A.GENERALEXAMINATION/VITALSIGNS(一般检查)1.Introduceyourselftopatient,usuallylastnameandtitleandhavealittleconversationtorelaxthepatientandtojudgementalstate.2.WashhandsbeforestartingexaminationPreferably,thisshouldbedoneinviewofthepatient.3.Patientisseatedinachair4.Palpateradial(wrist)Pulsesforatleast30secondsandrecordTheexaminerplacesthepadofhisindex,middleandringfingersovertheradialartery.Ifproperlydone,theexaminershouldbeabletofeelthearterypulsatingundertheexaminerfingertips.Theradialpulsemaybemeasuredfor30seconds,thenthepulseperminutecanbefoundbymultiplyingbytwo.Attentionshouldalsobepaidtotherhythm.Theexaminershouldnotusehisthumbtopalpateanypulse.5.Palpatebothradial(wrist)pulsessimultaneouslyforsymmetryforatleast30seconds6.Measurerespiratoryratefor30secondsandrecordTheexaminerunobtrusivelymeasurespatientrespiratoryrate.Thismaybeaccomplishedbytheexaminerleavinghishandsonthepatientwristsforanother30secondsaftermeasuringtheradialpulsessothepatientdoesnotrealizethattheexamineriswatchinghimbreathe.Thedepthandrhythmshouldalsobenoticed.Therespiratoryratecanalsobemeasuredduringthebackexam.7.MeasurebloodpressureonrightarmBloodpressuremaybemeasuredwiththepatientinasittingorlyingposition.Ineachposition,thearteryinwhichthebloodpressureistobemeasuredshouldbeattheleveloftheheart(atthelevelofthefourthintercostalspaceinthesittingposition;atthelevelofthemiddleaxillarylineinthelyingposition).Thepatientarmshouldberestingonasmoothtableorsupportedbytheexaminer,andslightlyflexedattheelbow.8.Placecuffincorrectlocation2-3cmabovetheatecubitalcreaseTheexaminersecuresthebloodpressurecuffsnuglyovertheupper,armsothatonefingercanbeadmittedunderthecuff.Thecuffshouldbepositioned23cmabovetheantecubitalcreaseorelbowjoint.Putthemiddleofthecuffoverthebrachialartery.9.PalpatebrachialarteryTheexaminercanlocatethebrachialarterywhichliesslightlymedialtothetendonofthebicepsmuscleintheantecubitalfossa.Themercurycolumnonthemanometerdialshouldbeproperlycalibratedwiththepointerat0”beforethecuffisinflated(i.e.,alltheairshouldbepressedoutofthecuffbeforeitisinflated).Thestethoscopeisplacedfirmlyoverthebrachialartery.Theexaminersinflatesthecuffslowlybutsteadily.Untilthebrachialarterypulsedisappears.Thenhecontinuestoinflatecuff2.64.0kPa(2030mmHghigher,generallytoabout21.3kPa(160mmHg).10.MeasurebloodpressureoverbrachialarterytwiceandrecordthelowerreadingDeflatethecuffslowlyattherateofabout0.26kPa(2mmHg)Persecond.Thenumberwheretheexaminerhearsthefirstpulsesoundisthesystolicpressure.Thepulsesoundwillwakenandthendisappear.Thenumberwherethepulsesounddisappearsisthediastolicpressure.Ifthediffereneebetweenweakeningofthesoundanditsdisappearaneeis2.6kPa(20mmHg)orgreater,theexaminershouldrecordthesetwonumbers.Thecuffmustbecompletelyemptiedwiththepointerat0”beforeitisreinflated.ThesameproceduremaybefollowedforasecondmeasurementofB.P.inthesameoroppositearm.Thelowerpressureisrecordedasthepatientbloodpressure.Afterfinishingthemeasurement,theexaminerdeflatesandrollsupthecuff,leansthemanometeroveralittlesothemercurycolumndisappears,closesthemercurycolumnswitch,putstheballooninorder,andclosesthemanometer.B.HEADANDNECK(头颈部)Skull11.Palpateandobservescalp(partinghair,andobservinghairdensity,color,lustreanddistribution)Theexaminerpalpatestheentireskullusingbothhandsandsimultaneouslyexaminessymmetricalareas.Theexaminerpartsthehairtoobservethescalp,notinganyscaliness,deformities,lumps,tenderness,lesionsorscars.Theexamineralsoobservesthedensity,color,lustreanddistributionofthehair.Eyes12.Visualscreening:(omitted)13.Observecornea,sclera,conjunctivaandlacrimalpunctabygentlymovinglowereyelidsdown.CorneaExamination-Withobliquelightinginspectthecorneaforopacities,foreignbodiesetc.Inspectlowerpalpebral,fornical,bulbarconjunctivaandsclera.Askthepatienttolookupasyoudepresslowereyelidwithyourthumbexposinglowerpalpebral,fornical,bulbarconjunctivaandsclera.Inspecttheconjunctivaandscleraforcolor,andnotethevascularpatternagainstthewhitescleralbackground.Lacrimalsacexaminationbydigitalcompressionfornasolacrimalductobstruction-Askthepatienttolookup.Pressonthelowerlidclosetothemedialcanthus,justinsidetherimofthebonyorbit.Youarethuscompressingthelacrimalsac.Lookforfluidregurgitationoutofthepunctaintotheeye.Avoidthistestiftheareaisinflamedand/ortender(Figure2-3).14.Observescleraandbulbarconjunctivabygentlyelevatinguppereyelidwhilepatientlooksdown.Instructthepatienttolookdown.Raisetheuppereyelidslightlysothattheeyelashesprotrude,andtheninspectbulbarconjunctiva.Begentlesopatientdoesntear(Figure2-4).15.CheckcrnVflupperdivision:raisedeyebrows,wrinkleforeheadorforcedeyelidclosingNerveVisthefacialnerve.Upperfacialnerve-Totesttheupperdivision,theexaminerobservesthepatientandpalpebralfissure,thenaskspatienttoraisehiseyebrows,wrinklehisforeheadandclosehiseyes.Whenthepatientcloseshiseyestightly,theexaminerattemptstoprythemopentodeterminethestrength.Ifonesideofperipheralupperfacialnervei