1. General examination General examination is actually the first step of physical examination Inspection is the major method during general examination, combining with palpation, auscultation, and smelling The examiner should observe the following aspects of the patients: general appearance state of nutrition body habitus （体型） symmetry （对称性） posture( 姿势） speech

2. General appearance Sex Age Vital sign （生命征） Development/habitus （发育 / 体型） Nutritional status （营养状态） Consciousness （意识状况） Speech （ tone/voice) ( 语调 / 语态） Facial feature/expression （面容 / 表情） Position/posture （体位 / 姿势） Gait （步态）

3. Sex In female: estrogen and male hormone In male: male hormone Sex is involved in some specific disease female: SLE thyroid chlorosis ( 萎黄病 ) male: haemophilia ( 血友病 )

4. Sex Impacts of diseases on sex characters Female patients will be masculinized in long term use of corticosteriod （皮质类固醇） or adrenocortical tumor （肾上腺 皮质肿瘤） Male cirrhotic patient will develop gynecomastia （男性乳房发育） mainly because male hormone secretion was suppressed The impacts of normal sex chromosome on the sex and sex characters: biasexual abnormality klinefelter syndrome turner syndrome

5. Age Age is tightly related to some diseases Infant and children: rickets （佝偻病） measles （麻疹） diphtheria （白喉） Children and adolescence: tuberculoses （结核）, rheumatopyra （风湿热） Elder: carcinoma and sclerosis

6. Vital sign Vital signs are physical signs that indicate an individual is alive body temperature breath rate pulse blood pressure heart rate These signs can be measured/monitored to assess level of physical functioning of an individual Normal ranges of measurements of vital signs may change with age, sex, weight, exercise tolerance and condition

7. Body temperature Oral （口腔） Rectal （肛门） Axillary （腋下）

8. Body temperature Oral Place the thermometer under the tongue and close the mouth using the lips hold the thermometer tightly The patient must breath through the nose Leave the thermometer in the mouth for 5 min Reliable method Not suitable: infants unconscious

9. Body temperature Rectal Using a rectal thermometer Recommended for infants/small children Lubricate the bulb of the thermometer with a petroleum jelly Place the small child face down on a flat surface or lap Spread the buttocks and insert the bulb end of the thermometer about one-half to 1 inch into the anal canal After 5 min, remove the thermometer and read

10. Body temperature Axillary It is the least accurate method Place the thermometer in the armpit( 腋窝）, with the arm pressed against the body for 5 ~10 min before reading Read the thermometer by gripping the end opposite the bulb so that the numbers are facing you Roll the thermometer back and forth between your fingers until you see a silver reflection in the column

11. Body temperature Normal value Oral 36.3 0 C~37.2 0 C Rectal 36.5 0 C~37.7 0 C Axillary 36 0 C~37 0 C The normal body temperature varies from person to person, by age, and throughout day Being lowest in the early hours of the morning and highest in the afternoon The variation may range within 1 0 C Rectal T >Oral T> Axillary T (each in 0.5 0 C)

12. Body temperature It should be recorded on temperature recoding sheet -----so called “ body temperature curve” ( 体温曲线） Fever type is referred to those febrile （发热的） disease possessing certain characters of body temperature curve

13. Vital signs Breath The breath rhythm and rates should be recorded Pulse The rhythm and rates should be recorded

14. Vital signs---pulse 60~100 /min childhood Emotion Aged Night

15. Vital signs---blood pressure Blood pressure is a measurement of the force applied against the walls of arteries as heart pumps blood through the body Blood pressure readings are usually given as two numbers: for example, 110/70

16. Vital signs---blood pressure The first number is the systolic （收缩的） blood pressure reading, and it represents the maximum pressure exerted when the heart contracts The second number is the diastolic （舒张的） blood pressure reading, and it represents the pressure in the arteries when the heart is at rest.

17. Vital signs---blood pressure BP is continually changing depending on the activity, temperature, diet, emotional state, posture, physical state and drugs Ideal BP <120/<80 mmHg normal <130/<85 mmHg hypertension >140/90 mmHg

18. Vital signs---blood pressure

19. Development & habitus Development status is evaluated according to the age, intelligence （智力 ), body weight and sexual characters In normal adult, they are almost comparable During adolescent stage, the body experienced a rapid growth periods It is influenced by some factors race( 种族 ) inheritance( 遗传 ) endocrinology( 内分泌 ) nutrition living condition physical exercise

20. Types of habitus Asthenic type: slender, weak and lightweight （无力型） Sthenic type: average height and muscled （矮胖型） Ortho-sthenic type: normal proportions with （匀称型） normal stature ( 身材 )

21. Abnormal habitus Gigantism( 巨人症 ) It refers to the excessive liner growth that occurs with growth hormone (GH) excess when epiphyseal( 骺的 ) growth plates are open during childhood Acromegaly( 肢端肥大症 ) It indicates the disorder of GH excess in adulthood Pituitary dwarfism( 垂体性侏儒症 ) It may be due to dysfunction of the pituitary causing underproduction of growth hormone small stature normal proportions

22. Gigantism

25. Development & habitus Cretinism( 呆小症 ) It is characterized by arrested physical and mental development Eunuchism( 无睾症 ) Sex hormone control the formation/development of sex characters it may also affect the body development. If the secretion of sex hormone was severely suppressed, eunuchism may occur Rachitis( 佝偻病 ) Malnutrition during childhood may affect the development, for instance, vitamin D deficiency may lead to rachitis

26. Nutritional status One of the most important factors impacting an individual’s health and disease because it affects almost every system It can be evaluated mainly by skin, hair, muscle and subcutaneous fat in particular Chronic wasting( 消瘦 ) associated with loss of subcutaneous fat from calorie or protein deficiency

27. Nutritional status Changes in hair and nails are also common in nutritional deficiency Blindness may result from vitamin A deficiency The tongue may be large in iodine( 碘 ) or niacin( 烟酸 ) deficiency

28. Nutritional status In general the abnormal nutritional status can be described as obesity( 肥胖） and emaciation （消 瘦 ) Parameters: body weight ( 体重 ) Body mass index (BMI) ( 体重指数 ) Arm circumference ( 上臂周径 ) Skinfold thickness ( 皮褶厚度 )

29. Skinfold thickness

30. Malnutrition It is the condition that develops when the body does not get the right amount of the vitamin, minerals, and other nutrients it needs to maintain healthy tissue and organ function It is caused by inadequate intake or inadequate digestion of nutrients

31. Malnutrition Malnutrition may be mild enough to show no symptoms or so severe that the damage it has done is irreversible even though the individual may be kept alive (cachexia)( 恶病质 )

32. Overnutrition Overnutrition results from eating too much that exceed the normal consumption, not exercising enough, genetic factors, endocrinology, life habits The nutritional status of patient based on height and weight is interpreted by the body mass index (BMI) ( 体重指数 ) BMI is an international digestion of relative weight for stature BMI=weight (kg)/height (meter) 2

33. Overnutrition BMI <18.5 underweight 18.5~25.0 healthy weight 25.1~29.9 overweight >30 obsess WHO classification male >27 female>25 obesity

34. Consciousness It is a psychological and physiological state in which we are aware of our sensations, perceptions, feelings, thoughts etc Disturbance of consciousness memory deficit disorientation language disturbance reduced clarity During interview, the examiner has already gained much insight into the mental status of the patient The examiner could evaluate the thought, response, emotion, calculation ability and orientation

35. Consciousness Sommolence ( 嗜睡 ) Confusion ( 意识模糊 ) Stupor ( 昏睡 ) Coma ( 昏迷 ) Delirium ( 谵妄 )

36. Tone & Speech Dysarthria ( 构音障碍 ) is difficulty in articulation ( 分节发音 ) Dysphonia ( 发声困难 ) is difficult in phonation （发声）

37. Facial feature & expression The appearance of the head and face, their contours( 轮廓 ) and texture( 特征 ), often provides the first insight into the nature of illness. Some facial appearances are pathognomonic ( 特定的 )of disease The appearance of the patient’s face may also provide information regarding psychological makeup: is the person happy, sad, angry or anxious Some typical facial features are listed in textbook

39. Position It refers to patient’s body status Divided into: Active ( 自主 ) Passive ( 被动 ) Compulsive ( 强迫 )

40. Position Active position The patient can move his/her body freely, without any restriction It can be seen in normal adult, patients with mild diseases or at earlier stage of the diseases Passive position The patient can’t adjust or move his/her body It occurs in extremely sick or patients with unconsciousness

41. Compulsive position Compulsive supine position ( 仰卧位） The patient lie down on the beck, with two legs bending. Acute peritonitis Compulsive prostrate position （俯卧位） in order to relief the tenderness of back muscles. Rachis disease （脊柱病变） Compulsive side down position （侧卧位） in patients with one sided pleurisy or pleurorrhea( 胸腔积液 )

42. Compulsive position Orthopnea （端坐呼吸） A n abnormal condition in which a person must keep the head elevated (sit or stand) to breathe deeply or comfortably (orthopnea) or wakes up suddenly in the middle of the night short of breath (paroxysmal nocturnal dyspena) （阵发性夜间呼吸困难）. It can be seen in patients with lung or heart disease Squar down position （蹲位） It has been seen in patients with congenital heart disease

43. Compulsive position Compulsive rest position When patient suffers an angina attack it will force them to rest. The heart is then able to return to it’s normal working level Toss & turn position (alternative position) 辗转体位 Opisthotonos ( 角弓反张） It is an abnormal posturing condition characterized by rigidity and severe arching of the back, with head thrown backwards

44. Posture & gait Posture: the general way of holding the body Gait : a way or manner of walking G ait abnormalities describe unusual and uncontrollable problem with walking Gait disturbances may occur for a variety of reasons Gait may be changed by local pain in the foot, joint, claudication （跛行） of the hip （臀） or leg, bone disease etc

45. Gait Waddling gait （蹒跚步态） Characterized by a distinctive duck-like walk that may appear in childhood or later in life Scissor gait （剪刀式步态） Characterized by legs flexed slightly at the hips and knees, giving the appearance of crouching （卷缩）, with the knees and thighs （大腿） hitting or crossing in a scissors-like movement

46. Gait Steppage gait （跨阈步态） Characterized by foot drop where the foot hangs with the toes pointing down, causing the toes to scrape the ground while walking Propulsive (Festinating) gait （慌张步态） Characterized by stooped, rigid posture with head and neck bent forward Drunken man gait （醉酒步态） Characterized by unbalanced trunk, as drunken man like walking

47. Gait Ataxic gait （共济失调步态） Characterized by an abnormality of muscle control or an inability to finely coordinate movements, resulting in a jerky “to-and-fro” unsteady motion Intermittent claudication （间隙性跛行） It is leg pain (most often in the calves) that does not clear up after walking and is relieved by rest It is a symptom of peripheral artery disease (PAD)

48. Skin The skin is the largest organ of the body One of the best indicators of general health The examination of the skin is dependent on inspection, but palpation of a skin lesion must also be performed

49. Skin color Skin coloration is determined by the amount of pigment in the skin and the blood flowing through it The distribution of capillary, the thickness of the subcutaneous fat （皮下脂肪） may also affect it The color changes include Pallor （苍白） Cyanosis （发绀） Yellow skin （黄染） Redness （发红） Pigmentation （色素沉着） Discoloration （色素脱失）

50. Pallor Paleness may be the result of decreased blood supply to the skin (cold, fainting, shock, hypoglycemia) or decreased number of red blood cells (anemia) Fingers that turn paller when exposed to cold or stress Raynaud’s syndrome may cause sudden change in the finger color It is almost apparent on the face, lining of the eyes, inner mouth and nails

51. Cyanosis It is a bluish discoloration of the skin and mouth membranes from lack of oxygen Blood that is saturated with oxygen is bright red Blood that has lost its oxygen is dark bluish-red Person who has a large quantity of their blood which is deficient in oxygen tend to take on a bluish discoloration -----called “cyanosis” Cyanosis is more obvious in the mucous membranes and nail beds, particularly for dark-skinned people It may also appear on the feet, nose and ears

52. Cyanosis

53. Yellow skin A yellow discoloring the skin, mucous membranes and eyes, caused by too much bilirubin in the blood With the exception of physiologic jaundice in the newborn, all other jaundice indicates overload or damage to the liver or inability to move bilirubin from the liver through the biliary tract to the gut

54. Yellow skin A yellow to orange color may be imparted to the skin by excessive intake of beta carotene People who consume large quantities of carrots or carrot juice or take beta carotene tablets may develop a distinctly yellow-orange cast to their skin. The condition is called hypercarotenemia （高胡萝卜血症） Hypercarotenemia is easily distinguished from jaundice in that the sclera （巩膜） remain white, while people with true jaundice have a yellow sclera

55. Redness It is due to dilation of capillary, accelerating & increasing blood stream and increment of the red blood cells In physiological condition, it may be seen after sports or drinking In pathological condition, it may be caused by lung TB, scarlet fever, drug intoxication

56. Pigmentation Melanin （黑色素） is a pigment produced in the skin cells that causes skin coloration The production of melanin may be affected by heredity, heat, trauma, solar or ionizing radiation, heavy metals and other factors Changes in any of these factors can result in hyperpigmentation, hypopigmentation or both The changes may be temporary or permanent It can be either primary or secondary to other disease

57. Discoloration Vitiligo ( 白癜风） It is a skin condition in which there is loss of pigment from areas of skin resulting in irregular white patches with normal skin texture Associated with pernicious anemia, hyperthyroidism, Addison’s disease

58. Discoloration Leukoplakia （白斑） A precancerous lesion that develops on the tongue or the inside of the cheek as a response to chronic irritation Occasionaly, leukoplakia pathches develop on the female external genitalia

59. Discoloration Albinismus （白化病） It refers to a group of related conditions. These conditions are the result of altered genes that cause a defect of melanin production This defect results in the partial or full absence of pigment from the skin, hair and eyes

60. Moisture The moisture of skin is tightly related with the secretion of sweat gland Diaphoresis （大量出汗） is a medical term for profuse sweating It can be normal brought on by physical activity, emotional response, high environment temperature or a symptom of an underlying disease Overactive thyroid gland hypoglycemia Cold sweat: shock or dehydrated patients

61. Moisture Periodic sweating at night without an obvious cause may be caused by an underlying infection or malignancy Sweat absent: abnormal lack of sweat in response to heat. neurologic disorders skin disease congenital disorders some drugs burns dehydration

62. Elasticity Skin elasticity （皮肤弹性） is related with age, nutritional status, subcutaenous fat and the amount of liquid in the interstitial space

63. Rashes Skin rashes are frequently one of the manifestation of systemic diseases, and hence, they are important for the diagnosis of some special diseases The different rashes may occur in infectious disease, dermentological disease, drug or other allergic materials The rashes have some special regular patterns and sharps

64. Types of rashes Macule （斑疹） Roseola （玫瑰疹） Papules （丘疹） Maculopapulae （斑丘疹） Urticaria （荨麻疹）

65. Macule A macule is small, flat, distinct colored area of skin Does not include a change in skin texture or thickness

66. Rosela Rosela is a skin lesion that is small, solid, and raised. It may be seen in measles, drug rashes, eczema

67. Papule A papule is defined as a small (5 millimeters or less), solid lesion slightly elevated above the surface of the skin.

68. Maculopapulae It is plate lesion with redness around the papules It can be seen in scarlet fever and drug-induced rashes

69. Urticaria Urticaria (hive) are raised red welts of variuos size on the surface of the skin, often itchy, which come and go. It is associated with allergic reaction

70. Desquamation It is the detachment of cells from the surface of an epithelium In physiologic condition, it’s not easy to notice the desquamation In pathologic condition, lots of desquamation can be seen

71. Subcutaneous hemorrhage Bleeding into the skin & subcutaneous tissues According to the size of bleeding, it may be subdivided as follows: petechia （瘀点） <2mm purpura （紫癜） 3~5 mm ecchymosis （瘀斑） >5mm A hematoma （血肿） is a large collection that forms a lump

72. Spider angioma Spider angioma is a group of abnormal blood vessel that produces the appearance of a spider-web on the surface of the skin A spider angioma lesion typically has a red dot in the center with reddish extensions radiating out for some distance around it Liver palms

73. Edema Excessive build up of fluid in the tissues Either occurs throughout the body (generalized swelling) or limited to a specific part of the body (localized swelling) It can be either pitting （凹陷性） edema or non-pitting （非凹陷性） edema Mild : facial edema, peripheral edema Moderate: generalized edema Severe: generalized severe edema

74. Nodules & scar & hair Subcutaneous nodules are solid, raised bumps on the skin Scar tissue forms as skin heals after an injury or surgery A keloid is an abnormal scar that is thicker, different color and texture, extends beyond the edge of the wound

75. Nodules & scar & hair Pay attention to the pattern of distribution and texture of hair over the body Sparse/coarse: hypothyroidism chemotherapy Increased hair: Cushing’s disease neoplastic condition

76. Lymph notes The lymph notes are distributed all over the body The general physical examination can only palpate the superficial lymph notes The superficial lymph notes are in cluster distribution that drainage different part of lymphoid liquid Lymph nodes play an important part in the body’s defense against infection Swelling might occur even if the infection is trivial or not apparent. Tumor may also cause its swelling

77. Lymph notes Palpation is the major methods to detect the superficial lymph notes and it should be done sequentially

78. Lymph notes Lymph note enlargement either localized or systemically Localized : lymphadenitis tuberculous ~ malignant metastasis (gradually and painless) Systemically: lymphadenitis lymphoma leukemia