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 havea little conversation to relax the patient and to judge mental state.2. Wash hands before start ing exam in ati onPreferably, this should be done in view of the patie nt.3. Patie nt is seated

2、in a chair4. Palpate radial (wrist) Pulses for at least 30 sec onds and recordThe exam iner places the pad of his in dex, middle and ring fin gers over theradial artery. If properly done, the examiner should be able to feel theartery pulsating under the examiners fingertips. The radial pulse maybe m

3、easured for 30 sec on ds, the n the pulse perm inute can be found bymultipl ying by two. Atte ntio nshould also be paid tothe rhythm. Theexam iner should not use his thumb to palpate any pulse.5.Palpate both radial (wrist) pulses simultaneously for symmetry for at least 30 seconds6. Measure respirat

4、ory rate for 30 sec onds and recordThe examiner unobtrusivelymeasures patients re spiratory rate. This maybe accomplished by the examiner leaving his hands on the patients wristsfor another 30 seconds after measuring the radial pulses so the patientdoes not realize that the exam iner is watch ing hi

5、m breathe. The depth andrhythm should also be noticed. The respiratory rate can also be measured dur ing the backexam.7. Measure blood pressure on right armBlood pressure may be measured with the patie nt in a sitt ing or lyingpositi on. In each positi on, the artery in which the blood pressure is t

6、obe measured should be at the level of the heart (at the level of the fourth in tercostal spacein the sitt ing positi on; at the level of the middleaxillary line in the lying position). The patients arm should be resting on a smooth tableor supported by the examiner, and slightly flexed at the elbow

7、.8. Place cuff in correct locati on 2-3 cm above the atecubital creaseThe exam iner secures the blood pressure cuff snu gly over the upper, armso that one fin ger can be admitted un der the cuff. The cuff should bepositi oned 23 cm above the an tecubital crease or elbow joint. Put themiddle of the c

8、uff over the brachial artery.9. Palpate brachial arteryThe exam in er can locate the brachial artery which lies slightly medial tothe tendon of the biceps muscle in the antecubitalfossa. The mercury columnon the mano meter dial should be properly calibrated with the poin ter at“0”before the cuff is

9、inflated (i. e. , all the air should be pressedout of the cuff before it is in flated).The stethoscope is placed firmly over the brachial artery. The exam inersin flates the cuff slowly but steadily. Un til the brachial artery pulsedisappears. Then he continues to inflate cuff 2.64.0kPa (2030 mmHghi

10、gher, gen erally to about 21.3kPa (160mmHg).10. Measure blood pressure over brachial artery twice and record thelower read ingDeflate the cuff slowly at the rate of about 0.26kPa (2mmHg) Per sec ond.The number where the examiner hears the first pulse sound is the systolicpressure. The pulse sound wi

11、ll waken and then disappear. The number wherethe pulse sound disappears is the diastolic pressure. If the differe neebetwee n weake ning of the sound and its disappeara nee is 2.6kPa (20mmHg)or greater, the exam iner should record these two nu mbers. The cuff mustbe completely emptied with the point

12、er at“0”before it is reinflated.The same procedure may be followed for a sec ond measureme nt of B. P. i nthe same or opposite arm. The lower pressure is recorded as the patients bloodpressure. After finishing the measurement, the examiner deflates and rolls up the cuff, leans the mano meter over a

13、little so the mercury colu mndisappears, closes the mercury colu mn switch, puts the ballo on in order,and closes the mano meter.B. HEAD AND NECK(头颈部)Skull11.Palpate and observe scalp (parting hair, and observing hair density, color, lustreand distributio n)The examiner palpates the entire skull usi

14、ng both hands and simultaneouslyexam ines symmetrical areas. The exam iner parts the hair to observe thescalp, noting any scali ness, deformities, lumps, ten der ness, lesi ons orscars. The examiner also observes the density,color, lustre anddistribution of the hair.Eyes12. Visual screening:(omitted

15、)13.Observe corn ea, sclera, conjun ctiva and lacrimal pun cta by gen tlymoving lower eyelids dow n.Cornea Exam in ati on-With oblique lighti ng in spect the cornea for opacities, foreignbodies etc. Inspect lower palpebral, fornical, bulbar conjunctivaand sclera. Ask the patie nt to look up as you d

16、epress lower eyelid withyour thumb expos ing lower palpebral, forni cal, bulbar conjun ctiva andsclera.Inspect the conjunctivaand sclera for color, and note the vascularpatter n aga inst the white scleral backgro und.Lacrimal sac exam in ati on by digital compressi on for n asolacrimal ductobstructi

17、 on-Ask the patie nt to look up. Press on the lower lid close tothe medial can thus, just in side the rim of the bony orbit. You are thuscompressing the lacrimal sac. Look for fluid regurgitation out of thepun cta into the eye. Avoid this test if the area is in flamed an d/or ten der(Figure 2-3).14.

18、 Observe sclera and bulbar conj un ctiva by gen tly elevati ng uppereyelid while patie nt looks dow n,In struct the patie nt to look dow n.Raise the upper eyelid slightly so that the eyelashes protrude, and the ninspect sclera and bulbar conjunctiva.Be gentle so patient doesnt tear(Figure 2-4).15. C

19、heck crnVHupper division: raised eyebrows, wrinkle forehead orforced eyelid closi ng NerveVis the facial n erve.Upper facial n erve-To test the upper divisi on, the exam iner observes thepatients forehead and palpebral fissure, then asks patient to raise hiseyebrows, wrinkle his forehead and close h

20、is eyes. Whenthe patient closeshis eyes tightly, the examiner attempts to pry them open to determine thestrength. If one side of peripheral upper facial nerve is impaired (nuclear or below nuclear)the patients ability to wrinkle forehead decreases and the patient cant close his eye onthe affected si

21、de. If one side of central nerve is impaired, the patients ability to close hiseyes and wrinkle forehead will not be in flue need because the upper facial muscles arecon trolled by both sides of the corticocerebral motor area.16.Evaluate extraocular muscle functionin both eyes in 6 directions(left,

22、upper left, and lower left, right, upper right, lower right)The examiner positions himself in front of the patient and requests that, without moving thepatients head, the patients eyes follow examiners fin ger or a pen cil in six directions. Fin ger or pen cil should be 3040cm away from patients hea

23、d. The usual format is from mid left, to upperleft and the n dow n and the n to the right (Figure 2-5).17.Observe pupillary direct resp onse to lightThe exam iner asks the patie nt to look forward and shines a pen light or the light of theophthalmoscope into each pupil in turn. He should avoid shini

24、ng the light into both pupilssimulta neously and should ask the patie nt not to focus on the light source.When observing the direct pupillary response to light, the examiner will shine the light in toone eye and in spect for pupillary con stricti on in the sameeye. The pupillary constriction isrever

25、sed as soon as the light moves away. Use the same method to check the other eye.18.0bserve pupillary consensual response to lightWith the same method as obove, the exam iner shines the light into one eye and inspectsfor pupillary constriction in the opposite eye OR observes pupillary dilatio n in op

26、posite eyeas light is ext in guished.19.Check for con verge nee and accommodati onThe examiner, positioned in front of the patient, asks the patient to look into the dista neeand the n at his fin ger.The exam iners fin ger starts from1 meter away, the examiner will immediately move5 cmaway from the

27、bridgeof the patients nose. The examiner is observing the patients eyes for:a) pupillary con stricti on, andb) con verge nee (the coord in ated moveme nt of both eyes toward fixati on at the same near point as the patie nt focuses on a n ear object).Accommodatio n in cludesconverge nee and pupillary

28、constrictionas the patientfocuses on the near object. The accommodationwill vanish whe n cranial n erve川is damaged.Ears and Temporoma naibular joi nt30. Observe and palpate the auricles and observe postauricular regions bilaterallyThe exam iner pulls and palpates the auricles (outer ears), palpates

29、the preauricular(infront of) and posterior auricular regions (behind the ears) bilaterally. Ten der ness usuallyin dicates in flammati on.31.Palpate temporomandibular joint for tenderness and swelling(omitted )The temporomandibular joint (TMJ) is anterior to the external auditorycanal of the ear. Ex

30、amine for swelling and tenderness.32. Feel the moveme nt of the TMJ with in dex fin gers in sidepat ie ntsears or over jo intTo palpate the TMJ joint, the exam iner presses both sides simulta neouslywith one or two fin gers and asks the patie nt to ope n and close his mouth,or the exam iner places h

31、is in dex fin ger in the patie nts ear and gen tlypulls forward (anteriorly), asking the patient to open and close his mouth.(omitted )Nose38.In spectand palpate exter nal nose formalformatio nandin flammatio nBegin by exam ining the exter nal no se. The exam iner faces the patie nt.Observe skin col

32、or and shape of nose any palpate for and loss of structureor ten der ness from bridge, to tip, to wings of nose.39. Observe n asal vestibule without otoscopeA view of the nasal cavities is obtained by tilting the patients headback and elevating the tip of the nose with the thumb. The examiner should

33、 use a light.The n asal vestibule contains the n asal hairs, or vibrissae.Pay atte nti on to any folliculitis, forni cles, or deviated n asal septum.40.Turn the tip of the nose upwards and insert the tip of the speculum to inspectnasal vestibule and anterior part of nasal cavity for ulcer,crust, swe

34、lli ng, discharge, atrophy or perforati on41. Testpatency by inhalingthrough each nostrilseparately while theopposite nostril is held occluded (omitted )42.Palpate and/or percuss maxillary sinus for swelling and tendernessExam in atio n of the para nasal sinu ses is done more in directly tha n other

35、otolaryngeal procedures. The examiner cannot see into any of the sinuses. Palpation andpercussion may be used over the maxillary sinuses. Simulta neous fin ger pressure overboth maxillae will dem on strate differe nces in tendern ess.43.palpate and /or percuss frontal sinus for swellingand tendernes

36、sThe fron tal sinu ses are palpated at the inner part of the upper border of the bony orbit byfin ger pressure directed upward toward the floor ofthe sinus where the sinus wall is thin. Tenderness may be elicited in this way. Swellingcaused by tumors or retained secretionsmay cause a downwardbulge i

37、n the floor of the frontal sinus. The frontal sinuses may also be percussed.Mouth, lips, Phary nx44. Observe lips, buccal mucosa, teeth, gums and ton gueThe exam iner in spects the lips, all surfaces of the ton gue, gums, roofof mouth, and the buccal mucosa (the tissue lining the cheeks) by ask ingt

38、he patie nt to ope n his mouth and by shining a light into the area to beexam in ed. The exam iner may use a ton gue depressor to aid in specti on.Lips-The healthy lips are wet and red in color, This is caused by a rich capillary n etwork.Buccal mucoss-To examine the buccal mucosa it is necessary to

39、 shine a light into the patients mouth. The healthy buccal mucosa is pink and smooth.The duct of the parotid gla nd ope ns onto the buccal mucosa opposite the upper sec ondmolar.Teeth-There are 32 teeth in the full adult den titi on. The teeth are in spected for evide nee ofcavities and malocclusi o

40、n.Gums-The gums should be in spected for the prese nee of swelli ng, bleed ing or pigmentatio n.Ton gue-The ton gue is in spected for its shape, moti on and ulcerati on.45. Observe the floor of mouthIn spect the mouth for pigme ntati on, hemorrhage or masses (ask patie nt to touch tip ofton gue to r

41、oof of mouth).Gen erally, palpati on is not done in a n ormal exam. However, if a mass isfound on the floor of the mouth, palpation is important. If neoplasms are suspected, theyare detectable only by palpation. Also, the submaxillary, salivary ducts may containcalculi that are best feltby palpation

42、.Bima nual exam in atio n, using one gloved fin ger in side the mouth and the other handoutside, is best.46. In spect the posterior structures of the mouth for con gesti on,swelli ng or pus, positi on of uvula, and elevati on of the palate.Press a tongue blade, positioned over middle 1/3 of tongue,

43、firmly downto inspecttonsils,anteriorand posteriortonsillarpillars, andposterior phary nx. The exam iner can observe the elevatio n of the palateas the patient says“ah”. Simultaneously, hoarseness can be detected.The con scious patie nt should not be gagged.will show convexityin a male. The examiner

44、 inspects theskin of the neck47. Observe midli ne protrusi on of the ton gue (cr nThe examiner asks patient to stick out his tongue and observes midlineprotrusion, atrophy and fibrillation.48. Show teeth, puff out cheeks or purse lips (lower divisio n of crn%) ( omitted )49. Test con tracti on of ma

45、sseter (jaw) muscle or forced ope ning ofmouth aga inst resista nee (motor divisio n cr nV) ( omitted )50.Test for facial sense of pain and touch (must check at least 2 outof 3 sensory divisions for cr nV) ( omitted )51. Expose n eck correctly to observe appeara nee and skin of n eckThe patient sits

46、 upright.Ask patie nt to expose n eck en tirely whe n the n eck is to be exam in ed. Allclothing should be removed as far as the axillae, which allows the wholen eck to be see n in relati on ship to the thorax and permits in specti on and palpati on ofthe supraclavicular fossae.Observe the appearane

47、e of the skin of the neck. The examiner should observe the neckfor symmetry and pay attention to its appearanee. Abnormal lumps and pulsati ons maybe see n in this area. Gen erally, the thyroid cartilagefor erythema, spider an gioma, in fecti ons, ulcers or scars.Facial and cervical lymph no desPalp

48、ate lymph no des bilaterally. The exam iner may be positi oned in frontof or beh ind the patie nt and exam ine the lymph no des with the pads of hisin dex and middle fin gers. This should be done slowly and carefully to make certain thatthere aren t any abnormalities present. It is better if the exa

49、m iner moves the skin overthe un derly ing tissue rather tha n move hisfin gers over the surface of the skin. The exam iner may have the patie ntposition his head with his neck slightly flexed forward. The examiner palpates all no desbilaterally.For palpatio n of lymph no des, be sure to keep the sk

50、in and muscles relaxed.If the lymph no des are enl arged,note their locati on, size,nu mber,hardness, mobility, tenderness, adhesion, fusion, swelling, fistula orscars (Figure 2-14).52. Palpate preauricular no des (front of ears)53. Palpate post-auricular no des (back of ears)54. Palpate occipital n

51、o des (base of skull)_ 55. Palpate submaxillary no des (by bending fin ger un der patie nts jaw)Palpate subme ntal no des (by bending fin ger un der patie nts chin)57. palpate an terior cervical no des (superficial group un der mastoidand in front of ster no mastoid muscle)58. Palpate posterior cerv

52、ical no des (beh ind ster no mastoid muscle)59.Palpate supraclavicular no des (by bending fin ger above patie nts collarbone)Thyroid gla nd60. Palpate an d/or move thyroid cartilage with two fin gers check ingfor malformatio n and movability61. Palpate thyroid in correct an atomical locati on in fro

53、nt of orbeh ind the patie nt withboth han ds.The lateral lobes of the thyroid curve posteriorly around thesides of the trachea andthe esophagus. In additi on, they are partially covered by the ster no mastoid muscle.Thereareseveral differenttechniques for examining the thyroidgland. Manyexaminerswil

54、l palpate thethyroidgland both in front of and/or behind the patient. The examiner should56.iden tify the thyroid gla nd which lies across the trachea below the cricoid cartilage. (Iftheexam iner has the patie ntflex his n eck or turn his chin slightly toward the side to be exam in ed, itwill secure

55、 the relaxati onof the ster no mastoidmuscle, which is esse ntial for adequate exam in atio n ofthe thyroid.)62.Palpate isthmus of thyroid with and without swallowing:using thepads of his fin gers, the exam iner feels below the cricoid cartilage for theisthmus of the thyroid gland. If examiner stand

56、s in front, he examines with his thumbs, frombeh ind, with his in dex fin gers. Exam iner asks patie nt to swallow as he feels for theisthmus rising upward aga inst his fin gers. A good teaching point is that the thyroid gland isone of the few soft tissue structures in the n eck that moves with swal

57、lowi ng.63. Palpate thyroid gla nd (lobes) with and without swallow ingPalpation from the front-The thyroid is displaced to one side by applyingpressure with the thumb upon the thyroid cartilage. With the opposite hand, the dislodgedlobe of the thyroid can now be palpated between the thumb (held in

58、front of the ster nomastoid) and the 2nd and 3rd fin gers (Placed beh indthe ster no mastoid) This should be done before and duri ng swallow ing. Theprocedure is repeated for the opposite side (Figure 2-16).Palpati on from beh in d-Procedure is similar to palpati on from the frontexcept the thyroid

59、cartilage is displaced with the 2nd and 3rd fin gers.Thethumb of the opposite hand is now beh ind the ster no mastoid muscle and the2nd and 3rd fin gers are in front of it. (Figure 2-17).If thyroid is enl arged,no ticeits size, symmetry, hard ness, surface,ten dern ess, no dules, thrills, bruits, et

60、c.Carotid Artery64. Gen tly palpate carotid arteryWith the pads ofhis fin gers, the exam iner exerts gen tle pressure onpatie nts carotid arteries in the lower half of the n eck on the in sideedge of patie nts ster no mastoidmuscle. One should not palpate bothcarotids simultaneously as the patient m