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1、,Dyspnea,2023/4/1,Definition:Dyspnea is defined as an awareness of difficulty in breathing It is therefore a symptom,usually described by the patient as“short of breath,”whether the sensation is due to actual difficulty in breathing or is essentially an awareness of hyperventilation.If the symptom b
2、ecomes striking,it always companies with dilatation of nares,cyanosis,use of accessory muscles of respiration and abnormalities of respiratory rate,depth or rhythm.,2023/4/1,Respiratory diseases Circulatory diseases Poisoning Hematology Neuropsychogenic factors,Etiology,2023/4/1,Respiratory dyspnea,
3、Caused by abnormal ventilation and gas exchange,reduction in ventilatory capacity,hypercapnia and hypoxemia resulting from respiratory disease.Three clininal types:Inspiratory dyspnea Expiratory dyspnea Mixed dyspnea,2023/4/1,Inspiratory dyspnea,Tends to occur primarily when there is obstruction(suc
4、h as inflammation,edema,tumor and foreign body)in larynx,trachea and major bronchi.Characterized by the depression sigh,in which visible indrawing over the sternal notch,the supraclavioular spaces,the intercostal spaces and the epigastrium in the inspiration can be seen.Often accompanied by a coarse
5、,low pitched inspiratory wheezing and dry cough.,2023/4/1,Expiratory dyspnea,Expiratory dyspnea is due to the decrease of lung elasticity and spasm narrowing of the bronchioles and smaller bronchi as in emphysema,bronchial asthma and asthmatic bronchitis.Expiration is prolonged and laboured with whe
6、ezing.,2023/4/1,Mixed dyspnea,Occurs with the extensive lung disease,such as severe pneumonia,pulmonary fibrosis,massive atelectasis,pleural effusion and pneumothorax.Results in the decrease of ventilators and gas exchange capacity.Breathing is difficult during both inspiration and expiration.,2023/
7、4/1,Cardiac dyspnea,Cardiac dyspnea is usually attributable to pulmonary vascular congestion resulting from the left and/or right heart failure.,2023/4/1,Cardiac dyspnea,In Left-sided heart failure,compliance is reduced,and therefore,ventilation is decreased to the edematous lung regions and vital c
8、apacity reduced.Alveoli are stiff and more work is needed to overcome elastic recoil,the high alveolar pressure will stimulate stretch receptor and initiate the inflation reflex resulting in early turning off of inspiration and an increase in respiratory rate.,2023/4/1,Cardiac dyspnea,The dyspnea ca
9、used by right-sided heart failure is less severe than that one caused by left-sided.Mechanism:(1)The pressure of right atrial and superior vena cava is the natural stimulus of respiratory center.(2)The decrease of oxygen content and the accumulation of the acid metabolites,such as lactic,stimulate r
10、espiratory center.(3)The restriction of the respiratory movement caused by enlargement of liver resulting from congestion,ascites and pleural effusion.,2023/4/1,Cardiac dyspnea,Symptoms of congestive heart failure can cause orthopnea and paroxysmal nocturnal dyspnea when elevated-filling pressure is
11、 present.,2023/4/1,orthopnea,Orthopnea is difficulty in breathing in the supine position,this may be relived by sitting up,which reduces the degree of pulmonary congestion by pooling blood in the lower extremities and lowering left ventricular filling pressures,improving the diaphragmatic movement,i
12、ncreasing vital capacity.,2023/4/1,paroxysmal nocturnal dyspnea,Symptoms:The patient awakes short of breath at night,but often obtain relief by sitting up for a period of time.In the most advanced cases,the patients become acutely dyspneic,cyanotic and very frequently produce foamy sputum tinged wit
13、h blood.Signs:Moist rales at the both lung bases,tachycardia,wheezing and bronchospasm,the markedly accentuated second heart sound in the pulmonic area.,2023/4/1,Mechanism:Supine posture for sleep results in resorbtion of extracellular fluid into the intravascular space,causing arise in filling pres
14、sure.The paroxysmal dyspnea is termed as cardiac asthma.It can be seen in the hypertensive heart disease and coronary heart disease.,paroxysmal nocturnal dyspnea,2023/4/1,Toxic dyspnea,In the metabolic acidosis(uremia and diabetic ketosis),the acid metabolites stimulate the respiratory center,causin
15、g deep and regular respiration with snoring.The overdose of morphine and pentobarbital can depress respiratory center causing deep respiration or Cheyne-Stokess respiration,2023/4/1,Neuro-Psychogenic dyspnea,In patients suffering from cerebrovascular diseases(intracranial hemorrhage,elevated intrace
16、rebral pressure),the respiratory center loses the blood supply or is compressed.The respiration becomes deep,slow and irregular.In some cases the dyspnea may be psychogenic,which is characterized by repetitive deep,sighing respiration with numbness of extremities or lips,cheiropedal spasm.These are
17、also manifestations of acute hypocapnia and respiratory alkalosis.,2023/4/1,Hematological dyspnea,In severe anemia,sulfhemoglobinemia,methaemoglobinemia or carbon monoxide poisoning the decrease of oxygen-carrying capacity and oxygen content develop abnormal respiration and increased heart rate.The
18、respiration rate also increases in shock which stimulates respiration center because of hypotension.,2023/4/1,Accompanied SymptomParoxysmal dyspnea with wheezing.Dyspnea with chest pain.Dyspnea with fever.Dyspnea with cough and purulent sputum.Dyspnea with coma.,2023/4/1,Paroxysmal dyspnea with whee
19、zing It is present in bronchial asthma and cardiac asthma.Paroxysmal severe dyspnea is often seen in acute larynx edema,foreign body in bronchi,massive pulmonary embolism,and spontaneous pneumothorax.,2023/4/1,Dyspnea with chest pain.It is frequently observed in lobar pneumonia,pulmonary infarction,
20、spontaneous pneumothorax,acute exudative pleurisy,acute myocardial infarction,and bronchial carcinoma.,2023/4/1,Dyspnea with fever.It is commonly noted in pneumonia,lung abscess,pulmonary tuberculosis,pleurisy,acute pericarditis,and nervous system diseases.,2023/4/1,Dyspnea with cough and purulent s
21、putum.It is often present in chronic bronchitis,obstructive pulmonary emphysema with infection,purulent pneumonia,and lung abscess;Dyspnea with large amount of foamy sputum is often seen in acute left ventricular heart failure and organophosphorus poisoning.,2023/4/1,Dyspnea with coma.It suggests ce
22、rebral hemorrhage,meningitis,pneumonia with shock,uremia,diabetic ketoacidosis,and acute poisoning.,2023/4/1,Palpitation,2023/4/1,DefinitionPalpitation may be defined as an awareness of the beating of the heart,an awareness most commonly brought about by a change in the hearts rhythm or rate or by a
23、n augmentation of its contractility.,2023/4/1,Definition,Palpitation is not pathognomonic of any particular group of disorders;indeed,often it signifies not a primary physical disorder but rather a psychio disturbance.The diagnosis of the underlying disease is made largely on the basis of other asso
24、ciated symptoms and the data.,2023/4/1,Characteristics,Concern is more pronounced in patients who know or who have been told that they may have heart disease;to them palpitation may seem to be an omen of impeding disaster.,2023/4/1,Characteristics,The resulting anxiety may be associated with increas
25、ed activity of the autonomic nervous system,with consequent increases of the cardiac rate and rhythm and the vigor of contraction,the patients awareness of these changes may then lead to a vicious cycle,which ultimately be responsible for this incapacitation.,2023/4/1,Characteristics,Palpitation may
26、 be described in various terms,such as fluttering,flopping,and skipping“.In most cases the complaint is of a sensation of disturbed heartbeat.Theres wide variability in the sensitivity to alteration in cardiac activity among different individuals.,2023/4/1,Variability of the sensitivity,Some patient
27、s seem to be unaware of the most serious and chaotic dysrrhythmias;others are seriously troubled by an occasional extrasystole.The awareness of the heartbeat tends to be more common at night and during introspective moments,but is less marked during activity.,2023/4/1,Variability of the sensitivity,
28、Patients with organic heart disease and chronic disorders tend to accommodate to these abnormalities and are often less sensitive than normal persons to such events.Palpitation is particularly prominent when the precipitating cause for increased heart rate or contractility or arrhythmia is recent,tr
29、ansient,and episodic.,2023/4/1,Accompanied Symptom Precordial pain Fever Syncope or spasm Anemia Tabification,2023/4/1,Mechanism,Increased Stroke Volume Tachycardia Arrhythmia Individual differences,2023/4/1,Increased Stroke Volume,When palpitation is heavy and regular,it is usually caused by an aug
30、mented stroke volume,e.g.aortic or mitral regurgitation,ventricular septal defect,or of a variety of hyperkinetic circulatory states(anemia,arteriovenous fistula,thyrotoxicosis).,2023/4/1,Tachycardia,Palpitation may be experienced by normal persons who have engaged in strenuous physical effort or ha
31、ve been aroused emotionally.It may occur also in pathologic states,e.g.,high fever,severe anemia,or thyrotoxicosis,generally associated with several other alterations in cardiac function including acceleration of heart rate,more rapid development of intraventricular pressure during isometric contrac
32、tion,increased intensity of the heart sounds(especially S1),a short duration of systole,and a greater ejection velocity.,2023/4/1,Arrhythmia,It may also occur immediately after the onset of cardiac slowing,as with the sudden development of heart block,or upon the conversion of sinus rhythm from atri
33、al fibrillation.The ectopic beat and/or the compensatory pause may be the mechanism of palpitation,since both are associated with alteration in cardiac function.,2023/4/1,Important causes of palpitation,Disorders of the mechanism of the heartbeat.Organic or functional disturbance origination outside
34、 the circulatory systemPalpitation as a manifestation of the anxiety state,2023/4/1,Disorders of the mechanism of the heartbeat-Extrasystole,Patients may feel if the heart turns over.The pause following the premature contraction may be felt as an actual cessation of the heartbeat,in contrast with th
35、e complete unawarness of pauses of similar duration when atrial fibrillation with a slow ventricular rate occurs.The first ventricular contraction succeeding the pause may be felt as an unusually vigorous beat and will be described as ourding or thudding.,2023/4/1,Disorders of the mechanism of the h
36、eartbeat-Extrasystole,When extrasystoles are numerous,clinical differentiation from Af can be made by any procedure that will bring about a definite increase in the ventricular rate;at increasingly rapid heart rate,the extrasystoles usually diminish in frequency and then disappear,whereas the irregu
37、larity of atrial fibrillation increases.A-V block with dropped beats,is the only other common arrhythmia with which the premature contraction is likely to be confused;but simple auscultation will reveal the difference.,2023/4/1,Disorders of the mechanism of the heartbeat-Ectopic Tachycardia,Ectopic
38、Tachycardias are common and medically important causes of palpitation.(but Ventricular tachycardia is rarely manifested as palpitation)The mode of onset and offset gives the most important lead in distinguishing sinus from one of the various forms of ectopio tachycardias;sinus tachycardia commences
39、and ceases over the course of minutes or seconds,but not instantaneously as is characteristic of ectopic rhythm.,2023/4/1,Disorder of the mechanism of the heartbeat-Ectopic Tachycardia,If the patient is seen between attacks,the diagnosis,of ectopic tachycardia and its type will have to depend upon t
40、he history.Monitoring of the ECG with a portable tape recording system and asking the patient to record the time of onset and cessation of the palpitations are extremely helpful in determining their cause.,2023/4/1,Organic or functional disturbance origination outside the circulatory system,Thyrotox
41、icosisAnemiaacute infections HypoglycemiaDrugsTumors of the adrenal medulla(pheochromecytoma),2023/4/1,Thyrotoxicosis,In its fully developed form,thyrotoxicosis will usually be evident and offers little difficulty in diagnosis except in the elderly,in whom so-called apathetic hyperthyroidism may be
42、present.Thyrotoxicosis is particularly likely to be over-looked in the presence of myocardial failure.,2023/4/1,Anemia,When mild,anemia may cause palpitation during exertion;when severe,palpitation may be present at rest.Appropriate studies of the blood will clarify the situation.,2023/4/1,Hypoglyce
43、mia,Palpitation is often a prominent feature of the condition and appears to be related to release of catecholaminels.The diagnosis is confirmed by appropriate blood sugar estimations,by reproduction of the symptom when insulin is administered,and by prompt relief of symptoms on the administration o
44、f glucose.,2023/4/1,Drugs,The relationship between the development of palpitation and the use tobacco,tea,alcohol epinephrine,ephedrine,aminophylline,atroping,or thyroid extract is obvious.,2023/4/1,Abdominal Examination,Xue Huiping,2023/4/1,Introduction,2023/4/1,It is well known that advances in sc
45、ientific medicine have occasionally threatened to displace the history and physical examination in the evaluation of the patient.However,we usually discover that technologic advances serve to make the physical examination more rational and provide new understanding or objective documentation of long
46、-appreciated physical finding.,2023/4/1,New techniques for evaluation of the intra-abdominal contents include many biochemical,isotopic,ultrasonic,and angiographic methods.These advances,although improving our ability to detect,document,and interpret physical findings,have not superseded the need fo
47、r the skills of the medical interview and physical examination.An orderly approach to the examination of the abdomen will make possible the analysis of the symptoms arising from the many organs of the digestive and genitourinary systems found in this region.,2023/4/1,Palpation is an important step i
48、n abdominal examination and is difficult to learn,esp.the palpation of the liver and spleen,so we must practise more.,2023/4/1,We conform to the same basic steps of inspection,palpation,percussion,and auscultation used in this area as in other areas.,2023/4/1,2.Topographic anatomy,2023/4/1,There hav
49、e been several systems or methods devised for dividing the abdomen into topographic segments,but two kinds of commonly used systems or methods will be described here.Other methods may be found in any standard textbook of anatomy.,2023/4/1,Before you understand these two methods,at first you should k
50、now the following anatomic landmarks(Figure 1):,2023/4/1,xiphoid(ensiform)process(剑状突起)of sternum(胸骨)costal margin肋弓缘 umbilicus脐 anterosuperior iliac spine/anterior superior iliac spine髂前上棘 iliac crest髂骨嵴 inguinal ligament 腹股沟韧带,2023/4/1,superior margin of os pubis耻骨上缘 anterior midline前中线 lateral bo
