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理學檢查

General

  • 洗手：內外夾弓大立腕
  • 自介：住院醫師xxx
  • 確認：姓名、生日
  • 說明：indication, consent
  • 體位：擺姿勢
  • 隱私：拉圍簾（請護理師）

Initial

  • Appearance
  • T, P, R
  • BP, O2
  • EMV

Head & Neck

  • Eye：Pale conjunctiva, icteric sclera, exophthalmos, lid lag, ptosis
  • Ear：Tragus tenderness, canal erythema, membrane bulging, membrane perforation
  • Nose：Mucosal edema, purulent discharge, sinus tenderness
  • Mouth：Dentition, oral ulcer, tonsil swelling, tonsil exudate
  • Thyroid：Goiter, nodule, tenderness, texture, bruit
  • Lymph：Submental, submandibular, parotid, pre-auricular, post-auricular, occipital, anterior cervical, posterior cervical, supraclavicular
  • Vessel：EJV engorgement, JVP height, hepatojugular reflux, carotid bruit

Chest

  • Inspection：Zoster, inhalation (symmetry, accessory muscle, sternal retraction), shape (barrel, funnel, pigeon)
  • Palpation (lung)：Trachea deviation, chest expansion, tactile fremitus
  • Palpation (heart)：PMI, thrill, heave
  • Percussion (lung)：Hyperresonance, dullness (anterior + posterior)
  • Auscultation (lung)：Rhonchi, wheeze, coarse crackle, fine crackle (anterior + posterior)
  • Auscultation (heart)：Arrhythmia, gallop, murmur (2nd-right-sternal: A, 2nd-left-sternal: P, 4nd-left-sternal: T, 5nd-mid-calvicular: M)

Abdomen

  • Inspection：Distension, hernia, caput medusae, spider angioma
  • Auscultation：Bowel sound, bruits
  • Percussion：Tympany, dullness, ascites (fluid wave, shifting dullness)
  • Percussion (hepatobiliary)：Liver span, spleen span
  • Palpation：Tenderness (McBurney, Murphy), rebound tenderness, muscle guarding, mass
  • Palpation (hepatobiliary)：Hepatomegaly, splenomegaly
  • Test：Obturator, Psoas, Rovsing

Limb & Back

  • Inspection：Rash, deformation
  • Inspection (circulation)：Pallor, cyanosis, clubbing
  • Inspection (inflammation)：Erythema, swelling
  • Palpation (circulation)：Edema, pulse, CRT
  • Palpation (inflammation)：Warmth, tenderness
  • Percussion：CVA tenderness
  • Test (general)：ROM, MMT
  • Test (upper limb)：Tinel, Phalen, Finkelstein
  • Test (lower limb)：Drawer, stress, McMurray
  • Test (spine)：Spurling, SLRT, FABER
  • Test (nerve)：Asterixis, pronator drift

Neurologic

  • CN I：Smelling (scent)
  • CN II：Visual field (left-up/right-down, left-down/right-up), pupillary light reflex (direct, indirect)
  • CN III, IV, VI：Lateral (LR), lateral-up (SR), lateral-down (IR), medial (MR), medial-up (IO), medial-down (SO), convergence
  • CN V：Facial sensation (V1, V2, V3), mastication
  • CN VII：Facial motor (forehead wrinkle, close eye, show teeth, purse lip)
  • CN VIII：Hearing (Weber, Rinne)
  • CN IX, X：Uvula deviation (away from lesion side), palate no elevation (lesion side)
  • CN XI：SCM (turn head), trapezius (shrug shoulder)
  • CN XII：Tongue protrusion (to lesion side)
  • Motor：Atrophy, tone, strength (shoulder, elbow, wrist, hand, hip, knee, ankle)
  • Sensory：Touch, pain, vibration/proprioception (hand, forearm, arm, foot, leg, thigh)
  • Reflex：DTR (biceps, triceps, knee, ankle), Babinski, Hoffmann
  • Coordination：Finger-nose-finger, rapid alternating movement, gait (Romberg, tandem walk)
  • Test：Nuchal rigidity, Kernig, Brudzinski