体格检查英文版

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 examination

Preferably, this should be done in view of the patient.

3. Patient is seated in a chair

4. Palpate radial (wrist) Pulses for at least 30 seconds and record

The 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 be

measured for 30 seconds, then the pulse perminute 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 record

The

examiner

unobtrusively

measures

patient’s

res

piratory

rate.

This

may

be

accomplished

by

the

examiner

leaving his hands on the patient’s 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 also be noticed. The

respiratory rate can also be measured during the back exam.

7. Measure blood pressure on right arm

Blood 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

the

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

patient’s

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 cm above the atecubital crease

The 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

2

～

3

cm

above

the

antecubital

crease

or

elbow

joint.

Put

the

middle of the cuff over the brachial artery.

9. Palpate brachial artery

The 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 pressed 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 2.6

～

4.0kPa (20

～

30 mmHg higher,

generally to about 21.3kPa (160mmHg)).

10. Measure blood pressure over brachial artery twice and record the lower reading

Deflate

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 systolic pressure. The pulse sound will waken and then disappear. The number

where the pulse sound disappears is the diastolic pressure. If the difference between 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 pointer at “0” before it is reinflated. The same procedure may be followed

for a second measurement of B. P. in the same or opposite arm. The lo

wer pressure is recorded as the patient’s

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, 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 parts 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

）

e 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 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 obstruction-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. Observe 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 patient doesn’t tear (Figure 2

-4).

crn

Ⅶ

upper division: raised eyebrows, wrinkle forehead or forced eyelid closing Nerve

Ⅶ

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

close

his

eyes.

When

the

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 eye on the affected side. If one side of ce

ntral 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 both 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

penc

il

in

six

directions.

Finger

or

pencil

should

be

30

～

40

cm

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).

e pupillary direct response to light

The 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

direct

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

2

moves away. Use the same method to check the other eye.

e pupillary consensual response to light

With

the

same

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 accommodation

The 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

examiner

will

immediately

move

5

cm

away

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).

Accommodation

includes

convergence

and

pupillary

constriction

as

the

patient

focuses on the near object. The accommodation will vanish when cranial nerve

Ⅲ

is damaged.

Ears and Temporomanaibular joint

30. Observe and palpate the auricles and observe postauricular regions bilaterally

The 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 temporomandibular 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 patient’s ears or over joint

To palpate the TMJ joint, the examiner presses both sides simultaneously with one or two fingers and asks the

patient to open an

d close his mouth, or the examiner places his index finger in the patient’s ear and gently pulls

forward (anteriorly), asking the patient to open and close his mouth. (

omitted

)

Nose

38. Inspect and palpate external nose for malformation and inflammation

Begin 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 otoscope

A

view of the nasal cavities is obtained by tilting the patient’s 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, atrophy or perforation

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 tenderness

Examination

of

the

paranasal

sinuses

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 frontal sinus for swelling and tenderness

The

frontal

sinuses

are

palpated

at

the

inner

part

of

the

upper

border

of

the

bony

orbit

by

finger

pressure

directed upward toward the floor of the sinus where the sinus wall is thin. Tenderness may be elicited in this

way. Swelling caused by tumors or retained secretions may cause a downward bulge in the floor of the frontal

sinus. The frontal sinuses may also be percussed.

Mouth, lips, Pharynx

44. Observe lips, buccal mucosa, teeth, gums and tongue

The examiner inspects the lips, all surfaces of the tongue, gums, roof of mouth, and the buccal mucosa (the

3

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 buccal 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

evidence

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 mouth

Inspect

the

mouth

for

pigmentation,

hemorrhage

or

masses

(ask

patient

to

touch

tip

of

tongue

to

roof

of

mouth).

Generally, palpation is not done in a normal exam. However, if a mass is found 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 felt 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

tongue,

firmly

down

to

inspect

tonsils,

anterior

and

posterior tonsillar pillars, and posterior pharynx. The examiner can observe the elevation of the palate as the

patient say

s “ah”. Simultaneously, hoarseness can be detected. The conscious patient should not be gagged.

47. Observe midline protrusion of the tongue (cr n

Ⅻ

)

The 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

Ⅶ

) (

omitted

)

49.

Test

contraction

of

masseter

(jaw)

muscle

or

forced

opening

of

mouth

against

resistance

(motor

division cr n

Ⅴ

) (

omitted

)

50. Test for facial sense of pain and touch (must check at least 2 out of 3 sensory divisions for cr n

Ⅴ

)

(

omitted

)

51. Expose neck correctly to observe appearance and skin of neck

The patient sits upright.

Ask patient to expose neck entirely when the neck is to 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 symmetry and pay

attention to its appearance. Abnormal lumps and pulsations may be seen in this area. Generally, the thyroid

cartilage

will

show

convexity

in

a

male.

The

examiner

inspects

the

skin

of

the

neck

for

erythema,

spider

angioma, infections, ulcers or scars.

Facial and cervical lymph nodes

Palpate lymph nodes bilaterally. The examiner may be positioned in front of or behind the patient and examine

the lymph nodes with the pads of his index 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 moves the skin over the

underlying tissue rather than move his fingers over the surface of the skin. The examiner may have the patient

position his head with his neck slightly flexed forward. The examiner palpates all nodes bilaterally.

For palpation of lymph nodes, be sure to keep the skin and muscles relaxed. If the lymph nodes are enlarged,

4

note

their

location,

size,

number,

hardness,

mobility,

tenderness,

adhesion,

fusion, swelling,

fistula

or

scars

(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. Palpate submaxillary nodes (by bending finger under patient’s jaw)

56. Palpate submental nodes (by bending finger under patient’s chin)

57. palpate anterior cervical nodes (superficial group under mastoid and in front of sternomastoid muscle)

58. Palpate posterior cervical nodes (behind sternomastoid muscle)

59. Palpate supraclavicular nodes (by bending finger above patient’s collarbone)

Thyroid gland

60. Palpate and/or move thyroid cartilage with two fingers checking for malformation and movability

61. Palpate thyroid in correct anatomical location in front of or behind the patient with

both lateral lobes of the thyroid curve posteriorly around the sides of the trachea and

the esophagus. In addition, they are partially covered by the sternomastoid are

several different techniques for examining the thyroid gland. Many examiners will palpate the

thyroid gland both in front of and/or behind the patient. The examiner should identify the thyroid

gland which lies across the trachea below the cricoid cartilage. (If the examiner has the patient

flex his neck or turn his chin slightly toward the side to be examined, it will secure the relaxation

of the sternomastoid muscle, 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 the isthmus of the thyroid gland. If examiner stands in front, he examines with

his

thumbs,

from

behind,

with

his

index

fingers.

Examiner

asks

patient

to

swallow

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

tissue

structures in the neck that moves with swallowing.

63. Palpate thyroid gland (lobes) with and without swallowing

Palpation

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 fingers (Placed behind the sternomastoid) This

should be done before and during swallowing. The procedure 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 thumb 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 Artery

64. Gently palpate carotid artery

With the pads of his fingers, the examiner exerts gentle pressure on patient’s carotid arteries in the lower half of

the

neck

on

the

inside

edge

of

patient’s

sternomastoid

muscle.

One

should

not

palpate

both

caroti

ds

simultaneously as the patient might flle faint if both carotids are palpated at the same time.

Trachea

65. Palpate the position of trachea

Place the patient’s head erect and facing forward and make sure both shoulders are at the same horizontal le

vel.

Put index and fourth fingers at the sternoclavicular joints. Palpate trachea or the gaps between the trachea and

the joints with the middle finger to determine the position of the trachea.

Movement of Cervical Spine

66. Flexion (actively, if possible; if abnormal, do passively)

5

67. Extension (actively, if possible; if abnormal, do passively)

68. Lateral bending [ear- to-shoulder]; (actively, if possible; if abnormal, do passively)

69. Rotation (chin-to-shoulder), (actively, if possible; if abnormal, do passively)

70. Test rotation of patient’s head against resistance or check resistance of shrugged shoulders (cr n

Ⅵ

)

C. UPPER LIMBS (omitted)

71. Expose upper limbs

Hands

72. Inspect dorsa and palms and palpate all joints of hand

73. Check fingernails for clubbing or cyanosis

74. Ask patient to extend fingers

75. Ask patient to make a claw

76. Ask patient to make a fist

77. Check patient’s ability to perform thumb opposition

78. Check for distal muscle strength

Wrist

79. Observe and palpate wrist (for lumps, swelling, deformities, and tenderness)

80. Extension of wrist (bend backward)

81. Flexion of wrist (bend forward)

Elbow

82. palpate olecranon process and epicondyles

83. Palpate epitrochlear lymph nodes

84. Flexion

85. Check for upper arm muscle strength

86. Extension

87. Pronation and supination (with elbows locked at patient’s side)

Shoulder

88. Palpate both shoulders

89. Functional examination (3 screening maneuvers:hand over head to opposite ear, hands behind head,

touch lower border of opposite scapula)

90. Check for proximal muscle strength

91.

Test

sense

of

pain

or

touch;

at

least

2

of

3

positions

(upper

arm,

forearm,

&

hand)

on

each

upper

extremity bilaterally and symmetrically

’s upper limb test (test for drift of out

stretched arms with eyes closed)Deep Tendon Reflexes(The

reflexes should be checked bilaterally and both sides compared.)

Deep Tendon Reflexes

93. Biceps reflex

The examiner supports the patient’s arm which should be relaxed with the elbow bent at a

bout

90

degrees with the palm up. The examiner places his thumb against the biceps tendon on the inside of the patient’s

elbow

and

taps

it

with

the

reflex

hammer.

A

reflex

should

be

elicited.

The

normal

reflex

is

contraction

of

the

biceps causing a rapid flexion of the forearm. The reflex center is C5-6.

94. Triceps reflex

6