北京積水潭醫(yī)院體格檢查英文教學(xué)病例

1、2022-3班 體格檢查英文教學(xué)病歷T 36.5 C, P 72/min, R 18/min, BP 120/80mmHg.He was well developed and moderately nourished. Active position. His consciousness was clear and his speech was fluent. He was cooperative in the examination. His skin was not stained yellow. No cyanosis. No pigmentation.No skin eruption.

2、 No purpura. Spider angioma and liver palm were not seen. No pitting edema. Superficial lymph nodes were not found enlarged.HeadSkull: Hair was black, well distributed. No deformities.No scars. No tenderness.Eye: Visual fields was normal. Bilateral eyelids were not swelling. No entropion. No ptosis.

3、 Conjunctiva was not congestive, and was not pallor too. Sclera was anicteric. Eyeballs were not projected or depressed. Movement was normal. Bilateral pupils were round and equal in size. Direct and indirect pupillary reactions to light were existent.Ear: Bilateral auricles were symmetric and of no

4、 masses. No discharges were found in external auditory canals. No tenderness in mastoid area. Auditory acuity was normal.Nose: No abnormal discharges were found in nasal2022-3班 體格檢查英文教學(xué)病歷cavity. Septum nasi was in midline. No nares flaring. No epistaxis. No tenderness in nasal sinuses.Mouth: Oral mu

5、cous membrane was not cyanosis. Tongue was in midline. Tonsils were not enlarged.Neck: Symmetric and of no deformities. No masses. Thyroid was not enlarged. Trachea was in midline.Vascularmurmur can not be heard.ChestThe thoracic cage was symmetrical. No deformities. No tenderness. Superficial Veins

6、 could not be seen easily. No subcutaneousemphysema.Intercostalspace was neithernarrowed nor widened.Lungs:Respiratorymovement was bilaterallysymmetricwith the frequency of 18/min. diaphragmaticrespirationwas existent. Thoracic expansion and tactilefremitus were symmetric bilaterally. The degree of

7、excursionof lowerboundwas6cm.Nopleural frictionfremitus.Resonance washeardduringpercussion. Noabnormal breath sound was heard. No wheezes. No rales.Heart: No bulge and no abnormal impulse in precordial area. The point of apical impulse was palpable in the 5th intercostal space and 0.5cm inside of th

8、e left mid clavicular2022-3班 體格檢查英文教學(xué)病歷line and not diffuse. There was no thrill. Border of the heart was normal. The cardiac dullness was as follows. Heart rate was 72/min.Heart sounds were strong and no splitting. A2=P2. Cardiac rhythm was regular. No pathological murmurs. No pericardial friction

9、sound. Peripheral vessel sign was negative.Right (cm )InterspacesLeft (cm)2 H23 m44 1V6V8.5The distance from left midclavicular line to anterior mid line was 9cm.Abdomen:Flat and soft. No bulge or depression.pigmentation 、scar、hernia were not seen. No umbilical secretion . Subcutaneous varicose vein

10、 of abdominal wall was not seen. No gastric type 、intestinal type and peristalsis. There were not tenderness and rebound tenderness on abdomen. There was not mass can be palpable. Hepatojugulor reflux was negative. Murphy sign was negative. There were not percussion pain in hepatic area、splenic area

11、 and renal area. Tympanitic area over gastric2022-3班 體格檢查英文教學(xué)病歷bubble was existent. Shifting dullness was negative. Bowel sound can be heard, 4/min. There was not blood vessel murmur can be heard on abdomen.Anus、 rectum and genitalia: not be checked.Vertebral column and four limbs: vertebral column

12、and four limbs were not deformities. Activity was good. There were no tenderness and percussionpain in every spinalcrest. Lasgue sign was negative. No varicose vein of lower limb.No edema of lower limb.No acropachy andkoilonychias.Neural system: Facial perception was bilaterally symmetric. Masticato

13、ry movement was normal. Direct and indirect corneal reflex was existent. Zygomatic reflex was negative. Prefrontal stripe and nasolabial fold were bilaterally symmetric. It was powerful to turn his head and shrug his shoulders. Pain sensation was bilaterally symmetric. Muscle force was V degree. Muscle tone was normal, no muscular atrophy. No ataxia. Abdominal reflex was existent. Biceps reflex 、 triceps reflex 、 radial periosteal reflex 、 patellar reflex 、 Achilles r