第十一章  标准化病人体检项目[COMPLETE PHYSICAL EXAMINATION CHECKLIST
       (standard patient, SP)]
       1、一般检查/生命体征[GENERAL EXAMINATION/VITAL SIGNS]
       •向病人介绍自己的姓名，职责。通过简短交谈，了解病人的精神状态
       •检查前洗手
       •让病人取坐位
       •检查桡动脉脉搏至少30秒，并记录
       •检查脉搏对称性
       •计数呼吸频率至少30秒，并记录
       •测量右上臂血压
       •将袖带缚于上臂正确位置
       •触诊肱动脉
       •测量血压两次，记录较低值
       •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、头部和颈部[HEAD AND NECK]
           （1）头颅[Skull]
       •检查头颅（分开头发观察）
       •Palpate and observe scalp (parting hair, and observing hair density, color,lustre and distribution)
       （2）眼[Eyes]
       •检查视力
       •检查角膜、下份巩膜、结膜和泪囊：置拇指于下睑中份，轻轻向下按下睑，请病人向上看
       •检查上份巩膜及球结膜：置拇指于上睑中份，轻轻向上牵拉上睑，请病人向下看
       •面神经（第Ⅶ对颅神经）上支运动功能的检查，皱眉、皱额或紧闭双目
       •检查双眼眼外肌六个方向运动功能
       •瞳孔直接对光反射
       •检查调节反射
       •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）检眼镜检查[OPhthalmoscopic Examination]
       •调整病人者坐位高度，以检查者感觉舒适为宜
       •关暗室内光线，以利观察眼内情况
       •正确握持检眼镜
       •右手持检眼镜站在右前方，用右眼检查受检者的右眼
       •左手持镜眼镜站在左前方，用左眼检查受检者的左眼
       •调整方位开始检查
       •用检眼镜检查角膜、晶状体和玻璃体
       •观察眼底视乳头及其周围视网膜
       •检查四个象限的视网膜血管
       •检查黄斑（嘱受检查注视光源）
       •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）耳及颞下颌关节[Ears]
       •观察和触诊双侧耳廓及周围
       •触诊双侧颞下颌关节，注意有无肿胀及触痛
       •双手指置于耳屏前或稍插入外耳道，检查颞颌关节的运动
       •用手稍向后上方牵拉耳廓，使外耳道变直，以便插入耳镜
       •插入耳镜观察鼓膜医学全.在线提供
       •使受检查者不感疼痛
       •检查听力
       •用适当方法分别检查双耳听力
       •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]
       •观察及触诊外鼻有否畸形，压痛等
       •观察鼻前庭（不用鼻镜，可用电筒）
       •插入鼻镜观察前庭、中隔、鼻甲及鼻粘膜。检查过程中，病人头部逐渐后仰
       •分别压闭一侧鼻孔，令病人吸气，检查其通气情况
       •按压双侧上颌窦区，有无肿痛
       •按压双侧额窦区，有无肿痛
       •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]
       •检查唇、颊粘膜、牙、牙龈、舌
       •检查口底
       •检查口咽部有无充血、肿胀及溢脓
       •嘱受检者向前伸舌，观察有无偏歪以检查第Ⅶ对颅神经功能
       •嘱受检者露齿、鼓腮或吹口哨，以检查第Ⅻ对颅神经功能
       •检查咬肌肌力，嘱受检者对抗阻力张口
       •检查三叉神经感觉支（至少2/3部位）
       •暴露和观察颈部
       •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）淋巴结[Lymph nodes]
       •触诊耳前淋巴结：双侧耳前区
       •触诊耳后淋巴结：双侧耳后区
       •触诊枕后淋巴结：枕外隆凸下方
       •触诊下颌下淋巴结：屈曲手指于下颌骨内侧触诊
       •触诊颏下淋巴结：屈曲手指于颏下中线处触诊
       •触诊颈前淋巴结浅组：位于乳突下，胸锁乳肌前缘浅表处
       •触诊颈后淋巴结：位于胸锁乳突肌后缘浅表处
       •触诊锁骨上淋巴结：屈曲手指在锁骨与胸锁乳突肌之间的交角处触诊
       •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）甲状腺[Thyroid gland]
       •用双指触摸甲状软骨，检查其移动度及有无疼痛
       •用双手从患者前面或后面在正确部位触诊甲状腺
       •触摸甲状腺狭部、配合吞咽动作
       •触摸甲状腺侧叶、配合吞咽动作
       •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）颈动脉、气管[Carotid Artery and Trachea]
       •触诊颈动脉
       •检查气管位置
       •Gently palpate carotid artery(bilaterally)
       •Palpate the position of trachea
       （10）颈椎运动[Movement of Cervical Spine]
       •屈曲
       •后伸
       •侧弯（耳—肩运动）
       •旋转（颏—肩运动）
       •嘱受检者对抗阻力作头部旋转或耸肩以检查第Ⅺ对颅神经功能
       •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]
       •正确暴露上肢
       •Expose upper limbs
       （1）手[Hands]
       •观察手掌、手背，触诊双手各关节
       •检查双手及指甲，有无紫绀和杵状指
       •伸展手指
       •弯曲近指间和远指间关节呈爪状
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       •拇指对掌运动
       •检查远端肌力
       •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]
       •触诊双手腕有无肿块、水肿、畸形和压痛
       •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]
       •触诊鹰嘴和肱骨髁状突
       •触诊滑车上淋巴结
       •屈肘
       •检查上臂肌力
       •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]
       •触诊双肩
       •功能检查（三个过筛试验：一手越过头顶触摸对側耳朵；双臂上举，双手置于后枕；一手从背后触及对侧肩胛下角）
       •检查上肢近端肌力
       •检查触觉或痛觉（至少2/3部位）
       •贝勒氏（Barre`s）上肢轻瘫试验（闭眼）
       •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.)]
       •肱二头肌反射
       •肱三头肌反射
       •桡骨骨膜反射
       •Biceps reflex
       •Triceps reflex
       •Brachioradialis reflex
       （6）共济运动[Coordination]
       •快速轮替动作
       •指鼻试验（睁眼）
       •指鼻试验（闭眼）
       •Rapid alternating movement
       •Finger to nose test (with open eyes)
       •Finger to nose test (with closed eyes)
       4、背部[BACK]
       •正确暴露背部
       •逐个触诊脊柱棘突，检查有无畸形、压痛
       •逐个叩击脊椎棘突（或用间接叩击法）检查有无叩痛
       •检查肾区压痛和叩击痛
       •检查胸廓活动度和对称性
       •嘱受检者稍前倾，双上肢交叉，双手分别置于对侧肩部
       •叩诊后胸部
       •双侧对称地叩诊后胸部
       •叩诊肺下界移动范围
       •嘱受检者轻微张口作深呼吸
       •听诊后胸部
       •双侧对称地听诊后胸部
       •听觉语音（耳语音）
       •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)]
       •充分暴露双侧乳房
       •坐位（或站立位）观察乳房
       •前倾位观察乳房
       •双臂高举过头观察乳房
       •用手指掌面以适当压力触诊右乳房
       •按内上、外上、尾部、内下、外下顺序触诊右乳房，至少4/5部位
       •触诊右乳晕及乳头，注意乳头溢液
       •用手指掌面以适当压力触诊左乳房
       •按内上、外上、尾部、内下、外下顺序触诊左乳房，至少4/5部位
       •触诊左乳晕及乳头，注意乳头溢液
       •教检者作乳房自我检查
       •检查受检者右腋窝
       •触诊右腋窝5群淋巴结
       •检查受检者左腋窝
       •触诊左腋窝5群淋巴结
       •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]
       •视、触胸部
       •双侧对称地叩诊肺尖
       •叩诊前胸和侧胸
       •双侧对称地听诊肺尖
       •听诊前、侧胸部
       •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、心脏[HEART]医学 全在.线提供www.med126.com
       •嘱受检者仰卧，粗略估计颈静脉压
       •观察心前区（取切线方向）
       •用手掌、手指触诊心尖搏动
       •用手掌触诊心前区
       •叩诊心脏相对浊音界
       •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）用膜型胸件听诊[Auscultate with diaphragm]
       •肺动脉瓣区（胸骨左缘第2肋间隙）
       •主动脉瓣区（胸骨右缘第2肋间隙）
       •主动脉瓣第二听诊区（胸骨左缘第3、4肋间隙）
       •二尖瓣区（心尖部）
       •三尖瓣区（胸骨左缘第4、5肋间隙或胸骨体下端稍偏右）
       •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）用钟型胸件听诊[Auscultate with bell]
       •肺动脉瓣区
       •主动脉瓣区
       •主动脉瓣第二听诊区
       •二尖瓣区
       •三尖瓣区
       •Pulmonary area
       •Aortic area
       •Second aortic area
       •Mitral area (Apical area)
       •Tricuspid area
       8、腹部[ABDOMEN]
       •正确暴露腹部
       •头下置一小枕，嘱受检者屈膝、尽量放松腹肌、双上肢置于躯干两侧，平静呼吸
       •视诊腹部
       •听诊肠鸣音
       •叩诊腹部
       •叩诊肝浊音界
       •触诊腹部时应注意受检者面部表情及退缩反应
       •浅部触诊
       •深部触诊
       •单手法触诊肝脏
       •双手法触诊肝脏
       •在前正中线触诊肝脏
       •双手法触诊脾脏
       •右侧卧位触诊脾脏
       •双手触诊法检查双侧肾脏
       •检查腹部的触觉和痛觉
       •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]
       •充分暴露和视诊双下肢
       •触诊双侧腹股沟浅表淋巴结（横组）
       •触摸双侧腹股沟浅表淋巴结（纵组）
       •触诊双侧股动脉
       •触诊双侧足背动脉
       •检查双下肢水肿
       •检查下肢触觉或痛觉（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）髋[Hips]
       •屈髋
       •内旋和外旋运动
       •检查下肢近端肌力
       •Check flexion of the hip
       •Check internal/external rotation of the hip
       •Check proximal muscle strength
       （2）膝[Knee]
       •检查髌骨运动
       •屈膝
       •检查膝周肌力
       •触诊膝关节
       •检查膝反射
       •Examine movement of patella
       •Flexion of knee
       •Check for muscle strength around knee
       •Palpate the knee joint
       •Test knee jerk
       （3）踝[Ankle]
       •触诊踝关节（包括跟腱）
       •检查双下肢远端肌力
       •背屈和跖屈
       •内翻和外翻
       •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
       •检查双足位置觉
       •检查跟腱反射
       •检查跖反射
       •罗姆伯格征（Romberg征即闭目难立征）检查
       •步态观察
       •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）腰椎运动[Movement of lumbar spine]
       •俯屈
       •仰伸
       •侧弯
       •旋转
       •Flexion
       •Extension
       •Lateral bending
       •Rotation
       来源：医学全在线