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
