北京积水潭医院体格检查英文教学病例

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1、T36・5°C,P72/min,R18/min,BP120/80mmHg・Hewaswelldevelopedandmoderatelynourished.Activeposition.Hisconsciousnesswasclearandhisspeechwasfluent・Hewascooperativeintheexamination.Hisskinwasnotstainedyellow.Nocyanosis・Nopigmentation.Noskineruption.Nopurpura・Spiderangiom

2、aandliverpalmwerenotseen.Nopittingedema・Superficiallymphnodeswerenotfoundenlarged.HeadSkull:Hairwasblack,welldistributed.Nodeformities.Noscars・Notenderness.Eye:Visualfieldswasnormal.Bilateraleyelidswerenotswelling.Noentropion.Noptosis.Conjunctivawasnotcongestive

3、,andwasnotpallortoo.Sclerawasanicteric.Eyeballswerenotprojectedordepressed・Movementwasnormal.Bilateralpupilswereroundandequalinsize・Directandindirectpupillaryreactionstolightwereexistent.Ear:Bilateralauriclesweresymmetricandofnomasses・Nodischargeswerefoundinexte

4、rnalauditorycanals.Notendernessinmastoidarea・Auditoryacuitywasnormal.Nose:Noabnormaldischargeswerefoundinnasalcavity.Septumnasiwasinmidline.Nonaresflaring.Noepistaxis・Notendernessinnasalsinuses・Mouth:Oralmucousmembranewasnotcyanosis.Tonguewasinmidline.Tonsilswer

5、enotenlarged・Neck:Symmetricandofnodeformities・Nomasses・Thyroidwasnotenlarged・Tracheawasinmidline・Vascularmurmurcannotbeheard・ChestThethoraciccagewassymmetrical・Nodeformities・Notenderness・SuperficialVeinscouldnotbeseeneasily.Nosubcutaneousemphysema・Intercostalspa

6、cewasneithernarrowednorwidened・Lungs:Respiratorymovementwasbilaterallysymmetricwiththefrequencyof18/min・diaphragmaticrespirationwasexistent.Thoracicexpansionandtactilefremitusweresymmetricbilaterally・Thedegreeofexcursionoflowerboundwas6cm.Nopleuralfrictionfremit

7、us.Resonancewasheardduringpercussion.Noabnormalbreathsoundwasheard・Nowheezes・Norales・Heart:Nobulgeandnoabnormalimpulseinprecordialarea・Thepointofapicalimpulsewaspalpableinthe5thintercostalspaceand0.5cminsideoftheleftmidclavicularlineandnotdiffuse・Therewasnothril

8、l.Borderoftheheartwasnormal.Thecardiacdullnesswasasfollows.Heartratewas72/min・Heartsoundswerestrongandnosplitting.A2=P2・Cardiacrhythmwasregular.Nofrictionsound.pathol