標(biāo)準(zhǔn)化病人體檢項(xiàng)目中英文

標(biāo)準(zhǔn)化病人體檢項(xiàng)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(dòng)脈脈搏至少30秒，并記錄

·檢查脈搏對(duì)稱性

·計(jì)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(dòng)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(qǐng)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(qǐng)病人向下看

·面神經(jīng)（第Ⅶ對(duì)顱神經(jīng)）上支運(yùn)動(dòng)功能的檢查，皺眉、皺額或緊閉雙目

·檢查雙眼眼外肌六個(gè)方向運(yùn)動(dòng)功能

·瞳孔直接對(duì)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(gè)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(dòng)

·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

·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(duì)顱神經(jīng)功能

·囑受檢者露齒、鼓腮或吹口哨，以檢查第Ⅻ對(duì)顱神經(jīng)功能

·檢查咬肌肌力，囑受檢者對(duì)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

（7）淋巴結(jié)[Lymph nodes]

·觸診耳前淋巴結(jié)：雙側(cè)耳前區(qū)

·觸診耳后淋巴結(jié)：雙側(cè)耳后區(qū)

·觸診枕后淋巴結(jié)：枕外隆凸下方

·觸診下頜下淋巴結(jié)：屈曲手指于下頜骨內(nèi)側(cè)觸診

·觸診頦下淋巴結(jié)：屈曲手指于頦下中線處觸診

·觸診頸前淋巴結(jié)淺組：位于乳突下，胸鎖乳肌前緣淺表處

·觸診頸后淋巴結(jié)：位于胸鎖乳突肌后緣淺表處

·觸診鎖骨上淋巴結(jié)：屈曲手指在鎖骨與胸鎖乳突肌之間的交角處觸診

·Palpate preauricular nodes (front of ears)

·Palpate post-auricular nodes (back of ears)

·Palpate occipital nodes (base of skull)

·Palpate submaxillary nodes (by bending finger under patient`s jaw)

·Palpate submental nodes (by bending finger under patient`s chin)

· Palpate anterior cervical nodes (superficial group under mastoid and the front of sternomastoid muscle)

·Palpate posterior cervical nodes (behind sternomastoid muscle)

·Palpate supraclavicular nodes (by bending finger above patient`s collarbone)

（8）甲狀腺[Thyroid gland]

·用雙指觸摸甲狀軟骨，檢查其移動(dòng)度及有無疼痛

·用雙手從患者前面或后面在正確部位觸診甲狀腺

·觸摸甲狀腺狹部、配合吞咽動(dòng)作

·觸摸甲狀腺側(cè)葉、配合吞咽動(dòng)作

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

·Palpate thyroid in correct anatomical location in front of or behind the patient with both hands

·Palpate isthmus of thyroid with and without swallowing

·Palpate thyroid gland(lobes) with and without swallowing

（9）頸動(dòng)脈、氣管[Carotid Artery and Trachea]

·觸診頸動(dòng)脈

·檢查氣管位置

·Gently palpate carotid artery(bilaterally)

·Palpate the position of trachea

（10）頸椎運(yùn)動(dòng)[Movement of Cervical Spine]

·屈曲

·后伸

·側(cè)彎（耳—肩運(yùn)動(dòng)）

·旋轉(zhuǎn)（頦—肩運(yùn)動(dòng)）

·囑受檢者對(duì)抗阻力作頭部旋轉(zhuǎn)或聳肩以檢查第Ⅺ對(duì)顱神經(jīng)功能

·Flexion (actively, if possible; if abnormal, do passively)

·Extension (actively, if possible; if abnormal, do passively)

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

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

·Test rotation of patient`s head against resistance or check resistance of shrugged shoulders (cr n XI)

3、上肢[UPPER LIMBS]

·正確暴露上肢

·Expose upper limbs

（1）手[Hands]

·觀察手掌、手背，觸診雙手各關(guān)節(jié)

·檢查雙手及指甲，有無紫紺和杵狀指

·伸展手指

·彎曲近指間和遠(yuǎn)指間關(guān)節(jié)呈爪狀

·握拳

·拇指對(duì)掌運(yùn)動(dòng)

·檢查遠(yuǎn)端肌力

·Inspect dorsa and palms and palpate all joints of hand

·Check fingernails for clubbing or cyanosis

·Ask patient to extend fingers

·Ask patient to make a claw

·Ask patient to make a fist

·Check patient`s ability to perform thumb opposition

·Check for distal muscle strength

（2）腕[Wrist]

·觸診雙手腕有無腫塊、水腫、畸形和壓痛

·背伸

·掌曲   

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

·Extension of wrist (bend backward)

·Flexion of wrist (bend forward)

（3）肘[Elbow]

·觸診鷹嘴和肱骨髁狀突

·觸診滑車上淋巴結(jié)

·屈肘

·檢查上臂肌力

·伸肘

·旋前和旋后

·Palpate olecranon process and epicondyles

·Palpate epitrochlear lymph nodes

·Flexion

·Check for upper arm muscle strength

·Extension

·Pronation and supination (with elbows locked at patient`s side)

（4）肩[Shoulder]

·觸診雙肩

·功能檢查（三個(gè)過篩試驗(yàn)：一手越過頭頂觸摸對(duì)側(cè)耳朵；雙臂上舉，雙手置于后枕；一手從背后觸及對(duì)側(cè)肩胛下角）

·檢查上肢近端肌力

·檢查觸覺或痛覺（至少2/3部位）

·貝勒氏（Barre`s）上肢輕癱試驗(yàn)（閉眼）

·Palpate both shoulders

·Functional examination (3 screening maneuvers: hand over head to opposite ear, hands behind head, touch lower border of opposite scapula)

·Check for proximal muscle strength

·Test sense of pain or touch:at least 2 of 3 positions (upper arm, forearm, & hand) on each upper extremity bilaterally and symmetrically

·Barre`s upper limb test (test for drift of outstretched arms with eyes closed)

（5）腱反射[Deep Tendon Reflexes(The reflexes should be checked bilaterally and both sides com-pared.)]

·肱二頭肌反射

·肱三頭肌反射

·橈骨骨膜反射

·Biceps reflex

·Triceps reflex

·Brachioradialis reflex

（6）共濟(jì)運(yùn)動(dòng)[Coordination]

·快速輪替動(dòng)作

·指鼻試驗(yàn)（睜眼）

·指鼻試驗(yàn)（閉眼）

·Rapid alternating movement

·Finger to nose test (with open eyes)

·Finger to nose test (with closed eyes)

4、背部[BACK]

·正確暴露背部

·逐個(gè)觸診脊柱棘突，檢查有無畸形、壓痛

·逐個(gè)叩擊脊椎棘突（或用間接叩擊法）檢查有無叩痛

·檢查腎區(qū)壓痛和叩擊痛

·檢查胸廓活動(dòng)度和對(duì)稱性

·囑受檢者稍前傾，雙上肢交叉，雙手分別置于對(duì)側(cè)肩部

·叩診后胸部

·雙側(cè)對(duì)稱地叩診后胸部

·叩診肺下界移動(dòng)范圍

·囑受檢者輕微張口作深呼吸

·聽診后胸部

·雙側(cè)對(duì)稱地聽診后胸部

·聽覺語音（耳語音）

·Expose the back correctly

·Palpate spinous processes one by one (check for scoliosis and tenderness)

·Test for percussion pain of spinal column one by one (or by indirect method)

·Test CVA for kidney tenderness by pressure and indirect fist percussion

·Palpate thoracic expansion and symmetry

·Have patient cross arms in front and touch opposite shoulder

·Percuss posterior lung fields

·Percuss posterior lung fields comparatively and symmetrically

·Measure diaphragmatic excursion

·Instruct the patient to breathe a little deeply with mouth open slightly

·Auscultate posterior lung fields

·Auscultate comparatively and symmetrically

·Vocal audible resonance

5、乳房（女性）[BREASTS (FEMALE)]

·充分暴露雙側(cè)乳房

·坐位（或站立位）觀察乳房

·前傾位觀察乳房

·雙臂高舉過頭觀察乳房

·用手指掌面以適當(dāng)壓力觸診右乳房

·按內(nèi)上、外上、尾部、內(nèi)下、外下順序觸診右乳房，至少4/5部位

·觸診右乳暈及乳頭，注意乳頭溢液

·用手指掌面以適當(dāng)壓力觸診左乳房

·按內(nèi)上、外上、尾部、內(nèi)下、外下順序觸診左乳房，至少4/5部位

·觸診左乳暈及乳頭，注意乳頭溢液

·教檢者作乳房自我檢查

·檢查受檢者右腋窩

·觸診右腋窩5群淋巴結(jié)

·檢查受檢者左腋窩

·觸診左腋窩5群淋巴結(jié)

·Expose both breasts completely

·Inspect both breasts symmetrically in sitting position

·Inspect both breasts symmetrically with patient leaning forward

·Inspect both breasts symmetrically with arms raised above head

·Inspect both breasts symmetrically with hands on hips and squeeze

·Palpate patient`s right breast with pads of fingers of right hand, applying gentle pressure

·Palpate right breast in the 5 following areas;superinternal, superlateral, tail, inferinternal, inferlateral (at least 4 of 5 parts of the breast should be palpated)

·Palpate nipples, areola, attempt to express discharge from nipple

·Palpate patient`s left breast with pad of fingers and palm, applying gentle pressure.

·Palpate left breast in the folloing areas:superinternal, superlateral, tail, inferinternal, inferlateral.

·Palpate nipples, areola, attempt to express discharge from nipple.

·Teach patient breast self-examination.

Axillary Examinaton

·Inspect the patient`s right axilla.

·Palpate chains of lymph nodes on right:top , medial, anterior, posterior, lateral

·Inspects patients left axilla

·Palpate chains of lymph nodes on left: tcp, medial, anterior, posterior, lateral.

6、前胸和肺[ANTERIOR CHEST AND LUNGS]

·視、觸胸部

·雙側(cè)對(duì)稱地叩診肺尖

·叩診前胸和側(cè)胸

·雙側(cè)對(duì)稱地聽診肺尖

·聽診前、側(cè)胸部

·Inspect and palpate configuration and symmetry of chest

·Percuss supraclavicular fossae bilaterally and symmetrically

·Percuss anterior and lateral lung fields

·Auscultate supraclavicular fossae bilatcrally and symmetrically

·Auscultate anterior and lateral lung fields.

7、心臟[HEART]

·囑受檢者仰臥，粗略估計(jì)頸靜脈壓

·觀察心前區(qū)（取切線方向）

·用手掌、手指觸診心尖搏動(dòng)

·用手掌觸診心前區(qū)

·叩診心臟相對(duì)濁音界

·Screening test for elevated venous pressure.

·Observe precordium (view tangentially)

·Palpate apical area with palm and fingertips

·Palpate precordial area with palm

·Percuss relative dullness of the heart

（1）用膜型胸件聽診[Auscultate with diaphragm]

·肺動(dòng)脈瓣區(qū)（胸骨左緣第2肋間隙）

·主動(dòng)脈瓣區(qū)（胸骨右緣第2肋間隙）

·主動(dòng)脈瓣第二聽診區(qū)（胸骨左緣第3、4肋間隙）

·二尖瓣區(qū)（心尖部）

·三尖瓣區(qū)（胸骨左緣第4、5肋間隙或胸骨體下端稍偏右）

·Pulmonary area (second left ICS)

·Aortic area (second right ICS)

·Second aortic area (third and fourth left ICS)

·Mitral area (Apical area)

·Tricuspid area (fourth, fifth left ICS, LSB and RSB)

（2）用鐘型胸件聽診[Auscultate with bell]

·肺動(dòng)脈瓣區(qū)

·主動(dòng)脈瓣區(qū)

·主動(dòng)脈瓣第二聽診區(qū)

·二尖瓣區(qū)

·三尖瓣區(qū)

·Pulmonary area

·Aortic area

·Second aortic area

·Mitral area (Apical area)

·Tricuspid area

8、腹部[ABDOMEN]

·正確暴露腹部

·頭下置一小枕，囑受檢者屈膝、盡量放松腹肌、雙上肢置于軀干兩側(cè)，平靜呼吸

·視診腹部

·聽診腸鳴音

·叩診腹部

·叩診肝濁音界

·觸診腹部時(shí)應(yīng)注意受檢者面部表情及退縮反應(yīng)

·淺部觸診

·深部觸診

·單手法觸診肝臟

·雙手法觸診肝臟

·在前正中線觸診肝臟

·雙手法觸診脾臟

·右側(cè)臥位觸診脾臟

·雙手觸診法檢查雙側(cè)腎臟

·檢查腹部的觸覺和痛覺

·Expose abdomen completely from just below breasts to just above pubis

·Place pillow under head, bend knees, arms at side, have patient breathe normally.

·Observe abdomen.

·Auscultate for bowel sounds, place stethoscope in area of umbilicus

·Percuss abdomen

·Percuss liver span

·Watch patient`s face and response as you palpate abdomen

·Palpate superficially

·Palpate deeply

·Palpate liver at midclavicular with monomanual method.

·Palpate liver at midclavicular line with bimanual method

·Palpate liver at midsternal line

·Palpate spleen with bimanual method

·Palpate spleen with patient rolled toward his right side.

·Palpate kidneys with bimanual method

·Test for pain of light touch on abdominal wall

9、下肢[LOWER LIMBS]

·充分暴露和視診雙下肢

·觸診雙側(cè)腹股溝淺表淋巴結(jié)（橫組）

·觸摸雙側(cè)腹股溝淺表淋巴結(jié)（縱組）

·觸診雙側(cè)股動(dòng)脈

·觸診雙側(cè)足背動(dòng)脈

·檢查雙下肢水腫

·檢查下肢觸覺或痛覺（至少2/3部位）

·Expose and inspect lower limbs

·Palpate transverse group of superficial groin lymph nodes

·Palpate longitudinal group of superficial groin lymph nodes

·Femoral artery (groin)

·Dorsalis pedis artery (top of foot)

·Check for pitting edema

·Test for sense of pain or light touch in at least 2 or 3 positions

（1）髖[Hips]

·屈髖

·內(nèi)旋和外旋運(yùn)動(dòng)

·檢查下肢近端肌力

·Check flexion of the hip

·Check internal/external rotation of the hip

·Check proximal muscle strength

（2）膝[Knee]

·檢查髕骨運(yùn)動(dòng)

·屈膝

·檢查膝周肌力

·觸診膝關(guān)節(jié)

·檢查膝反射

·Examine movement of patella

·Flexion of knee

·Check for muscle strength around knee

·Palpate the knee joint

·Test knee jerk

（3）踝[Ankle]

·觸診踝關(guān)節(jié)（包括跟腱）

·檢查雙下肢遠(yuǎn)端肌力

·背屈和跖屈

·內(nèi)翻和外翻

·Palpate ankle joint including Achilles tendon

·Check for distal muscle strength

·Check movement at tibial-talar joint (dorsiflexion-plantar flexion)

·Check movement at subtalar joint (eversion-inversion)

（4）足[Foot]

·屈趾和伸趾

·檢查雙足位置覺

·檢查跟腱反射

·檢查跖反射

·羅姆伯格征（Romberg征即閉目難立征）檢查

·步態(tài)觀察

·Flexion of toes (curl toes) and extension of toes (straighten toes)

·Test position sense in both feet

·Ankle jerk

·Plantar reflex

·Perform Romberg test

·Check gait (arms swinging at side)

（5）腰椎運(yùn)動(dòng)[Movement of lumbar spine]

·俯屈

·仰伸

·側(cè)彎

·旋轉(zhuǎn)

·Flexion

·Extension

·Lateral bending

·Rotation

【責(zé)任編輯：博朗】