【正文】 matic movement ? Auscultation: breath sounds tracheal bronchial bronchovesicular vesicular Physical examination ? Heart: Inspection: apical impulse, or its location, area and intensity Palpation: assessing point of maximum impulse, thrills, fremitus Percussion: percuss the heart’ s borders, the relative dullness or absolute dullness borders Auscultation: the heart rates, rhythm, heart sounds, murmur（ 雜音 ） , abnormalities of the S1, S2, splitting of S2, systolic clicks, diastolic opening snaps, vocal fremitus, premature beats（ 早搏 ） Physical examination ? Radial artery (橈動(dòng)脈 ): pulse rate, rhythm (regular or irregular), pulse deficit（ 脈搏短促 ） . The pulse may be described as normal, diminished, increased, or doublepeaked. ? Peripheral vascular signs: capillary strike signs, bruits（ 雜音 ） , abnormal artery movement. Abdomen ? Inspection: symmetry, size, abdominal distention, pitting (concave abdomen), respiratory movement, skin lesion, pigmentation, surgical scar, umbilicus, hernia（ 疝 ） , body hair, venous distention and direction of blood flow, peristaltic waves（ 蠕動(dòng)波 )。 ecchymoses (淤斑 ) ? Palpation: the tenderness of abdominal wall, rebound tenderness, mass (location, size, shape, texture, tenderness, motion, mobility) Abdomen ? Liver: size, character, surface, edge, tenderness, motion. ? Gallbladder: size, shape, tenderness ? Spleen: size, character, tenderness, surface, edge ? Kidney: size, shape, character, tenderness, mobility ? Bladder: distention (膨脹 ) costovertebral（ 肋椎的 ) angle tenderness Abdomen ? Percussion: liver dullness borders, hepatic tenderness over the right upper quadrant, shifting dullness (移動(dòng)性濁音 ) ? Auscultation: bowel sounds(腸鳴音 ), vascular bruits ?Anus and rectum: anal fissure (肛裂 ) anal fistula (肛 瘺 ) pile(痔 ) digital rectal examination(肛指檢查 ) Genitalia ? Male: pubes(陰毛 ), penis(陰莖 ), glans(龜頭 ) scrotum (陰囊 ), testicles (睪丸 ), epididymis(副睪 ), ? Female: External: pubes, vagina(陰道 ), urethral meatus(尿道口 ), hymen(處女膜 ), labia minora (小陰唇 ), labia majora (大陰唇 ), clitoris(陰蒂 ) Internal: ovary(卵巢 ), uterus(子宮 ), fallopian tube (輸卵管 ) Physical examination ? Spine: tenderness, abnormal spinal extension/rotation, lateral deviation ? Extremities: deformity, venous distention, stiffness, limitation of motion, joint, strength Physical examination ? Nervous system: biceps tendon reflex (二頭肌反射 ) triceps tendon reflex (三頭肌反射 ) patellar tendon reflex (膝腱反射 ) Achilles tendon reflex (跟腱反射 ) abdominal superficial reflex (腹部反射 ) cremasteric superficial reflex(提睪反射 ) test for abnormal reflexes: babinski sign, chaddock’ s sign, hoffmann’ s sign ? Specialized subject: such as: surgery ophthalmology (眼科 ) gynecology (婦產(chǎn)科 ) Physical examination Laboratory and other special examinations ? Laboratory tests: record all those data that are associated with diagnosis, including three routing tests and other laboratory tests 24 h after admission. ? Special exam: gastroscopy, barium enema, Xray etc. Summary ? Combining with the case history, physical examination and laboratory data, propose the evidences of diagnosis, and finally set up the diagnosis ? Preliminary diagnosis ? Signature or stamps Common medical documents ? Record of admission ? Record of the course of disease ? Record of consultation ? Record for transferring to new department ? Record of discharge ? Record of death ? Others Record of admission 入院錄 ? The record of admission is the abstract form of full case record. The key points should be emphasized, and it should be written concisely(簡(jiǎn)明 ) or pendiously(簡(jiǎn)要 ), and should be finished with 24 h after admission by resident ? The chief plain and present illness are written in the same form as full case record, the others could be written in the short form, without the abstract