第十一章 標(biāo)準(zhǔn)化病人體檢項目[COMPLETE PHYSICAL EXAMINATION CHECKLIST
(standard patient, SP)]
1、一般檢查/生命體征[GENERAL EXAMINATION/VITAL SIGNS]
•向病人介紹自己的姓名，職責(zé)。通過簡短交談，了解病人的精神狀態(tài)
•檢查前洗手
•讓病人取坐位
•檢查橈動脈脈搏至少30秒，并記錄
•檢查脈搏對稱性
•計數(shù)呼吸頻率至少30秒，并記錄
•測量右上臂血壓
•將袖帶縛于上臂正確位置
•觸診肱動脈
•測量血壓兩次，記錄較低值
•Introduce yourself to patient, usually last name and title and have a little
conversation to relax the patient and to judge mental state.
•Wash hands before starting examinagion
•Patient is seated in a chair
•Palpate radial (wrist) pulses for at least 30 seconds and record
•Palpate both radial (wrist) pulses simultaneously for symmetry
•Measure respiratory rate for at least 30 seconds and record
•Measure blood pressure on right arm
•Place cuff in correct location 2-3 cm above the antecubital crease
•Palpate brachial artery
•Measure blood pressure over brachial artery twice and record the lower reading
2、頭部和頸部[HEAD AND NECK]
（1)頭顱[Skull]
•檢查頭顱（分開頭發(fā)觀察)
•Palpate and observe scalp (parting hair, and observing hair density, color,lustre and distribution)
（2)眼[Eyes]
•檢查視力
•檢查角膜、下份鞏膜、結(jié)膜和淚囊：置拇指于下瞼中份，輕輕向下按下瞼，請病人向上看
•檢查上份鞏膜及球結(jié)膜：置拇指于上瞼中份，輕輕向上牽拉上瞼，請病人向下看
•面神經(jīng)（第Ⅶ對顱神經(jīng))上支運(yùn)動功能的檢查，皺眉、皺額或緊閉雙目
•檢查雙眼眼外肌六個方向運(yùn)動功能
•瞳孔直接對光反射
•檢查調(diào)節(jié)反射
•Visual screening
•Observe cornea, sclera, conjunctive and lacrimal puncta by gently moving lower eyelids down.
•Observe sclera and bulbar conjunctiva by gently elevating upper eyelid while patient looks down
•Check cranial nerve(cr n) Ⅶ upper division:raised eyebrows, wrinkle forehead or forced eyelid closing.
•Evaluate extraocular muscle function in both eyes in 6 directions (left, upper left, and lower left, right, upper right, lower right)
•Observe pupillary direct response to light
•Observe pupillary consensual response to light
•Check for convergence and accommodation
（3)檢眼鏡檢查[OPhthalmoscopic Examination]
•調(diào)整病人者坐位高度，以檢查者感覺舒適為宜
•關(guān)暗室內(nèi)光線，以利觀察眼內(nèi)情況
•正確握持檢眼鏡
•右手持檢眼鏡站在右前方，用右眼檢查受檢者的右眼
•左手持鏡眼鏡站在左前方，用左眼檢查受檢者的左眼
•調(diào)整方位開始檢查
•用檢眼鏡檢查角膜、晶狀體和玻璃體
•觀察眼底視乳頭及其周圍視網(wǎng)膜
•檢查四個象限的視網(wǎng)膜血管
•檢查黃斑（囑受檢查注視光源)
•Position patient at height comfortable for examiner
•Dim lights of room
•Hold ophthalmoscope properly and use index finger to switch lenses
•To examine patient`s right eye, examiner holds ophthalmoscope with right hand and uses right eye
•To examine patient`s left eye, examiner holds ophthalmoscope with left hand and uses left eye
•Position to start ophthalmoscopic examination
•Inspect cornea, lens, and vitreous body for opacity with ophthalmoscope
•Inspect optic disc (color, margin, etc.)
•Trace retinal vessels in four quadrants
•Observe macula (patient asked to look directly at light of ophthalmoscope)
（4)耳及顳下頜關(guān)節(jié)[Ears]
•觀察和觸診雙側(cè)耳廓及周圍
•觸診雙側(cè)顳下頜關(guān)節(jié)，注意有無腫脹及觸痛
•雙手指置于耳屏前或稍插入外耳道，檢查顳頜關(guān)節(jié)的運(yùn)動
•用手稍向后上方牽拉耳廓，使外耳道變直，以便插入耳鏡
•插入耳鏡觀察鼓膜醫(yī)學(xué)全.在線提供
•使受檢查者不感疼痛
•檢查聽力
•用適當(dāng)方法分別檢查雙耳聽力
•Observe and palpate the auricles and observe postauricular regions bilaterally
•Palpate temporomandibular joint for tenderness and swelling
•Feel the movement of the TMJ with index fingers inside examinee`s ears or over joint
•Gently pull auricle upward and backward to ease insertion of otoscope
•Insert otoscope into external auditory meatus to observe tympanic membrane
•Insert otoscope without causing pain to the patient
•Evaluate auditory acuity
•Use proper technique to check auditory acuity separately in each ear
（5)鼻[Nose]
•觀察及觸診外鼻有否畸形，壓痛等
•觀察鼻前庭（不用鼻鏡，可用電筒)
•插入鼻鏡觀察前庭、中隔、鼻甲及鼻粘膜。檢查過程中，病人頭部逐漸后仰
•分別壓閉一側(cè)鼻孔，令病人吸氣，檢查其通氣情況
•按壓雙側(cè)上頜竇區(qū)，有無腫痛
•按壓雙側(cè)額竇區(qū)，有無腫痛
•Inspect and palpate external nose for malformation and inflammation
•Observe nasal vestibule without otoscope
•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
•Test patency by inhaling through each nostril separately while the opposite nostril is held occluded
•Palpate and/or percuss maxillary sinus for swelling and tenderness
•Palpate and/or percuss frontal sinus for swelling and tenderness
（6)口腔、唇、咽[Mouth, Lips, Pharynx]
•檢查唇、頰粘膜、牙、牙齦、舌
•檢查口底
•檢查口咽部有無充血、腫脹及溢膿
•囑受檢者向前伸舌，觀察有無偏歪以檢查第Ⅶ對顱神經(jīng)功能
•囑受檢者露齒、鼓腮或吹口哨，以檢查第Ⅻ對顱神經(jīng)功能
•檢查咬肌肌力，囑受檢者對抗阻力張口
•檢查三叉神經(jīng)感覺支（至少2/3部位)
•暴露和觀察頸部
•Observe lips, buccal mucosa, teeth, gums and tongue
•Observe the floor of mouth
•Inspect the posterior structures of the mouth for congestion, swelling or pus, position of uvula, and elevation of the palate
•Observe midline protrusion of the tongue(cr n Ⅻ)
•Show teeth, puff out cheeks or purse lips (lower division of cr n Ⅶ)
•Test contraction of masseter (jaw) muscle or forced opening of mouth against resistance (motor division cr n V)
•Test for facial sense of pain and touch (must check at least 2 out of 3 sensory divisions for cr n V)
•Expose neck correctly to observe appearance and skin of neck
