2 Contents Introductions General and Mental Headache, dizziness, vertigo Cardiovascular Chest pain, arrhythmia (hypertension & hypotension) Respirator

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2 2 Contents Introductions General and Mental Headache, dizziness, vertigo Cardiovascular Chest pain, arrhythmia (hypertension & hypotension) Respiratory Hyperventilation, breath sound (wheezing ) Abdominal Injury Abd. Pain, APP, distension, diarrhea, constipation Strain, sprain, dislocation, fracture, contusion

3 Introductions 3

4 4 Major Concepts Children are not little adults Differences relate to both growth and development patterns

5 5 Major Focus Major differences between children and adults Specific approaches and techniques to physical exam Interpretation of exam results

6 6 Major Concepts for Assessment and Health Promotion Development Medical history Nutritional status Growth and vital sign measurements Physical assessment Guidelines for well child supervision Anticipatory guidance Immunizations

7 7 School setting Children usually healthy Illness visits primarily common acute problems and some chronic illness issues Health screenings

8 8 Environmental Setting Safety is primary Pleasant, comfortable settings are helpful Accessible toys for young children are distracters and may reduce anxiety Age appropriate literature or items for teens and older children provide diversion in waiting areas

9 9 General Approaches Toward Examining the Child Head-to-toe sequence for assessing adult clients Sequence for pediatric assessments generally altered to accommodate child s developmental needs

10 10 Approach to School-Age Child To accommodate child s problems and developmental needs Respect modesty Address questions more directly to child Explain in concrete terms Medical diagrams or teaching dolls are helpful Elicit their active participation in history, exam and care plan Answer questions honestly

11 11 Approach to Adolescents Confidentiality, privacy, protection of modesty are important Offer to examine alone, without parent present Address questions to patient Keep in mind, depression is more common in adolescents, especially girls

12 12

13 General and Mental Headache, dizziness, vertigo 13

14 14 ( ) ( barbiturates )

15 15

16 16-1

17 17-2 (AVM, Aneurysm ) sign sign

18 18 (PQRST) / / 39 CT, MRI, L-P, ESR,

19 19-1

20 20-2

21 (Dizziness, lightheadedness) (Vertigo) ()(syncope) 21

22 22 (vertigo) ()(syncope) (Dizziness) (disequilibrium)

23 23 (Vertigo) -1

24 24 vs (Vertigo) -2 ( ) 随 Friendreich

25 25 (syncope) -1

26 26 (syncope ) -2 CBC, E -, Ca ++, Mg +, Glucose Brain CT, Holter EKG, Echo, Doppler Doppler

27 27 (Dizziness, lightheadedness) -1

28 vs 28 (Dizziness, lightheadedness) -2

29 29-1 Romberg test

30 30-2 Heel-to-toe Hop in place

31 vs ACE warfarin ( ) phenytoincarbamazepine

32 vs meclizine () Epley() ()

33 Cardiovascular Chest pain Arrhythmia (Hyper- or hypotension) 33

34 34 troduction Pulse pressure Normally, SBP exceeds DBP by about 40 mmhg Narrowed Medical causes Aortic stenosis Cardiac tamponade Heart failure shock Widened Medical causes Aortic insufficiency Arteriosclerosis Febrile disorders Increased intracranial pressure (IICP)

35 35 Pulsus alternans A sign of severe left-sided heart failure Regular, alternating pattern of a weak and a strong pulse Result from the change in stroke volume that occurs with beat-to-beat alteration in the left ventricle s contractility Normal left ventricular function has seldom persists for more than beats Measure when SBP varies more than mmhg Closely evaluate the patient s HR, RR, and BP

36 36 Setting-sun sign (Sunset eyes) Result of pressure on Cr.N. Setting-sun sign may be intermittent Late and ominous sign of increased. Typically revealing an area of sclera above the irises

37 37 Chest pain -1

38 38 Chest pain -2 (AMI, ) ( ) ( )

39 39 Chest pain -3 ( )

40 40 Chest pain -4

41 41 1. P Palliative and Provocation Q Quality R Region and Radiation S Severity (Quantity) T Timing (Onset and course since onset) U Understanding patient s perception (Client s underlying concern) 2. 3.

42 42 Arrhythmia

43 43 Arrhythmia -2

44 44 Arrhythmia -3

45 45 Arrhythmia -4

46 46

47 47 (PMI) PMI PMI ( )

48 48

49 49 S1S2

50 50 Murmur

51 51-1 ( ) ---

52 52-2 (Homan s sign) (Capillary refill time) (Pitting edema) (Trendelenburg test) (Manual compression)

53 -3 53 (Trendelenburg test) Perthes test

55 55 (Manual compression) 20

56 Respiratory Hyperventilation Breath sound (wheezing ) 56

57 57 Louis angle 迹 5 6 8

58 58-1 Inspection / Palpation Tactile Fremitus; T/F

59 59-2 Percussion Resonance, Hyper-resonance, Dullness, Flatness Auscultation

60 60 Inspection

61 61 Palpation Auscultation

62 62-1 (crackles)

63 63-2 (wheeze)

64 64-3 (rhonchi) (stridor) ( ) (friction rubs)

65 65-4 sign ninety-nine e-e ninety-nine one, two, three

66 T/F rales T/F rales wheeze rales rales T/F wheeze T/F T/F T/F T/F Tactile Fremitus; T/F 66 wheeze T/F rales rales

67 67

68 68 Oximeter (Pulse Oximeter) (Hemoglobin)

69 Hyperventilation PaCO 2 69

70 70

71 71-1 PaCO 2 Ca ++ (tetany) Ca ++ PaCO 2 mmhg (Dizziness) ( )

72 72-2 SNS mmhg mmhg HR (carotid bodies)

73 73 (Air hunger)

74 74-1

75 75-2 SNS Benzodiazepine (TCA) (MAO)

76 (4) (3) (2) (1) (0) Nijmegen Questionnaire-

77 Abdominal Abdominal Pain APP, Abd. Pain, distension, diarrhea, constipation 77

78 78

79 79

80 80

81 81 Abdominal Pain

82 82

83 83

84 84 1

85 85 2

86 86 3

87 87

88 88 McBurney's sign Rovsing s sign Iliopsoas test; Psoas sign Obturator muscle sign WBC 10,000/mm 3

89 89

90 %10%

91 91

92 92 X

93 93-1 Noro Vipoma AIDS

94 94-2

95 95

96 G/S Lactate Ringer 20cc/kg challenge D5S D51/2NS D5 1/4 NS

100 % 3040% 80% 2-19% 99%

101 101

102 102

103 103

104 Injury Strain, sprain, dislocation, fracture, contusion 104

105 105

106 106 A. B. C. D.

107 107

108

109 109

110 110 PRICE P R Ice C Elevation

111 111

112 112

113 113

114 114

115 ( ) 115

116 116

117 117

118 118

119 119 増

120 120 30

121 増 121

122 122 PRICE PRICE

123 123

124 PRICE 2448

125 125 PRICE PRICE 24

126 126

127 127

2

2011.07.05 1 2 3 2008/06/14 99 ~ 100 4 2008/06/14 300 91 93 2495 2219 578 1000 3 5 2011-03-24 43% 57% 208 6 99 ~ 100-1 99 ~ 100-2 7 - http://www.youtube.com/watch?v=bnsi4icp8oo - http://www.youtube.com/watch?v=ibbxfolqnyu