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,*,单击此处编辑母版标题样式,单击此处编辑母版文本样式,第二级,第三级,第四级,第五级,体格检查(二）,1,Inspection：,腹纹：abdominal striae外形：contour膨胀：distension平坦的：flat腹胀不对称：asymmetrical distension蛙腹：frog belly腹部普遍膨隆（凹陷）：general prominenoe (retraction) of the abdomen,五、腹部,Abdomen,2,Inspection：,腹围增大：increased abdominal girth肠型：intestinal pattern (or contour)阶梯样蠕动波：peristaltic wave in ladder pattern脐膨出：projection of the umbilicus膨隆的：protuberant舟状腹：scaphoid abdomen,妊娠纹：,striae gravidarumstriae of pregnancy静脉曲张：varicose veins; dilated tortuous veins；varicoaty可见胃蠕动：visible gastric peristalsis,3,Inspection：,1. Inspection reveals visible peristaltic waves passing from left to right across the upper abdomen.2. Findings on inspection are a distended abdomen covered by tense, shiny skin.3. ln the upper abdomen, dilated tortuous veins are seen in which the blood flows upwards,4,Palpation：,板样强直:board-like rigidity肝脾肿大：hepatosplenomegaly肝肿大：hepatomegaly；enlargement of the liver腹壁松弛：lax abdominal wall,墨菲(氏)征：,Murphys sign肌卫：muscle guarding反跳痛：rebound tenderness强直：rigidity脾肿大：splenomegaly;enlargement of the spleen压痛：tenderness,5,Palpation：,1. Rebound tenderness and board-like rigidity of the abdominal musculature are present in all abdomen2. The patient has a palpable loop of thickened bowel in the left lower quadrant3. A firm tumor mass, about 3 cm in diameter, is felt 4 centimeters below the costal margin at the external margin of the right rectus muscle,6,Percussion：,浊音：dullness移动性浊音:shifting dullness鼓音：tyrnpanitic resonance；1. Percussion of the abdomen demonstrates tympany throughout2. There is no shifting dullness3. On percussion there is dullness in the flanks and tympanitic in the middle,7,Auscultation：,浊音：dullness肠鸣：Borborygmi击水声：splashes肠鸣音：bowel soundsperistaltic sounds气过水声：gurgling；borborygmus of bubbling quality振水声：succusion sound；clapotage；clapotement,8,外展：abduction指端肥大：acromegaly内收：adduction关节强硬:ankylosis髁关节强硬：ankylopodia前屈：anteflexion撕脱：avulsion,胼胝：,callus杵状指：clubbing； clubbed finger骨性强直：bony ankylosis,六、,Extremity and spine,9,褥疮：decubitus；bedsore脊柱畸形：deformity of spine背侧屈曲：dorsiflexion伸直：extension屈曲：flexion前屈：forward bending膝内翻：genu varum; bowleg膝外翻：knock-knee; genu valgus脊柱后凸（驼背）：kyphosis；rachiocyphosis侧弯：lateral bending；脊柱前凸：lordosis,10,跛行：,limping；limp脊柱前侧突：lordoscoliosis平足：pes planus; flat foot足外翻：pes valgus足内翻：pesvarus凹陷性水肿：pitting (brawny) edema多指（趾）：polydactylia旋前：pronation脊柱侧凸：scoliosis旋转：rotation脊柱后侧凸：scoliokyphosis,11,脊柱左侧凸：scoliosis with a convexity to the left side瘘管形成：sinus tract formation关节僵硬：stiff-joint背部僵硬：stiffness of the back旋后：supination并（指）趾：syndactyly腹侧屈曲：ventriflexion垂腕：wrist drop,12,感觉异常：perverted sensation；paresthesia指端感觉异常：acroparesthesia痛觉缺失：alganesthesia对侧感觉：allochiria触觉迟钝：amblyaphia感觉丧失：anesthesia实体觉丧失：astereognosis味觉迟钝：amblygeustia束带状感觉：cincture sensation;girdle sensation；zonesthesia,七、Nerve and Muscle,13,蚁走感：creeping sensation；formication平衡感：equilibrium sense； static sense味觉：gustatory sense；taste sense感觉减退：hypoesthesia；hyperesthesia运动觉：kinesthetic sensations冷幻觉：paradoxical cold sensations压觉：pressure sense；姿势觉：posture sense,14,本体感觉:proprioceptive sense；温觉:sensations of warmth；thermic sense空间觉:space sense,实体觉:stereognostic sense紧张感觉:strain sensations触觉:tactil sensations麻刺感:tingling震动觉:vibratory sense,15,交叉性瘫痪：alternate paralysis麻醉后麻痹：anesthesia paralysis联合麻痹：association paralysis 延髓性麻痹：bulbar paralysis扑翼样震颤：asterixis,无力性延髓麻痹：,astheno-bulbospinal paralysis；bulbospinal paralysis,手足徐动症：,athetosis,手足搐搦：,tetany,16,共济失调：ataxia产伤麻痹：birth paralysis行走徐缓：bradybasia中枢性麻痹：central paralysis舞蹈样运动：choreiform movement同向性麻痹：conjugate paralysis；symparalysis面神经麻痹：facial paralysis弛缓性麻痹：flaccid paralysis全身性麻痹：general paralysis；general paralysis of the insane偏瘫：hemiplegia,17,不全麻痹：incomplete paralysis；paresis小儿麻痹，脊髓灰质炎：infantile paralysis不随意运动：involuntary movement单瘫：monoplegia肌纤颤：muscular fibrillation肌阵挛：myoclonus麻痹：paralysis截瘫：paraplegia,18,跟腱反射：achilles tendon reflex肛门反射：anal reflex股二头肌反射：biceps femoris reflexes肱二头肌反射：biceps jerk reflexes拥抱反射：clasping reflex；embrace reflex；Moros reflex结膜反射：conjunctival reflexes角膜反射：corneal reflex咳嗽反射：cough reflex提睾反射：cremasteric reflexes光反射：light reflex瞳孔反射：pupillary reflex,19,跟腱反射：achilles tendon reflex肛门反射：anal reflex股二头肌反射：biceps femoris reflexes肱二头肌反射：biceps jerk reflexes拥抱反射：clasping reflex；embrace reflex；Moros reflex结膜反射：conjunctival reflexes角膜反射：corneal reflex咳嗽反射：cough reflex提睾反射：cremasteric reflexes光反射：light reflex瞳孔反射：pupillary reflex,20,Blood：,红细胞计数：,red blood cell count血红蛋白定量分析：measurement ofhemoglobin红细胞比积：hematocrit(Hct)白细胞计数：white blood cell count白细胞分类计数：white blood cell differential count嗜酸粒细胞计数：eosinocyte count平均红细胞容积：mean corpuscular volume(MCV),Lab examination,21,平均红细胞血红蛋白含量：mean corpuscular hemoglobin (MCH)平均红细胞血红蛋白浓度：mean corpuscular hemoglobin concentration(MCHC)平均红细胞直径：measurement of red cell diameter网织红细胞计数：reticulocyte count红细胞形态观察：morphologic observation of red blood cell巨红细胞：megalocyte,22,球形红细胞：spherocyte椭圆形红细胞：elliptocyte靶形红细胞：target cell镰形红细胞：sickle cell棘形红细胞：acanthocyte泪滴状红细胞：cacryocyte裂片细胞：schistocyte口形红细胞：stomatocyte皱缩红细胞：crenocyte低色素性小红细胞：hypochromic microcyte,23,嗜碱性点彩红细胞：basophilic stippling cell有核红细胞：nucleated erythrocyte缗钱状形成：rouleaux-formation染色体小体：Howell-JoUy bodies卡波氏环Cabots ring红细胞沉降率：erythrocyte sedimentation rate(ESR),24,Bone Marrow：,原粒细胞：Myeloblast早幼粒细胞：Promyelocyte中幼粒细胞：Myelocyte晚幼粒细胞：Metamyelocyte杆状核粒细胞：band form多形核粒细胞：polymorphonuclears中性粒细胞：neutrophil嗜碱性粒细胞：basophil嗜酸性粒细胞： eosinophil,25,原红细胞：Pronormoblast早幼红细胞：basophilic pronormoblast中幼红细胞：polychromatophilic normoblast晚幼红细胞：orthochromatic normoblast原淋巴细胞：lymphoblast幼淋巴细胞：prolymphocyte淋巴细胞：lymphocyte原单核细胞：monoblast幼单核细胞：promonocyte单核细胞：monocyte,26,原浆细胞：plasmablast幼浆细胞：proplasmacyte浆细胞：plasma cell网状细胞：reticular cell原巨核细胞：megakaryoblast幼巨核细胞：promegakaryocyte颗粒巨核细胞：granular megakaryocyte产血小板颗粒细胞：platelet-producingmegakaryocyte裸核巨细胞：”bare-nucleus form of megakaryocyte,27,血小板计数：platelet count出血试验：bleeding time血小板粘附性试验：platelet adhesivenesstest血小板聚集性试验：platelet aggregation test血块收缩定量测定：clot retraction quantitative assay凝血时间：coagulation time复钙时间：recalcification time复钙时间交叉试验：cross test of recalcification time,28,活化凝血时间：activated coagulation time白陶土部分凝血活酶时间：kaolin partial thromboplastin time（KPTT）KPTT纠正时间：correction test of KPTT凝血酶原消耗试验：prothrombin consumption test凝血酶原生成试验：Biggs thromboplastin generation test简易凝血活酶生成试验：simple thromboplastin generation test,29,尿素氮测定：urea nitrogen assay肌酐测定：creatinine assay尿酸测定：uric acid assay氨基酸氮测定：amino acid nitrogen assay内生肌酐清除试验：endogenous creatinine clearance test 尿素清除试验：urea clearance test酚红排泄试验：phenolsulfonphthalein exctetion test对氨马尿酸清除试验：paraaminohippurate clearance test;,30,谷丙转氨酶：glutamic pyruvic transaminase谷草转氨酶：glutamic oxalo-acetic transaminase血清精氨酰琥珀酸裂解酶：serum argino succinatelyase血清谷氨酸脱氢酶：serum glutamic dehydrogenase血清山梨醇脱氢酶：serum sorbitol dehydrogenase血清鸟嘌呤酶：serum guanine deaminase,31,血清碱性磷酸酶：serum alkaline phosphatase血清谷氨酰转肽酶：serum gamma glutamyltranspeptidase血清,5- 核苷酸酶：serum 5-nucleotidase,血清亮氨酸氨基肽酶：,serum leucine aminopeptidase,血清异柠檬酸脱氢酶：,serum isocritrate dehydrogenase,血清腺苷脱氨酶：,serum adenosine deaminase血清单胺氧化酶：serum monoamine oxidase,32,血清胆碱酯酶：serum cholinesterase血清蛋白：serum protein血清白蛋白：albumin血清球蛋白：globulin麝香草酚絮状试验：thymol flocculation test麝香草酚浊度试验：thymoturbidity test硫酸锌浊度试验：zinc sulfate turbidity test血清胆红素：serum bilirubin黄疸指数：icteric index,33,Physical examination of a healthy person,34,He is a middle developed and well-nourished 40 year-old man with blood pressure of 17. 3/10. 7KPa，a pulse of 80/min and respiration of 16/min. Active position. Free movement. There were no purpurae, jaundice or scar on his skin,他是一位发育中等，营养较好的40岁男性。血压17.3/10.7KPa，脉搏80次/分，呼吸16次/分。自动体位。活动自如。皮肤无紫癜、黄疸或疤痕,General conditions,35,The shape of his head was normal. The hair was black and lustrous. The quality and distribution of axillary and pubic hair were normal.,头颅外形正常，毛发黑、有光泽。腋毛和阴毛形状和分布正常。,Head,36,Eyes :,There was no injection on the conjunctivae. Sclerae were not icteric ( anicteric). The pupils were round and equal, reactive well to light and accommodation,眼：结膜不充血，巩膜无黄染。两瞳孔等大、等圆。光反射和调节良好,37,Ears :,No abnormal pinnae ( = auricles). The external canals were clear without pus. The tympanic membranees showed good light reflex, and neither injection nor perforation. Noraml hearing. No tenderness over the mastoids,耳：耳廓正常。外耳道清洁，无脓液。鼓膜光反射良好，无充血、穿孔。听力正常。乳突无压痛。,38,Nose：,The nose showed no deformity or flaringof the alae nosi. No bloody or pusy discharge. The turbinates were not hypertrophic. There was no diviation of the septum. No tenderness over the sinuses. The nasolabial grooves wereequal bilaterally,鼻：无畸形或鼻翼扇动。鼻腔无血性或脓性分泌物。鼻甲不肥大。鼻中膈不偏移。副鼻窦无压痛。两侧鼻唇沟对称。,39,Mounth：,The lips were red and moist. No cyanosis. All teeth were present and good. The tongue was thinly coated with normal papillae. No petechiae and no ulcer in the mucosa. No injection on the pharynx. The tonsils were not hypertrophic,口：口唇红润，无紫绀。牙齿完好。舌苔薄，乳头正常。粘膜无出血点或溃疡。咽不充血，扁桃体不肥大,40,Neck :,Supple. The thyroid was not enlarged. The trachea was in the midline. Flat neck veins. Carotid pulsations were not marked,颈：软，甲状腺不肿大。气管居中。颈静脉平坦，无明显颈动脉搏动。,41,Breast :,(Man) The breasts were male without masses or discharge.(Female) The breaste were normal female and pendulous, devoid of palpable masses. The nipples showed not discharge and retraction,乳腺：男：正常男性乳房，无肿块及分泌物。女：正常女性乳房，悬垂状，未触及肿块。乳头无分泌物，不凹陷。,Chest,42,Inspection: The PMI ( point of maximum impulse) was in 5th left intercostal space inside of the mid clavicular line and not diffusePalpation: The PMI was equal to inspection. No thrill,望诊：心尖搏动位于左锁骨中线内侧第5肋间隙，不弥散。触诊：最强搏动点与望诊一致。无震颤。,Chest: Heart,43,Percussion:The heart percussed normal in size. Picture as follows,叩诊：心脏浊音界大小正常，如下图所示：,Chest: Heart,To midmost line,intercostal,To midmost line,1.0cm,II,2.0cm,1.5cm,III,3.5cm,2.0cm,IV,5.0cm,44,Auscultation: The heart sounds were strong & no splitting. A rate of 80/ nun. Cardiac rhythm was regular. No pathological murmurs. Only grade I /IV ,soft systolic murmur at the apex,Chest: Heart,45,Inspection: The breathing was mainly thoracic in type. The chest movement was good. The rhythm was equal (regular) Palpation: The fremitus was equal bilaterallyPercussion: Both lungs were resonant. The right lower limits at the 9th costa and the left at the 10th posteriorlyAuscultation: Breath sounds were clear without pathological sounds or rales,Chest: Lung,46,Inspection： Flat. No scar and no dilated vein seenPalpation: Soft. No tenderness. No palpable masses or organomegalyPercussion: Tympanitic resonance. No shifting dullnessAuscultation: Normal bowel sounds ( No increased or decreased bowel sounds),Abdomen,47,Extremities ( Limbs ):Free movement. No abnormality N. S. : ( Neural system)Physiological reflexes were present without pathological reflexesGenitourinary system: (Man)：Normal adult external genitalia of man. No swelling testes or hydrocele Digital examination not done(Feman): Normal, married vulva. Vagina and uterus were not examined,Other systems,48,Complete History,49,Name:,Li ping,Sex:,Male,Age:,25ys,Race:,Han,Occupation:,worker,Married status:,married,Address:,No 2, Feng Yang road, Bengbu,Date of admission:,March 15th, 1987,Date of record:,March 15th, 1987,Offerer of medical history:,patient himself,Reliability of history,: reliable,Basic Information,50,C.C. (=Cheif complaint):,Palpitation, breathlessness and edema fora week,P. I. ( = Present illness) :,The patient came in this morning with gradually increasing palpitation and dyspnea of a week duration. He cant recline,had to sleep on three pillows or to sit up in bed to catch his breath. In recent week, loss of appetite, urination decreased, only twice daily passing about 600ml. Edema bacame increasingly apparent in the lower limbs.,51,Arthralgia is often present in the last 10 years, especially in the knees, ankles and shoulder joints when its cold. Antirheumatic therapy (included Aspirin and prednison etc. ) was given forRheumatic fever“ 8 years ago.Rheumatic heart disease was diagnosed when he was admitted to our hospital about one year ago,52,Operative history:,Tonsillectomy was performed for chronic tonsillitis before 5 years.,Infectious history,(Contagious history) :He had contact with patient who had pulmonary tuberculosis tor a month abouthalf a year ago.,Allergic history :,He had no history of allergy to drugs.,53,Respiratory system:,No history of hemoptysis, frequent coughor fever,Circulatory system (Cardiovascular system):,(He had) no palpitation and edema a year ago,Alimentary system (= Digestive system) :,No sour regurgitation, stomachache or hematemesis,Genitourinary system,:No polyuria, urgency of micturition, urodynia or markedly decreased sexual desire (= urge).,54,Hematopoietic system:,There was no history of subcutaneous bleeding or anemia,Endocrine system:,Drinking and eating were within normal. No tremor or excessive sweating,Kinetic system ( Locomotor system of skeletal system):,No restriction of the limb movement,Neural system:,No headache, paralysis or aphasia,55,Personal history:,He has been living here since he was born. Smokes an average of a packet of cigarettes daily for the past 7years. Didnt drink. He was not exposed to toxic substances in the couse of his work.He got married at the age of eighteen. He has two children,Family history:,His parents are living and well. There is no hypertension or diabetes in his family. His wife and two childrenare in good health. Grandfather died from uremia in 1982,56,Physical Examination,He is a well developed, poorly nourished with Bp 17.3/ 10. 7KPa,P 110/min and R 28/min. Orthopnea. Slight cyanosis in the lips. No sign of bleeding or anemia on the skin. Superficial lymph nodes were not palpable,57,Head：,Examinations of the hair, eyes, ears, nose and throat showed no visible abnormality,Neck：,The neck was supple. No palpable thyroid gland. The trachea was not deviated,Physical Examination,58,Lungs:Inspection：,The chest was flat with normal contour. The respiration was accelerated mildly,Palpation：,The fremitus was equal without exaggeration or diminution,Percussion：,The chest was clear to percussion,Auscultation：,There were no rales,rhonchi, wheezes or rubs present,Physical Exam: Chest,59,Heart:Inspection：,The apical beat was diffused and visible in the 4th and 5th interspace out of the left midclavicular line,Palpation:,Apex beat was marked and diffuse. Systolic thrill at the apex,Percussion：,The left border of cardiac dullness was displaced futher to the left upper and about 2cm beyond the left midclavicular line at the 4th interspace.,Physical Exam: Chest,60,Heart:Auscultation：,Cardiac rhythm was regular at 110 per minute. There were a systolic murmur IV / W, harsh and a grade II / VI diastolic murmur, rumbling at the apex. No obvious pathological murmurs at other valve areas,Physical Exam: Chest,61,Inspection:,slight protuberance. No dilated vein,Palpation:,Soft. Liver was 3 fingerboads below the right costal margin and was soft, smooth and painful to pressure. Hepato-jugular reflux was positive. No palpable spleen or other masses,Percussion:,Shifting dullness was negative,Auscultation:,Borborygmi were mildly diminished,Physical Exam: Abdomen,62,Extremities:,Marked pitting edema from the feet to scrotum,Neural system:,Pathological reflexes were not elicited.,Genitourinary system:,Examination of genitalia was not done.,Physical Exam: Other systems,63,Primary diagnosis:,Rheumatic heart disease,mitral insufficiencymitral stenosischronic heart failuregrade I / V heart dysfunction,64,
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