceed 5 pounds.

General Inspection

Inspect the overall health, nutritional status, neuromuscular coordination, and emotional state as the woman walks into the exam room and climbs on the examination table.

• Face.

The mask of pregnancy, chloasma黄褐斑, is normal. It consists of irregular brownish patches around the eyes or across the bridge of the nose.

• Breasts Inspect the breasts and nipples for symmetry and color. The venous pattern may be marked, the nipples and areolae are dark, and Montgomery’s glands are prominent.

Abdomen

Position the pregnant woman in a semi-sitting position with her knees flexed • Inspect any scars or striae, the shape and contour of the abdomen, and the fundal height. Purplish striae and linea nigra are normal in pregnancy. The shape and contour may indicate pregnancy size • Palpate the abdomen for: • Organs or masses. The mass of pregnancy is expected. Fetal movements. These can usually be felt by the examiner after 24 weeks (and by the mother at 18–20 weeks). • Uterine contractility. The uterus contracts irregularly after 12 weeks and often in response to palpation during the third trimester. The abdomen then feels tense or firm to the examiner, and it is difficult to feel fetal parts.

Measure the fundal height with a tape measure if the woman is more than 20 weeks’ pregnant. Holding the tape as illustrated and following the midline of the abdomen, measure from the top of the symphysis pubis to the top of the uterine fundus. After 20 weeks, measurement in centimeters should roughly equal the weeks of gestation.

• Auscultate the fetal heart, noting its rate (FHR), location, and rhythm.

• Use either: • A doptone, with which the FHR is audible after 12 weeks, or A fetoscope, with which it is audible after 18 weeks.

• The rate is usually in the 160s during early pregnancy, and then slows to the 120s to 140s near term. After 32 to 34 weeks, the FHR should increase with fetal movement

The location of the audible FHR is in the midline of the lower abdomen from 12 to 18 weeks of gestation. After 28 weeks, the fetal heart is heard best over the fetal back or chest. The location of the FHR then depends on how the fetus is positioned. Palpating the fetal head and back helps you identify where to listen.

• If the fetus is head down with the back on the woman’s left side, the FHR is heard best in the lower left quadrant. If the fetal head is under the xiphoid process (breech presentation) with the back on the right, the FHR is heard in the upper right quadrant.

Genitalia, Anus, and Rectum

• Inspect the external genitalia, noting the hair distribution, the color, and any scars.

Special Techniques

MODIFIED LEOPOLD’S MANEUVERS

• These maneuvers are important adjuncts to palpation of the pregnant abdomen beginning at 28 weeks of gestation. They help determine where the fetus is lying in relation to the woman’s back (longitudinal or transverse), what end of the fetus is presenting at the pelvic inlet (head or buttocks), where the fetal back is located, how far the presenting part of the fetus has descended into the maternal pelvis, and the estimated weight of the fetus.

• This information is necessary to assess the adequacy of fetal growth and the probability of successful vaginal birth

First Maneuver (Upper Pole). Stand at the woman’s side facing her head. Keeping the fingers of both examining hands together, palpate gently with the fingertips to determine what part of the fetus is in the upper pole of the uterine fundus.

Second Maneuver (Sides of the Maternal Abdomen). • Place one hand on each side of the woman’s abdomen, aiming to capture the body of the fetus between them. Use one hand to steady the uterus and the other to palpate the fetus.

Third Maneuver (Lower Pole). • Turn and face the woman’s feet. Using the flat palmar surfaces of the fingers of both hands and, at the start, touching the fingertips together, palpate the area just above the symphysis pubis. Note whether the hands diverge with downward pressure or stay together. This tells you whether or not the presenting part of the fetus, head or buttocks, is descending into the pelvic inlet. If the presenting fetal part is descending, palpate its texture and firmness. If not, gently move your hands up the lower abdomen and capture the presenting part between your hands.

Fourth Maneuver (Confirmation of the Presenting Part). With your dominant hand grasp the part of the fetus in the lower pole, and with your nondominant hand, the part of the fetus in the upper pole. With this maneuver, you may be able to distinguish between the head and the buttocks