体格检查英文版

1、A. GENERAL EXAMINATION/VITAL SIGNS(一般检查)1. Introduce yourself to patient, usually last name and title and have a little conversation to relax the patient and to judge mental state.2. Wash hands before starting examinationPreferably, this should be done in view of the patient.3. Patient is seated in

2、a chair4. Palpate radial (wrist) Pulses for at least 30 seconds and recordThe examiner places the pad of his index, middle and ring fingers over the radial artery. If properly done, the examiner should be able to feel the artery pulsating under the examiner ' s fingertips. The radial pulse may b

3、e measured for 30 seconds, then the pulse perminute can be found by multiplying by two. Attentionshould also be paid to the rhythm. Theexaminer should not use his thumb to palpate any pulse.5. Palpate both radial (wrist) pulses simultaneously for symmetry for at least 30 seconds6. Measure respirator

4、y rate for 30 seconds and recordThe examiner unobtrusively measures patient ' s re spiratory rate. This maybe accomplished by the examiner leaving his hands on the patient ' s wristsfor another 30 seconds after measuring the radial pulses so the patientdoes not realize that the examiner is w

5、atching him breathe. The depth and rhythm should also be noticed. The respiratory rate can also be measured during the back exam.7. Measure blood pressure on right armBlood pressure may be measured with the patient in a sitting or lying position. In each position, the artery in which the blood press

6、ure is to be measured should be at the level of the heart (at the level of the fourth intercostal space in the sitting position; at the level of the middleaxillary line in the lying position). The patient ' s arm should be resting on a smooth table or supported by the examiner, and slightly flex

7、ed at the elbow.8. Place cuff in correct location 2-3 cm above the atecubital creaseThe examiner secures the blood pressure cuff snugly over the upper, armso that one finger can be admitted under the cuff. The cuff should be positioned 23 cm above the antecubital crease or elbow joint. Put themiddle

8、 of the cuff over the brachial artery.9. Palpate brachial arteryThe examiner can locate the brachial artery which lies slightly medial tothe tendon of the biceps muscle in the antecubital fossa. The mercury column on the manometer dial should be properly calibrated with the pointer at “0" befor

9、e the cuff is inflated (i. e. , all the air should be pressedout of the cuff before it is inflated).The stethoscope is placed firmly over the brachial artery. The examinersinflates the cuff slowly but steadily. Until the brachial artery pulsedisappears. Then he continues to inflate cuff 2.64.0kPa (2

10、0 30 mmHghigher, generally to about 21.3kPa (160mmHg).10. Measure blood pressure over brachial artery twice and record thelower readingDeflate the cuff slowly at the rate of about 0.26kPa (2mmHg) Per second.The number where the examiner hears the first pulse sound is the systolicpressure. The pulse

11、sound will waken and then disappear. The number wherethe pulse sound disappears is the diastolic pressure. If the differencebetween weakening of the sound and its disappearance is 2.6kPa (20mmHg)or greater, the examiner should record these two numbers. The cuff must be completely emptied with the po

12、inter at"0" before it is reinflated.The same procedure may be followed for a second measurement of B. P. inthe same or opposite arm. The lower pressure is recorded as the patient ' s blood pressure. After finishing the measurement, the examiner deflates and rolls up the cuff, leans the

13、 manometer over a little so the mercury column disappears, closes the mercury column switch, puts the balloon in order,and closes the manometer.B. HEAD AND NECK（头颈部）Skull11. Palpate and observe scalp (parting hair, and observing hair density, color, lustre and distribution)The examiner palpates the

14、entire skull using both hands and simultaneously examines symmetrical areas. The examiner parts the hair to observe the scalp, noting any scaliness, deformities, lumps, tenderness, lesions orscars. The examiner also observes the density, color, lustre and distribution of the hair.Eyes12. Visual scre

15、ening:(omitted )12. Observe cornea, sclera, conjunctiva and lacrimal puncta by gently moving lower eyelids down.Cornea Examination-With oblique lighting inspect the cornea for opacities, foreign bodies etc. Inspect lower palpebral, fornical, bulbar conjunctiva and sclera. Ask the patient to look up

16、as you depress lower eyelid with your thumb exposing lower palpebral, fornical, bulbar conjunctiva and sclera. Inspect the conjunctiva and sclera for color, and note the vascular pattern against the white scleral background.Lacrimal sac examination by digital compression for nasolacrimal duct obstru

17、ction-Ask the patient to look up. Press on the lower lid close to the medial canthus, just inside the rim of the bony orbit. You are thus compressing the lacrimal sac. Look for fluid regurgitation out of the puncta into the eye. Avoid this test if the area is inflamed and/or tender(Figure 2-3).14. O

18、bserve sclera and bulbar conjunctiva by gently elevating upper eyelid while patient looks down,Instruct the patient to look down.Raise the upper eyelid slightly so that the eyelashes protrude, and then inspect sclera and bulbar conjunctiva. Be gentle so patientdoesn' t tear(Figure 2-4).15. Check

19、 crn VH upper division: raised eyebrows, wrinkle forehead or forced eyelid closing Nerve VH is the facial nerve.Upper facial nerve-To test the upper division, the examiner observes the patient ' s forehead and palpebral fissure, then asks patient to raise his eyebrows, wrinkle his forehead and c

20、lose his eyes. Whenthe patient closes his eyes tightly, the examiner attempts to pry them open to determine the strength. If one side of peripheral upper facial nerve is impaired (nuclear or below nuclear) the patient ' s ability to wrinkle forehead decreases and the patient can' t close his

21、 eye on the affected side. If one side of central nerve is impaired, the patient ' s ability to close his eyes and wrinkle forehead will not be influenced because the upper facial muscles are controlled by both sides of the corticocerebral motor area.16. Evaluate extraocular muscle function in b

22、oth eyes in 6 directions (left, upper left, and lower left, right, upper right, lower right)The examiner positions himself in front of the patient and requests that, without moving the patient ' s head, the patient ' s eyes follow examiner ' s finger or a pencil in six directions. Finger

23、 or pencil should be 3040cm away from patient ' s head. The usual format is from mid left, to upper left and then down and then to the right (Figure 2-5).17. Observe pupillary direct response to lightThe examiner asks the patient to look forward and shines a penlight or the light of the ophthalm

24、oscope into each pupil in turn. He should avoid shining the light into both pupils simultaneously and should ask the patient not to focus on the light source.When observing the direct pupillary response to light, the examiner will shine the light into one eye and inspect for pupillary constriction i

25、n the sameeye. The pupillary constriction is reversed as soon as the light moves away. Use the same method to check the other eye.18. Observe pupillary consensual response to lightWith the same method as obove, the examiner shines the light into one eye and inspects for pupillary constriction in the

26、 opposite eye OR observes pupillary dilation in opposite eye as light is extinguished.19. Check for convergence and accommodationThe examiner, positioned in front of the patient, asks the patient to look into the distance and then at his finger. The examiners finger starts from 1 meter away, the exa

27、miner will immediately move5 cmaway from the bridgeof the patient ' s nose. The examiner is observing the patient ' s eyes for:a) pupillary constriction, and b) convergence (the coordinated movement of both eyes toward fixation at the same near point as the patient focuses on a near object).

28、 Accommodation includes convergence and pupillary constriction as the patient focuses on the near object. The accommodation will vanish when cranial nerve m is damaged.Ears and Temporomanaibular joint30. Observe and palpate the auricles and observe postauricular regionsbilaterallyThe examiner pulls

29、and palpates the auricles (outer ears), palpates the preauricular(in front of) and posterior auricular regions (behind the ears) bilaterally. Tenderness usually indicates inflammation.31. Palpate temporomandibular joint for tenderness and swelling (omitted )The temporomandibular joint (TMJ) is anter

30、ior to the external auditorycanal of the ear. Examine for swelling and tenderness.32. Feel the movement of the TMJ with index fingers inside pat ient ' s ears or over jointTo palpate the TMJ joint, the examiner presses both sides simultaneouslywith one or two fingers and asks the patient to open

31、 and close his mouth, or the examiner places his index finger in the patient' s ear and gentlypulls forward (anteriorly), asking the patient to open and close his mouth. (omitted )Nose38. Inspect and palpate external nose for malformation and inflammationBegin by examining the external nose. The

32、 examiner faces the patient.Observe skin color and shape of nose any palpate for and loss of structureor tenderness from bridge, to tip, to wings of nose.39. Observe nasal vestibule without otoscopeA view of the nasal cavities is obtained by tilting the patient' s headback and elevating the tip

33、of the nose with the thumb. The examiner should use a light. The nasal vestibule contains the nasal hairs, or vibrissae.Pay attention to any folliculitis, fornicles, or deviated nasal septum.40. Turn the tip of the nose upwards and insert the tip of the speculum to inspect nasal vestibule and anteri

34、or part of nasal cavity for ulcer, crust, swelling, discharge, atrophy or perforation41. Test patency by inhaling through each nostril separately while the opposite nostril is held occluded (omitted )42. Palpate and/or percuss maxillary sinus for swelling and tendernessExamination of the paranasal s

35、inuses is done more indirectly than other otolaryngeal procedures. The examiner cannot see into any of the sinuses. Palpation and percussion may be used over the maxillary sinuses. Simultaneous finger pressure over both maxillae will demonstrate differences in tenderness.43. palpate and /or percuss

36、frontal sinus for swelling and tendernessThe frontal sinuses are palpated at the inner part of the upper border of the bony orbit by finger pressure directed upward toward the floor ofthe sinus where the sinus wall is thin. Tenderness may be elicited in this way. Swelling caused by tumors or retaine

37、d secretions may cause a downward bulge in the floor of the frontal sinus. The frontal sinuses may also be percussed.Mouth, lips, Pharynx44. Observe lips, buccal mucosa, teeth, gums and tongueThe examiner inspects the lips, all surfaces of the tongue, gums, roof of mouth, and the buccal mucosa (the

38、tissue lining the cheeks) by asking the patient to open his mouth and by shining a light into the area to be examined. The examiner may use a tongue depressor to aid inspection.Lips-The healthy lips are wet and red in color, This is caused by a rich capillary network.Buccal mucoss-To examine the buc

39、cal mucosa it is necessary to shine a light into the patient ' s mouth. The healthy buccal mucosa is pink and smooth.The duct of the parotid gland opens onto the buccal mucosa opposite the upper second molar.Teeth-There are 32 teeth in the full adult dentition. The teeth are inspected for eviden

40、ce of cavities and malocclusion.Gums-The gums should be inspected for the presence of swelling, bleeding or pigmentation.Tongue-The tongue is inspected for its shape, motion and ulceration.45. Observe the floor of mouthInspect the mouth for pigmentation, hemorrhage or masses (ask patient to touch ti

41、p of tongue to roof of mouth).Generally, palpation is not done in a normal exam. However, if a mass isfound on the floor of the mouth, palpation is important. If neoplasms are suspected, they are detectable only by palpation. Also, the submaxillary, salivary ducts may contain calculi that are best f

42、elt by palpation.Bimanual examination, using one gloved finger inside the mouth and the other hand outside, is best.46. Inspect the posterior structures of the mouth for congestion, swelling or pus, position of uvula, and elevation of the palate.Press a tongue blade, positioned over middle 1/3 of to

43、ngue, firmly downto inspect tonsils, anterior and posterior tonsillar pillars, and posterior pharynx. The examiner can observe the elevation of the palateas the patient says“ah” . Simultaneously, hoarseness can be detected.The conscious patient should not be gagged.xn)47. Observe midline protrusion

44、of the tongue (cr nThe examiner asks patient to stick out his tongue and observes midline protrusion, atrophy and fibrillation.48. Show teeth, puff out cheeks or purse lips (lower division of cr n VH) ( omitted )49. Test contraction of masseter (jaw) muscle or forced opening of mouth against resista

45、nce (motor division cr nV ) ( omitted )50. Test for facial sense of pain and touch (must check at least 2 out of 3 sensory divisions for cr nV ) ( omitted )51. Expose neck correctly to observe appearance and skin of neckThe patient sits upright.Ask patient to expose neck entirely when the neck is to

46、 be examined. All clothing should be removed as far as the axillae, which allows the whole neck to be seen in relationship to the thorax and permits inspection and palpation of the supraclavicular fossae.Observe the appearance of the skin of the neck. The examiner should observe the neck for symmetr

47、y and pay attention to its appearance. Abnormal lumps and pulsations may be seen in this area. Generally, the thyroid cartilagewill show convexity in a male. The examiner inspects the skin of the neckfor erythema, spider angioma, infections, ulcers or scars.Facial and cervical lymph nodesPalpate lym

48、ph nodes bilaterally. The examiner may be positioned in frontof or behind the patient and examine the lymph nodes with the pads of hisindex and middle fingers. This should be done slowly and carefully to make certain that there aren' t any abnormalities present. It is better if the examiner move

49、s the skin over the underlying tissue rather than move hisfingers over the surface of the skin. The examiner may have the patientposition his head with his neck slightly flexed forward. The examinerpalpates all nodes bilaterally.For palpation of lymph nodes, be sure to keep the skin and muscles rela

50、xed.If the lymph nodes are enlarged, note their location, size, number, hardness, mobility, tenderness, adhesion, fusion, swelling, fistula orscars (Figure 2-14).52. Palpate preauricular nodes (front of ears)53. Palpate post-auricular nodes (back of ears)54. Palpate occipital nodes (base of skull)55

51、. Palpate submaxillary nodes (by bending finger under patient' sjaw)56.Palpate submental nodes (by bending finger under patient ' s chin)57. palpate anterior cervical nodes (superficial group under mastoidand in front of sternomastoid muscle)58. Palpate posterior cervical nodes (behind stern

52、omastoid muscle)59. Palpate supraclavicular nodes (by bending finger above patient ' s collarbone)Thyroid gland60. Palpate and/or move thyroid cartilage with two fingers checkingfor malformation and movability61. Palpate thyroid in correct anatomical location in front of or behind the patient wi

53、thboth hands.The lateral lobes of the thyroid curve posteriorly around the sides of the trachea andthe esophagus. In addition, they are partially covered by the sternomastoid muscle.There areseveral different techniques for examining the thyroid gland. Manyexaminers will palpate thethyroid gland bot

54、h in front of and/or behind the patient. The examiner shouldidentify the thyroidgland which lies across the trachea below the cricoid cartilage. (If the examiner has the patientflex his neck or turn his chin slightly toward the side to be examined, it will secure the relaxationof the sternomastoid m

55、uscle, which is essential for adequate examination of the thyroid.)62. Palpate isthmus of thyroid with and without swallowing: using the pads of his fingers, the examiner feels below the cricoid cartilage for theisthmus of the thyroid gland. If examiner stands in front, he examines withhis thumbs, f

56、rom behind, with his index fingers. Examiner asks patient toswallow as he feels for the isthmus rising upward against his fingers. A good teaching point is that the thyroid gland is one of the few soft tissuestructures in the neck that moves with swallowing.63. Palpate thyroid gland (lobes) with and

57、 without swallowingPalpation from the front-The thyroid is displaced to one side by applying pressure with the thumb upon the thyroid cartilage.With the opposite hand,the dislodged lobe of the thyroid can now be palpated between the thumb (held in front of the sternomastoid) and the 2nd and 3rd fing

58、ers (Placed behind the sternomastoid) This should be done before and during swallowing. Theprocedure is repeated for the opposite side (Figure 2-16).Palpation from behind-Procedure is similar to palpation from the front except the thyroid cartilage is displaced with the 2nd and 3rd fingers. The thum

59、b of the opposite hand is now behind the sternomastoid muscle and the 2nd and 3rd fingers are in front of it. (Figure 2-17).If thyroid is enlarged, notice its size, symmetry, hardness, surface, tenderness, nodules, thrills, bruits, etc.Carotid Artery64. Gently palpate carotid arteryWith the pads of his fingers, the