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您現(xiàn)在的位置: 醫(yī)學(xué)全在線 > 醫(yī)學(xué)英語 > 英語教學(xué) > 英文病歷 > 正文:標(biāo)準(zhǔn)化病人體檢項目[COMPLETE PHYSICAL EXAMINATION CHECKLIST
    

標(biāo)準(zhǔn)化病人體檢項目[COMPLETE PHYSICAL EXAMINATION CHECKLIST


(4)肩[Shoulder]
•觸診雙肩
•功能檢查(三個過篩試驗:一手越過頭頂觸摸對側(cè)耳朵;雙臂上舉,雙手置于后枕;一手從背后觸及對側(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(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)共濟運動[Coordination]
•快速輪替動作
•指鼻試驗(睜眼)
•指鼻試驗(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
•逐個觸診脊柱棘突,檢查有無畸形、壓痛
•逐個叩擊脊椎棘突(或用間接叩擊法)檢查有無叩痛
•檢查腎區(qū)壓痛和叩擊痛
•檢查胸廓活動度和對稱性
•囑受檢者稍前傾,雙上肢交叉,雙手分別置于對側(cè)肩部
•叩診后胸部
•雙側(cè)對稱地叩診后胸部
•叩診肺下界移動范圍
•囑受檢者輕微張口作深呼吸
•聽診后胸部
•雙側(cè)對稱地聽診后胸部
•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.

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