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moderatelty。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posture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coloringmaterialloss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edema10,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[softtissueinjury]·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]乳房[breast]3、肺[lung]·呼吸缓慢(急促)[bradypnea(tachypnea)]·呼吸浅慢(深快)[hypopnea(hyperpnea)]·呼吸不规则[irregularrespiration]·点头呼吸[noddingbreathing]·端坐呼吸[orthopnea]·三凹征[retractionsignofthreefossae]·叹息样呼吸[sighingrespiration]·浅快[shallowandrapid]·呼(吸)气性呼吸困难[expiratory(inspiratory)dyspnea]·呼吸道烧伤(塌陷)[burn(collapse)ofrespiratorytract(airway)]·呼吸道阻塞[respiratorytractobstruction]·呼吸均匀(呼吸加深或加快)[eupnea(exaggeratedoraccleratedrespiratory)]·呼吸停止[apnea]·呼吸费力[respirationislabored]·语音(触觉)震颤[vocal(tactile)fremitus]·语颤相等(减弱、增强)[vocalfremitusisequal(diminished,accentuated)]·间接(直接)叩诊[mediate(immediate)percussion]·浊(实、鼓、清、过清、金属)音[dullness(flatness,tympany,vesicularresonance,hyperresonance,bell)]·移动范围[rangeofmovement]·呼吸音消失(减弱,增强)[absence(diminution,exaggeration)ofbreathsound]·呼吸音粗(清)[soundofbreath(SOB)isrough(clear)]·支气管(支气管肺泡,肺泡)音[bronchophony(bronchovesicularsound,vesicularsound)]·管状呼吸音[tubularbreathsound]·捻发音[crepitantrales]·爆裂音[crackles]·干(湿)罗音[dry(moist)rales]·细(中等、粗)罗音[fine(medium,coarse)rales]·呼(吸)气未罗音[end-inspiratory(expiratory)rales]·胸膜摩擦音[pleuralfrictionrub]·呼(吸)气延长[prolongedinspiratory(expiratory)]·高(低)调鼾音[sibilant(sonorous)rhonchi(sonorousrales)]·哨笛音[sibilantrales]·哮鸣音[wheezing]·小(中、大)水泡音[small(middle,big)bubbles]·支气管语音[bronchophony]·耳语音[whispered]·羊鸣音[egophony]·高(低)音调[high(low)-pitched]·两肺部(右背部)[overbothlungfields(rightback)]·两(左)肺底[overtheboth(left)lowerlung]·整个肺野[thewholelungfield]·左(右)上(下)肺[theleft(right)upper(lower)lung]·肺尖(底)[apex(base)oflung]4、心脏[Heart]心房心室室间隔房间隔主动脉瓣肺动脉瓣二尖瓣三尖瓣·用手掌(指尖)触诊心尖搏动[palpateapicalareawithpalmnumbness(fingertips)]·心前区隆起(凹陷)[precordialbulge(retraction)]·搏动弥漫(局限)[diffuse(local)pulsation]·负性搏动[inwardinpulse]·心尖搏动[apexbeat(apicalimpulse)]·剑突下搏动[xiphoideusalpulsaton]·抬举性心尖搏动[heavingapeximpulse]·心尖搏动最强点[pointofmaximalimpulse(PMI)]·锁骨中线[mid-calvicularline(MCL)]·肋间[intercostalspace(ICS)]·收缩(舒张)期震颤[systolic(diastolic)thrill]·心浊音界[theborderofcardiacdullnes]·心绝对(相对)浊音界扩大(缩小)[enlarged(diminished)absolute(relative)cardiacdullness]·叩诊心脏大小正常[heartsizeisnormalon(to)percussion]·心脏向左(右)扩大[cardiacdilation(enlargement)totheleft(right)]·第1(2、3、4)心音[S1(S2,S3,S4)]·第1心音增强(减弱,听不清)[firstheartsoundisexaggerate(decreased,muffled)]·生(病)理性杂音(分裂)[physiologic(pathological)murmur(splitting)]·生理性(固定、反常、逆)分裂[physiologic(fixed,paradoxical,reversed)splitting]·肺动脉瓣第2心音(=,)主动脉瓣第2心音[P2(=,)A2]·大炮音[connonsound]·心音消失[heartsoundisabsent(disapeared)]·心音增强(减弱)[accentuated(diminished)cardiacsound]·心音响亮(遥远)[cardiacsoundisloud(distant)]·收缩期(舒张期,连续性)杂音[systolic(diastolic,continuous)murmur]·收缩(舒张)前(中、晚)期杂音[pre-(mid-,post)systolic(diastolic)murmur]·全收缩期的[holosystolic(pansystolic)]·全舒张期的[holodiastolic(pandiastolic)]·低(高)音调[low(high)pitched]·递减(递增,递减-递增)性杂音[decrescendo(crescendo,decrescendo-crescendo)murmur]·呈喷射型[beejectionintype]·Ⅳ级喷射型收缩期杂音[gradeⅣ(I-Ⅳ/6)systolicejectionmurmur]·吹风样杂音[murmurofpuffingcharacter]·低音调隆隆样[low-pitchedrumblingquality]·柔和(粗糙)的[soft(harshorrough)]·吹风样(喷射性、隆隆样、沙沙声样、搔抓声样、机器声样、汽笛声样、倒水声样)杂音[blowing(ejection,rumbling,rustting,scratching,machinary,whistling,pouring)murmur]·功能性(器质性)杂音[functi