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1、一般检查generalexamination一,性别sex男Male女Female二,年龄age三,生命体征:vitalage体温bodytemperaturea,口测法oralmeasurementb,肛测法archosmeasurementc,腋测法axilmeasurement呼吸respirations脉搏pulse血压bloodpressure四,发育development体型(Habitus):无力型(asthenictype)、超力型(sthenictype)、正力型(orthosthenictype)五,营养stateofnutrition:良好well、中等moderatel
2、ty。肥胖(Obesity)、消瘦slake六,意识consciousness:嗜睡drowsiness、意识模糊cloudingofconsciousness昏睡hyponody、昏迷coma(浅,中,深度),谵妄acuteconfusionalstate七,语调tone语态voice八,面容facialfeatures急性病容faceofacuteill,慢性病容chronicdiseaseface,贫血面容anemicface,甲亢面容hyperthyreosisfeature,粘液性水肿面容myxedemaface,二尖瓣面容mitralfacies,满月脸面容moonface,肢端肥
3、大症面容acromegalyfacies,伤寒面容typhoidface,病危面容,Hippocratesface表情expression正常normal,淡漠indifference烦躁不安dysphoria,痛苦suffering忧郁gloom九,体位positiona,自主体位activepositionb,被动体位passiveposition极度意识衰竭和丧失culminationconsciousnessfailureandlossc,强迫体位compulsiveposition强迫坐位(端坐呼吸)compulsivesittingposition(orthopnea)十,姿势po
4、sture十一,步态gaitaa,蹒跚步态waddlinggaitb,醉酒步态drinkenmangaitc,共济失调步态ataxicgaitd,慌张步态festinatinggaite,跨閱步态steppagegaitf,剪刀步态scissorgaitg,间歇性跛行intermittentgait十二,皮肤skin1,颜色skincolora,苍白pallor贫血anaemiab,发红redness发热feverc,发绀cyanosis缺氧hypoxiad,黄染stainedyellow肝病liverdiseasee,色素沉着pigmentation肝病liverdiseasef,色素脱失c
5、oloringmaterialloss白化症albinismus2,湿度moisture干燥dry脱水dewat湿润moist休克shock3,弹性elasticity4,皮疹skineruptiona斑疹maculateb玫瑰疹roseolac丘疹papules;d斑丘疹maculopapulate,e荨麻疹urticaria5,脱屑scales6赘生物vegetation7,皮下出血subcutaneoushemorrhagea瘀点petechiab瘀斑ecchymosisc紫癜purpurad血肿hematome8,蜘蛛痣spiderangioma肝掌liverpalms9,水肿edem
6、a10,皮下结节subcutaneousnodules11,瘢痕scar12,毛发hair13,淋巴lymph体检(胸腹部)[Physicalexamination(chestandbelly)]1、肋骨和软组织[ribsandsofttissure]·胸骨上切迹[suprasternalnotch]·浮肋[freeribs]·胸壁[chestwall]·扁平(桶状、佝偻、漏头、鸡)胸[flat(barrel,rachitic,funnel,pigeon)chest]·皮下气肿[subcutaneousemphysema]·捻发音[Crepitus]·软组织损伤[softtissueinjur
7、y]·肋骨畸形[abnormalityoftheribs(ribdeformity,costalanomaly)]·肋软骨畸形[costochondraldeformity]·肋软骨增生[costalcartilagehyperplasia]·肋下切口[subcostalincision]·肋间隙宽(窄)[wide(narrow)intercostalspace]2、乳房[breast]3、肺[l