体格检查英文版Word格式文档下载.docx
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1.Introduceyourselftopatient,usuallylastnameandtitleandhavealittleconversationtorelaxthepatientandtojudgementalstate.
2.Washhandsbeforestartingexamination
Preferably,thisshouldbedoneinviewofthepatient.
3.Patientisseatedinachair
4.Palpateradial(wrist)Pulsesforatleast30secondsandrecord
Theexaminerplacesthepadofhisindex,middleandringfingersovertheradialartery.Ifproperlydone,theexaminershouldbeabletofeelthearterypulsatingundertheexaminer’sfingertips.Theradialpulsemaybemeasuredfor30seconds,thenthepulseperminutecanbefoundbymultiplyingbytwo.Attentionshouldalsobepaidtotherhythm.Theexaminershouldnotusehisthumbtopalpateanypulse.
5.Palpatebothradial(wrist)pulsessimultaneouslyforsymmetryforatleast30seconds
6.Measurerespiratoryratefor30secondsandrecord
Theexaminerunobtrusivelymeasurespatient’srespiratoryrate.Thismaybeaccomplishedbytheexaminerleavinghishandsonthepatient’swristsforanother30secondsaftermeasuringtheradialpulsessothepatientdoesnotrealizethattheexamineriswatchinghimbreathe.Thedepthandrhythmshouldalsobenoticed.Therespiratoryratecanalsobemeasuredduringthebackexam.
7.Measurebloodpressureonrightarm
Bloodpressuremaybemeasuredwiththepatientinasittingorlyingposition.Ineachposition,thearteryinwhichthebloodpressureistobemeasuredshouldbeattheleveloftheheart(atthelevelofthefourthintercostalspaceinthesittingposition;
atthelevelofthemiddleaxillarylineinthelyingposition).Thepatient’sarmshouldberestingonasmoothtableorsupportedbytheexaminer,andslightlyflexedattheelbow.
8.Placecuffincorrectlocation2-3cmabovetheatecubitalcrease
Theexaminersecuresthebloodpressurecuffsnuglyovertheupper,armsothatonefingercanbeadmittedunderthecuff.Thecuffshouldbepositioned2~3cmabovetheantecubitalcreaseorelbowjoint.Putthemiddleofthecuffoverthebrachialartery.
9.Palpatebrachialartery
Theexaminercanlocatethebrachialarterywhichliesslightlymedialtothetendonofthebicepsmuscleintheantecubitalfossa.Themercurycolumnonthemanometerdialshouldbeproperlycalibratedwiththepointerat“0”beforethecuffisinflated(i.e.,alltheairshouldbepressedoutofthecuffbeforeitisinflated).
Thestethoscopeisplacedfirmlyoverthebrachialartery.Theexaminersinflatesthecuffslowlybutsteadily.Untilthebrachialarterypulsedisappears.Thenhecontinuestoinflatecuff~(20~30mmHghigher,generallytoabout(160mmHg)).
10.Measurebloodpressureoverbrachialarterytwiceandrecordthelowerreading
Deflatethecuffslowlyattherateofabout(2mmHg)Persecond.Thenumberwheretheexaminerhearsthefirstpulsesoundisthesystolicpressure.Thepulsesoundwillwakenandthendisappear.Thenumberwherethepulsesounddisappearsisthediastolicpressure.Ifthedifferencebetweenweakeningofthesoundanditsdisappearanceis(20mmHg)orgreater,theexaminershouldrecordthesetwonumbers.Thecuffmustbecompletelyemptiedwiththepointerat“0”beforeitisreinflated.ThesameproceduremaybefollowedforasecondmeasurementofB.P.inthesameoroppositearm.Thelowerpressureisrecordedasthepatient’sbloodpressure.Afterfinishingthemeasurement,theexaminerdeflatesandrollsupthecuff,leansthemanometeroveralittlesothemercurycolumndisappears,closesthemercurycolumnswitch,putstheballooninorder,andclosesthemanometer.
B.HEADANDNECK
(头颈部)
Skull
11.Palpateandobservescalp(partinghair,andobservinghairdensity,color,lustreanddistribution)
Theexaminerpalpatestheentireskullusingbothhandsandsimultaneouslyexaminessymmetricalareas.Theexaminerpartsthehairtoobservethescalp,notinganyscaliness,deformities,lumps,tenderness,lesionsorscars.Theexamineralsoobservesthedensity,color,lustreanddistributionofthehair.
Eyes
12.Visualscreening:
(omitted)
cornea,sclera,conjunctivaandlacrimalpunctabygentlymovinglowereyelidsdown.
CorneaExamination-Withobliquelightinginspectthecorneaforopacities,foreignbodiesetc.Inspectlowerpalpebral,fornical,bulbarconjunctivaandsclera.Askthepatienttolookupasyoudepresslowereyelidwithyourthumbexposinglowerpalpebral,fornical,bulbarconjunctivaandsclera.Inspecttheconjunctivaandscleraforcolor,andnotethevascularpatternagainstthewhitescleralbackground.
Lacrimalsacexaminationbydigitalcompressionfornasolacrimalductobstruction-Askthepatienttolookup.Pressonthelowerlidclosetothemedialcanthus,justinsidetherimofthebonyorbit.Youarethuscompressingthelacrimalsac.Lookforfluidregurgitationoutofthepunctaintotheeye.Avoidthistestiftheareaisinflamedand/ortender(Figure2-3).
14.Observescleraandbulbarconjunctivabygentlyelevatinguppereyelidwhilepatientlooksdown,
Instructthepatienttolookdown.
Raisetheuppereyelidslightlysothattheeyelashesprotrude,andtheninspectscleraandbulbarconjunctiva.Begentlesopatientdoesn’ttear(Figure2-4).
crnⅦupperdivision:
raisedeyebrows,wrinkleforeheadorforcedeyelidclosingNerveⅦisthefacialnerve.
Upperfacialnerve-Totesttheupperdivision,theexaminerobservesthepatient’sforeheadandpalpebralfissure,thenaskspatienttoraisehiseyebrows,wrinklehisforeheadandclosehiseyes.Whenthepatientcloseshiseyestightly,theexaminerattemptstoprythemopentodeterminethestrength.Ifonesideofperipheralupperfacialnerveisimpaired(nuclearorbelownuclear)thepatient’sabilitytowrinkleforeheaddecreasesandthepatientcan’tclosehiseyeontheaffectedside.Ifonesideofcentralnerveisimpaired,thepatient’sabilitytoclosehiseyesandwrinkleforeheadwillnotbeinfluencedbecausetheupperfacialmusclesarecontrolledbybothsidesofthecorticocerebralmotorarea.
16.Evaluateextraocularmusclefunctioninbotheyesin6directions(left,upperleft,andlowerleft,right,upperright,lowerright)
Theexaminerpositionshimselfinfrontofthepatientandrequeststhat,withoutmovingthepatient’shead,thepatient’seyesfollowexaminer’sfingerorapencilinsixdirections.Fingerorpencilshouldbe30~40cmawayfrompatient’shead.Theusualformatisfrommidleft,toupperleftandthendownandthentotheright(Figure2-5).
pupillarydirectresponsetolight
Theexaminerasksthepatienttolookforwardandshinesapenlightorthelightoftheophthalmoscopeintoeachpupilinturn.Heshouldavoidshiningthelightintobothpupilssimultaneouslyandshouldaskthepatientnottofocusonthelightsource.
Whenobservingthedirectpupillaryresponsetolight,theexaminerwillshinethelightintooneeyeandinspectforpupillaryconstrictioninthesameeye.Thepupillaryconstrictionisreversedassoonasthelightmovesaway.Usethesamemethodtochecktheothereye.
pupillaryconsensualresponsetolight
Withthesamemethodasobove,theexaminershinesthelightintooneeyeandinspectsforpupillaryconstrictionintheoppositeeyeORobservespupillarydilationinoppositeeyeaslightisextinguished.
forconvergenceandaccommodation
Theexaminer,positionedinfrontofthepatient,asksthepatienttolookintothedistanceandthenathisfinger.Theexaminersfingerstartsfrom1meteraway,theexaminerwillimmediatelymove5cmawayfromthebridgeofthepatient’snose.Theexaminerisobservingthepatient’seyesfor:
a)pupillaryconstriction,andb)convergence(thecoordinatedmovementofbotheyestowardfixationatthesamenearpointasthepatientfocusesonanearobject).Accommodationincludesconvergenceandpupillaryconstrictionasthepatientfocusesonthenearobject.TheaccommodationwillvanishwhencranialnerveⅢisdamaged.
EarsandTemporomanaibularjoint
30.Observeandpalpatetheauriclesandobservepostauricularregionsbilaterally
Theexaminerpullsandpalpatestheauricles(outerears),palpatesthepreauricular(infrontof)andposteriorauricularregions(behindtheears)bilaterally.Tendernessusuallyindicatesinflammation.
31.Palpatetemporomandibularjointfortendernessandswelling(omitted)
Thetemporomandibularjoint(TMJ)isanteriortotheexternalauditorycanaloftheear.Examineforswellingandtenderness.
32.FeelthemovementoftheTMJwithindexfingersinsidepatient’searsoroverjoint
TopalpatetheTMJjoint,theexaminerpressesbothsidessimultaneouslywithoneortwofingersandasksthepatienttoopenandclosehismouth,ortheexaminerplaceshisindexfingerinthepatient’searandgentlypullsforward(anteriorly),askingthepatienttoopenandclosehismouth.(omitted)
Nose
38.Inspectandpalpateexternalnoseformalformationandinflammation
Beginbyexaminingtheexternalnose.Theexaminerfacesthepatient.Observeskincolorandshapeofnoseanypalpateforandlossofstructureortendernessfrombridge,totip,towingsofnose.
39.Observenasalvestibulewithoutotoscope
Aviewofthenasalcavitiesisobtainedbytiltingthepatient’sheadbackandelevatingthetipofthenosewiththethumb.Theexaminershouldusealight.Thenasalvestibulecontainsthenasalhairs,orvibrissae.Payattentiontoanyfolliculitis,fornicles,ordeviatednasalseptum.
40.Turnthetipofthenoseupwardsandinsertthetipofthespeculumtoinspectnasalvestibuleandanteriorpartofnasalcavityforulcer,crust,swelling,discharge,