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1、 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 a chair 4. Palpate radial （wrist） Pul

2、ses 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 examiners fingertips. The radial pulse may be measured for 30 seconds, then the pulse p

3、erminute can be found by multiplying by two. Attention should also be paid to the rhythm. The examiner should not use his thumb to palpate any pulse. 5. Palpate both radial （wrist） pulses simultaneously for symmetry for at least 30 seconds 6. Measure respiratory rate for 30 seconds and recordThe exa

4、miner unobtrusively measures patients respiratory rate. This may be accomplished by the examiner leaving his hands on the patients wrists for another 30 seconds after measuring the radial pulses so the patient does not realize that the examiner is watching him breathe. The depth and rhythm should al

5、so 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 pressure is to be measured should be at the level of th

6、e heart （at the level of the fourth intercostal space in the sitting position; at the level of the middle axillary line in the lying position）. The patients arm should be resting on a smooth table or supported by the examiner, and slightly flexed at the elbow. 8. Place cuff in correct location 2-3 c

7、m above the atecubital creaseThe examiner secures the blood pressure cuff snugly over the upper, arm so that one finger can be admitted under the cuff. The cuff should be positioned 23 cm above the antecubital crease or elbow joint. Put the middle of the cuff over the brachial artery. 9. Palpate bra

8、chial arteryThe examiner can locate the brachial artery which lies slightly medial to the 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” before the cuff is inflated （i. e. , all the air should be pr

9、essed out of the cuff before it is inflated）.The stethoscope is placed firmly over the brachial artery. The examiners inflates the cuff slowly but steadily. Until the brachial artery pulse disappears. Then he continues to inflate cuff （2030 mmHg higher, generally to about （160mmHg）. 10. Measure bloo

10、d pressure over brachial artery twice and record the lower readingDeflate the cuff slowly at the rate of about （2mmHg） Per second. The number where the examiner hears the first pulse sound is the systolic pressure. The pulse sound will waken and then disappear. The number where the pulse sound disap

11、pears is the diastolic pressure. If the difference between weakening of the sound and its disappearance is （20mmHg） or greater, the examiner should record these two numbers. The cuff must be completely emptied with the pointer at “0” before it is reinflated. The same procedure may be followed for a

12、second measurement of B. P. in the same or opposite arm. The lower pressure is recorded as the patients blood pressure. After finishing the measurement, the examiner deflates and rolls up the cuff, leans the manometer over a little so the mercury column disappears, closes the mercury column switch,

13、puts the balloon in order, and closes the manometer.B. HEAD AND NECK（头颈部）Skull 11. Palpate and observe scalp （parting hair, and observing hair density, color, lustre and distribution）The examiner palpates the entire skull using both hands and simultaneously examines symmetrical areas. The examiner p

14、arts the hair to observe the scalp, noting any scaliness, deformities, lumps, tenderness, lesions or scars. The examiner also observes the density, color, lustre and distribution of the hair.Eyes 12. Visual screening:（omitted） cornea, sclera, conjunctiva and lacrimal puncta by gently moving lower ey

15、elids 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 as you depress lower eyelid with your thumb exposing lower palpebral, fornical, bulbar conjunctiva an

16、d 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 obstruction-Ask the patient to look up. Press on the lower lid close to the medial canthus, just inside the

17、 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. Observe sclera and bulbar conjunctiva by gently elevating upper eyelid while patient looks down,Instr

18、uct 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 patient doesnt tear （Figure 2-4）. crn upper division: raised eyebrows, wrinkle forehead or forced eyelid closing Nerve is the facial nerve.Upper f

19、acial nerve-To test the upper division, the examiner observes the patients forehead and palpebral fissure, then asks patient to raise his eyebrows, wrinkle his forehead and close his eyes. When the patient closes his eyes tightly, the examiner attempts to pry them open to determine the strength. If

20、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 on the affected side. If one side of central nerve is impaired, the patients ability to close his eyes and wrinkle forehead will not

21、be influenced because the upper facial muscles are controlled by both sides of the corticocerebral motor area. 16. Evaluate extraocular muscle function in both eyes in 6 directions （left, upper left, and lower left, right, upper right, lower right）The examiner positions himself in front of the patie

22、nt and requests that, without moving the patients head, the patients eyes follow examiners finger or a pencil in six directions. Finger or pencil should be 3040 cm away from patients head. The usual format is from mid left, to upper left and then down and then to the right （Figure 2-5）. pupillary di

23、rect response to lightThe examiner asks the patient to look forward and shines a penlight or the light of the ophthalmoscope 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 direc

24、t pupillary response to light, the examiner will shine the light into one eye and inspect for pupillary constriction in the same eye. The pupillary constriction is reversed as soon as the light moves away. Use the same method to check the other eye. pupillary consensual response to lightWith the sam

25、e method as obove, the examiner shines the light into one eye and inspects for pupillary constriction in the opposite eye OR observes pupillary dilation in opposite eye as light is extinguished. for convergence and accommodationThe examiner, positioned in front of the patient, asks the patient to lo

26、ok into the distance and then at his finger. The examiners finger starts from 1 meter away, the examiner will immediately move 5 cm away from the bridgeof the patients nose. The examiner is observing the patients eyes for:a） pupillary constriction, and b） convergence （the coordinated movement of bot

27、h eyes toward fixation at the same near point as the patient focuses on a near object）. Accommodation includes convergence and pupillary constriction as the patient focuses on the near object. The accommodation will vanish when cranial nerve is damaged.Ears and Temporomanaibular joint 30. Observe an

28、d palpate the auricles and observe postauricular regions bilaterallyThe examiner pulls 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 temporomandibula

29、r joint for tenderness and swelling （omitted）The temporomandibular joint （TMJ） is anterior to the external auditory canal of the ear. Examine for swelling and tenderness. 32. Feel the movement of the TMJ with index fingers inside patients ears or over jointTo palpate the TMJ joint, the examiner pres

30、ses both sides simultaneously with one or two fingers and asks the patient to open and close his mouth, or the examiner places his index finger in the patients ear and gently pulls forward （anteriorly）, asking the patient to open and close his mouth. （omitted） Nose 38. Inspect and palpate external n

31、ose for malformation and inflammationBegin by examining the external nose. The examiner faces the patient. Observe skin color and shape of nose any palpate for and loss of structure or tenderness from bridge, to tip, to wings of nose. 39. Observe nasal vestibule without otoscopeA view of the nasal c

32、avities is obtained by tilting the patients head back and elevating the tip 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 anterior part of nasal cavity for ulcer, crust, swelling, discharge,