北京积水潭医院体格检查英文教学病例.doc

T 36.5℃, P 72/min, R 18/min, BP 120/80mmHg. He was well developed and moderately nourished. Active position. His consciousness was clear and his speech was fluent. He was cooperative in the examination. His skin was not stained yellow. No cyanosis. No pigmentation. No skin eruption. No purpura. Spider angioma and liver palm were not seen. No pitting edema. Superficial lymph nodes were not found enlarged. Head Skull: Hair was black, well distributed. No deformities. No scars. No tenderness. Eye: Visual fields was normal. Bilateral eyelids were not swelling. No entropion. No ptosis. Conjunctiva was not congestive, and was not pallor too. Sclera was anicteric. Eyeballs were not projected or depressed. Movement was normal. Bilateral pupils were round and equal in size. Direct and indirect pupillary reactions to light were existent. Ear: Bilateral auricles were symmetric and of no masses. No discharges were found in external auditory canals. No tenderness in mastoid area. Auditory acuity was normal. Nose: No abnormal discharges were found in nasal cavity. Septum nasi was in midline. No nares flaring. No epistaxis. No tenderness in nasal sinuses. Mouth: Oral mucous membrane was not cyanosis. Tongue was in midline. Tonsils were not enlarged. Neck: Symmetric and of no deformities. No masses. Thyroid was not enlarged. Trachea was in midline. Vascular murmur can not be heard. Chest The thoracic cage was symmetrical. No deformities. No tenderness. Superficial Veins could not be seen easily. No subcutaneous emphysema. Intercostal space was neither narrowed nor widened. Lungs: Respiratory movement was bilaterally symmetric with the frequency of 18/min. diaphragmatic respiration was existent. Thoracic expansion and tactile fremitus were symmetric bilaterally. The degree of excursion of lower bound was 6cm.No pleural friction fremitus. Resonance was heard during percussion. No abnormal breath sound was heard. No wheezes. No rales. Heart: No bulge and no abnormal impulse