【正文】 the fact that a key finding is not present may help rule out a certain diagnosis. ? For example, the absence of tachycardia in a women with weight loss and a tremor(震顫 ) makes a diagnosis of hyperthyroidism less than likely。 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(簡明 ) or pendiously(簡要 ), 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. The format and content of record of admission ? General information of the patient ? Chief plaint ? Present history of illness ? Past history in summary ? Physical examination Vital signs General appearance and systemic ans Laboratory tests ? Preliminary diagnosis ? Signature Record of the course of disease 病程記錄 ? It records the progression and treatment of the whole courses of patient’ s disease during one’ s admission. It should be recorded with trueness, promptly, with prospective analysis. It actually reflects the quality of the medical treatment. ? It can be written once a day according to the changes of the disease. For those severe cases, it should be written several times per day. For those patients with mild illness, however, it could be written every 2~3 day. The content of records are generally including ? The patient’ s plains (about his/her disfort, moods, physiological status, food, sleep, relieve oneself, those can be further selected according to the need for the progression of the disease. ? The changes of disease, including signs and symptoms, or any new discovery, the results of various laboratory or other adjuvant examinations, the analysis, evaluations, or remarks on those data. The content of records are generally including ? The records of various manipulations, such as plural puncture, abdom