北京积水潭医院体格检查英文教学病例.doc

2011-3班 体格检查英文教学病历T 36.5, P 72/min, R 18/min, BP 120/80mmHg.He was well developed and moderately nourished. Active position. His consciousness was clear and his speech was fluent. He was cooperative in the examination. His skin was not stained yellow. No cyanosis. No pigmentation. No skin eruption. No purpura. Spider angioma and liver palm were not seen. No pitting edema. Superficial lymph nodes were not found enlarged. HeadSkull: Hair was black, well distributed. No deformities. No scars. No tenderness. Eye: Visual fields was normal. Bilateral eyelids were not swelling. No entropion. No ptosis. Conjunctiva was not congestive, and was not pallor too. Sclera was anicteric. Eyeballs were not projected or depressed. Movement was normal. Bilateral pupils were round and equal in size. Direct and indirect pupillary reactions to light were existent. Ear: Bilateral auricles were symmetric and of no masses. No discharges were found in external auditory canals. No tenderness in mastoid area. Auditory acuity was normal. Nose: No abnormal discharges were found in nasal cavity. Septum nasi was in midline. No nares flaring. No epistaxis. No tenderness in nasal sinuses. Mouth: Oral mucous membrane was not cyanosis. Tongue was in midline. Tonsils were not enlarged. Neck: Symmetric and of no deformities. No masses. Thyroid was not enlarged. Trachea was in midline. Vascular murmur can not be heard.ChestThe thoracic cage was symmetrical. No deformities. No tenderness. Superficial Veins could not be seen easily. No subcutaneous emphysema. Intercostal space was neither narrowed nor widened. Lungs: Respiratory movement was bilaterally symmetric with the frequency of 18/min. diaphragmatic respiration was existent. Thoracic expansion and tactile fremitus were symmetric bilaterally. The degree of excursion of lower bound was 6cm.No pleural friction fremitus. Resonance was heard during percussion. No abnormal breath sound was heard. No wheezes. No rales. Heart: No bulge and no abnormal impulse in precordial area. The point of apical impulse was palpable in the 5th intercostal space and 0.5cm inside of the left mid clavicular line and not diffuse. There was no thrill. Border of the heart was normal. The cardiac dullness was as follows. Heart rate was 72/min.Heart sounds were strong and no splitting. A2=P2. Cardiac rhythm was regular. No pathological murmurs. No pericardial friction sound. Peripheral vessel sign was negative.Right （cm）InterspacesLeft (cm)2224368.5The distance from left midclavicular line to anterior mid line was 9cm.Abdomen: Flat and soft. No bulge or depression. pigmentation 、scar 、hernia were not seen. No umbilical secretion. Subcutaneous varicose vein of abdominal wall was not seen. No gastric type、intestinal type and peristalsis. There were not tenderness and rebound tenderness on abdomen. There was not mass can be palpable. Hepatojugulor reflux was negative. Murphy sign was negative. There were not percussion pain in hepatic area、splenic area and renal area. Tympanitic area over gastric bubble was existent. Shifting dullness was negative. Bowel sound can be heard, 4/min. There was not blood vessel murmur can be heard on abdomen. Anus、 rectum and genitalia: not be checked.Vertebral column and four limbs: vertebral column and four limbs were not deformities. Activity was good. There were no tenderness and percussion pain in every spinal crest. Lasgue sign was negative. No varicose vein of lower limb. No edema of lower limb. No acropachy and koilonychias. Neural system: Facial perception was bilaterally symmetric. Masticatory movement was normal. Direct and indirect corneal reflex was existent. Zygomatic reflex was negative. Prefrontal stripe and nasolabial fold were bilaterally symmetric. It was powerful to turn his head and shrug his shoulders. Pain sensation was bilaterally symmetric. Muscle force was degree. Muscle tone was normal, no muscular atrophy. No ataxia. Abdominal reflex was existent. Biceps reflex、 triceps reflex、 radial periosteal reflex、 patellar refle