1、A. GENERAL EXAMINATION/VITAL SIGNS(一般檢查)1. Introduce yourself to patient, usually last name and title and have a little conversation to relax the patient and to judge mental state.2. Wash hands before starting examination Preferably, this should be done in view of the patient.3. Patient is seated in

2、 a chair4. Palpate radial (wrist) Pulses for at least 30 seconds and recordThe examiner places the pad of his index, middle and ring fingers over the radial artery. If properly done, the examiner should be able to feel the artery pulsating under the examiner fisn gertips. The radial pulse may be mea

3、sured for 30 seconds, then the pulse perminute can be found by multiplying by two. Attention should also be paid to the rhythm. The examiner should not use his thumb to palpate any pulse.5. Palpate both radial (wrist) pulses simultaneously for symmetry for at least 30 seconds6. Measure respiratory r

4、ate for 30 seconds and recordThe examiner unobtrusively measures patient ress piratory rate. This may be accomplished by the examiner leaving his hands on the patient s wrists for another 30 seconds after measuring the radial pulses so the patientdoes not realize that the examiner is watching him br

5、eathe. The depth and rhythm should also be noticed. The respiratory rate can also be measured during the back exam.7. Measure blood pressure on right armBlood pressure may be measured with the patient in a sitting or lying position. In each position, the artery in which the blood pressure is to be m

6、easured should be at the level of the heart (at the level of the fourth intercostal space in the sitting position; at the level of the middle axillary line in the lying position). The patient resting on a smooth table or supported by the examiner, and slightly flexed at the elbow.8. Place cuff in co

7、rrect location 2-3 cm above the atecubital creaseThe examiner secures the blood pressure cuff snugly over the upper, arm so that one finger can be admitted under the cuff. The cuff should be positioned 2 3 cm above the antecubital crease or elbow joint. Put the middle of the cuff over the brachial a

8、rtery.9. Palpate brachial arteryThe examiner can locate the brachial artery which lies slightly medial to the tendon of the biceps muscle in the antecubital fossa. The mercury column on the manometer dial should be properly calibrated with the pointer at “ 0 ” before the cuff is inflated (i. e. , al

9、l the air should be pressed out of the cuff before it is inflated).The stethoscope is placed firmly over the brachial artery. The examiners inflates the cuff slowly but steadily. Until the brachial artery pulse disappears. Then he continues to inflate cuff 2.6 4.0kPa (2030 mmHg higher, generally to

10、about 21.3kPa (160mmHg).10. Measure blood pressure over brachial artery twice and record the lower reading Deflate the cuff slowly at the rate of about 0.26kPa (2mmHg) Per second. The number where the examiner hears the first pulse sound is the systolic pressure. The pulse sound will waken and then

11、disappear. The number where the pulse sound disappears is the diastolic pressure. If the difference between weakening of the sound and its disappearance is 2.6kPa (20mmHg) or greater, the examiner should record these two numbers. The cuff must be completely emptied with the pointer at“ 0” before it

12、is reinflated. The same procedure may be followed for asecond measurement of B. P. in the same or opposite arm. The lower pressure is recorded as the patient pressure. After finishing the measurement, the examiner deflates and rolls up the cuff, leans the manometer over a little so the mercury colum

13、n disappears, closes the mercury column switch, puts the balloon in order, and closes the manometer.B. HEAD AND NECK(頭頸部)Skull11. Palpate and observe scalp (parting hair, and observing hair density, color, lustre and distribution)The examiner palpates the entire skull using both hands and simultaneo

14、usly examines symmetrical areas. The examiner parts the hair to observe the scalp, noting any scaliness, deformities, lumps, tenderness, lesions or scars. The examiner also observes the density, color, lustre and distribution of the hair.Eyes12. Visual screening(: omitted )13.Observe cornea, sclera,

15、 conjunctiva and lacrimal puncta by gently moving lower eyelids down.Cornea Examination-With oblique lighting inspect the cornea for opacities, foreign bodies etc. Inspect lower palpebral, fornical, bulbar conjunctiva and sclera. Ask the patient to look up as you depress lower eyelid with your thumb

16、 exposing lower palpebral, fornical, bulbar conjunctiva and sclera. Inspect the conjunctiva and sclera for color, and note the vascular pattern against the white scleral background.Lacrimal sac examination by digital compression for nasolacrimal duct obstruction-Ask the patient to look up.Press on t

17、he lower lid close to the medial canthus, just inside the rim of the bony orbit. You are thus compressing the lacrimal sac. Look for fluid regurgitation out of the puncta into the eye. Avoid this test if the area is inflamed and/or tender(Figure 2-3).14. Observe sclera and bulbar conjunctiva by gent

18、ly elevating upper eyelid while patient looks down, Instruct the patient to look down.Raise the upper eyelid slightly so that the eyelashes protrude, and then inspect sclera and bulbar conjunctiva. Be gentle so patient doesn t tea-4r )(.F igure 215. Check crn upper division: raised eyebrows, wrinkle

19、 forehead or forced eyelid closing Nerve is the facial nerve.Upper facial nerve-To test the upper division, the examiner observes the patient s forehead and pthen asks patient to raise his eyebrows, wrinkle his forehead and close his eyes. When the patient closes his eyes tightly, the examiner attem

20、pts to pry them open to determine the strength. If one side of peripheral upper facial nerve is impaired (nuclear or below nuclear) the patient s ability to wrinkle forehead decreases andcan t close his eye on the affected side. If one side of central nerve is impaired, the patienteyes and wrinkle f

21、orehead will not be influenced because the upper facial muscles are controlled by both sides of the corticocerebral motor area.16. Evaluate extraocular muscle function in both eyes in 6 directions (left, upper left, and lower left, right, upper right, lower right)The examiner positions himself in fr

22、ont of the patient and requests that, without moving the patientpatient s eyes follow examiners finger or a penctiiol nins .s Fixi ndgireerc or pencil should be 3040 cm awayfrom patient s head. The usual format is from mid left, to upper left and then down and then to the right (Figure2-5).17.Observ

23、e pupillary direct response to lightThe examiner asks the patient to look forward and shines a penlight or the light of the ophthalmoscope into each pupil in turn. He should avoid shining the light into both pupils simultaneously and should ask the patient not to focus on the light source.When obser

24、ving the direct pupillary response to light, the examiner will shine the light into one eye and inspect for pupillary constriction in the same eye. The pupillary constriction is reversed as soon as the light moves away. Use the same method to check the other eye.18.Observe pupillary consensual respo

25、nse to lightWith the same method as obove, the examiner shines the light into one eye and inspects for pupillary constriction in the opposite eye OR observes pupillary dilation in opposite eye as light is extinguished.19.Check for convergence and accommodationThe examiner, positioned in front of the

26、 patient, asks the patient to look into the distance and then at his finger.The examiners finger starts from 1 meter away, the examiner will immediately move 5 cm away from the bridgeof the patient nso se. The examiner is observing the patient esy es for:a) pupillary constriction, and b) convergence

27、 (the coordinated movement of both eyes toward fixation at the same near point as the patient focuses on a near object). Accommodation includes convergence and pupillary constriction as the patient focuses on the near object. The accommodation will vanish when cranial nerve is damaged.Ears and Tempo

28、romanaibular joint30. Observe and palpate the auricles and observe postauricular regions bilaterallyThe examiner pulls and palpates the auricles (outer ears), palpates the preauricular(in front of) and posterior auricular regions (behind the ears) bilaterally. Tenderness usually indicates inflammati

29、on.31. Palpate temporomandibular joint for tenderness and swelling (omitted)The temporomandibular joint (TMJ) is anterior to the external auditory canal of the ear. Examine for swelling and tenderness.32. Feel the movement of the TMJ with index fingers inside patientr over joint s ears oTo palpate t

30、he TMJ joint, the examiner presses both sides simultaneously with one or two fingers and asks the patient to open and close his mouth, or the examiner places his index finger in the patient forward (anteriorly), asking the patient to open and close his mouth. (omitted )Nose38. Inspect and palpate ex

31、ternal nose for malformation and inflammationBegin by examining the external nose. The examiner faces the patient. Observe skin color and shape of nose any palpate for and loss of structure or tenderness from bridge, to tip, to wings of nose.39. Observe nasal vestibule without otoscopeA view of the

32、nasal cavities is obtained by tilting the patient s head back and elevating the tithe thumb. The examiner should use a light. The nasal vestibule contains the nasal hairs, or vibrissae. Pay attention to any folliculitis, fornicles, or deviated nasal septum.40. Turn the tip of the nose upwards and in

33、sert the tip of the speculum to inspect nasal vestibule and anteriorpart of nasal cavity for ulcer, crust, swelling, discharge, atrophy or perforation41. Test patency by inhaling through each nostril separately while the opposite nostril is held occluded (omitted )42. Palpate and/or percuss maxillar

34、y sinus for swelling and tendernessExamination of the paranasal sinuses is done more indirectly than other otolaryngeal procedures. The examiner cannot see into any of the sinuses. Palpation and percussion may be used over the maxillary sinuses. Simultaneous finger pressure over both maxillae will d

35、emonstrate differences in tenderness.43. palpate and /or percuss frontal sinus for swelling and tendernessThe frontal sinuses are palpated at the inner part of the upper border of the bony orbit by finger pressure directed upward toward the floor of the sinus where the sinus wall is thin. Tenderness

36、 may be elicited in this way. Swelling caused by tumors or retained secretions may cause a downward bulge in the floor of the frontal sinus. The frontal sinuses may also be percussed.Mouth, lips, Pharynx44. Observe lips, buccal mucosa, teeth, gums and tongueThe examiner inspects the lips, all surfac

37、es of the tongue, gums, roof of mouth, and the buccal mucosa (the tissue lining the cheeks) by asking the patient to open his mouth and by shining a light into the area to be examined. The examiner may use a tongue depressor to aid inspection.Lips-The healthy lips are wet and red in color, This is c

38、aused by a rich capillary network.Buccal mucoss-To examine the buccal mucosa it is necessaryt o shine a light into the patient mso uth. The healthy buccal mucosa is pink and smooth. The duct of the parotid gland opens onto the buccal mucosa opposite the upper second molar.Teeth-There are 32 teeth in

39、 the full adult dentition. The teeth are inspected for evidence of cavities and malocclusion.Gums-The gums should be inspected for the presence of swelling, bleeding or pigmentation.Tongue-The tongue is inspected for its shape, motion and ulceration.45. Observe the floor of mouthInspect the mouth fo

40、r pigmentation, hemorrhage or masses (ask patient to touch tip of tongue to roof of mouth). Generally, palpation is not done in a normal exam. However, if a mass is found on the floor of the mouth, palpation is important. If neoplasms are suspected, they are detectable only by palpation. Also, the s

41、ubmaxillary, salivary ducts may contain calculi that are best felt by palpation. Bimanual examination, using one gloved finger inside the mouth and the other hand outside, is best.46. Inspect the posterior structures of the mouth for congestion, swelling or pus, position of uvula, and elevation of t

42、he palate.Press a tongue blade, positioned over middle 1/3 of tongue, firmly down to inspect tonsils, anterior and posterior tonsillar pillars, and posterior pharynx. The examiner can observe the elevation of the palate as the patient says “ ah ” . Simultaneously, hoarseness can be detected. The con

43、scious patient should not be gagged.47. Observe midline protrusion of the tongue (cr n )The examiner asks patient to stick out his tongue and observes midline protrusion, atrophy and fibrillation.48. Show teeth, puff out cheeks or purse lips (lower division of cr n ) (omitted )49. Test contraction o

44、f masseter (jaw) muscle or forced opening of mouth against resistance (motor division cr n ) (omitted )50. Test for facial sense of pain and touch (must check at least 2 out of 3 sensory divisions for cr n ) (omitted )51. Expose neck correctly to observe appearance and skin of neckThe patient sits u

45、pright.Ask patient to expose neck entirely when the neck is to be examined. All clothing should be removed as far as the axillae, which allows the whole neck to be seen in relationship to the thorax and permits inspection and palpation of the supraclavicular fossae.Observe the appearance of the skin

46、 of the neck. The examiner should observe the neck for symmetry and pay attention to its appearance. Abnormal lumps and pulsations may be seen in this area. Generally, the thyroid cartilage will show convexity in a male. The examiner inspects the skin of the neck for erythema, spider angioma, infect

47、ions, ulcers or scars.Facial and cervical lymph nodesPalpate lymph nodes bilaterally. The examiner may be positioned in front of or behind the patient and examine the lymph nodes with the pads of his index and middle fingers. This should be done slowly and carefully to make certain that there aren t

48、 any abnormalities present. It is bxeattmerin ife trh me oeves the skin over the underlyingtissue rather than move his fingers over the surface of the skin. The examiner may have the patient position hishead with his neck slightly flexed forward. The examiner palpates all nodes bilaterally.For palpa

49、tion of lymph nodes, be sure to keep the skin and muscles relaxed. If the lymph nodes are enlarged, note their location, size, number, hardness, mobility, tenderness, adhesion, fusion, swelling, fistula or scars (Figure 2-14).52. Palpate preauricular nodes (front of ears)53. Palpate post-auricular n

50、odes (back of ears)54. Palpate occipital nodes (base of skull)55. Palpate submaxillary nodes (by bending finger under patient s jaw)56. Palpate submental nodes (by bending fingeru nder patient s chin)57. palpate anterior cervical nodes (superficial group under mastoid and in front of sternomastoid m

51、uscle)58. Palpate posterior cervical nodes (behind sternomastoid muscle)59. Palpate supraclavicular nodes (by benidng finger above patient s collarbone)Thyroid gland60. Palpate and/or move thyroid cartilage with two fingers checking for malformation and movability61. Palpate thyroid in correct anato

52、mical location in front of or behind the patient with both hands.The lateral lobes of the thyroid curve posteriorly around the sides of the trachea and the esophagus. In addition, they are partially covered by the sternomastoid muscle.There are several different techniques for examining the thyroid

53、gland. Many examiners will palpate the thyroid gland both in front of and/or behind the patient. The examiner should identify the thyroid gland which lies across the trachea below the cricoid cartilage. (If the examiner has the patient flex his neck or turn his chin slightly toward the side to be ex

54、amined, it will secure the relaxation of the sternomastoid muscle, which is essential for adequate examination of the thyroid.)62. Palpate isthmus of thyroid with and without swallowing: using the pads of his fingers, the examiner feels below the cricoid cartilage for the isthmus of the thyroid glan

55、d. If examiner stands in front, he examines with his thumbs, from behind, with his index fingers. Examiner asks patient to swallow as he feels for the isthmus rising upward against his fingers. A good teaching point is that the thyroid gland is one of the few soft tissue structures in the neck that

56、moves with swallowing.63. Palpate thyroid gland (lobes) with and without swallowing Palpation from the front-The thyroid is displaced to one side by applying pressure with the thumb upon the thyroid cartilage. With the opposite hand, the dislodged lobe of the thyroid can now be palpated between the

57、thumb (held in front of the sternomastoid) and the 2nd and 3rd fingers (Placed behind the sternomastoid) This should be done before and during swallowing. The procedure is repeated for the opposite side (Figure 2-16). Palpation from behind-Procedure is similar to palpation from the front except the

58、thyroid cartilage is displaced with the 2nd and 3rd fingers. The thumb of the opposite hand is now behind the sternomastoid muscle and the 2nd and 3rd fingers are in front of it. (Figure 2-17).If thyroid is enlarged, notice its size, symmetry, hardness, surface, tenderness, nodules, thrills, bruits, etc. Carotid Artery64. Gently palpate carotid arteryWith the pads of his fingers, the examiner exerts gentle pressure on patient s carotid arteriethe neck on the inside edge of patient sste rnomastoid muscle. One should not palpate both carotids simultaneously as the pa