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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 ......
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 ......
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