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1、病 情 观 察Observing state of an illnessmethods of observing state of an illness methodsdirect observation methods indirect observation methods inspection auscultation palpation percussion smelling inquiry communicating reading recuring to apparatus 方方 颅颅尖尖 颅颅contents of observing state of an illness ge
2、neral conditions vital signsconsciousness pupil mentation special examinations and drug treatments general conditions development and habitus diet and nutrition facial features and expression position posture and gait sleep skin and mucosa vomitus excreta 发育 应通过患者年龄,智力,和体格成长状态(身高、体重、第二性征)之间的关系进行综合评价
3、成人发育正常指标:头部的长度为身高的1/71/8胸围为身高的1/2双上肢展开后,左右指端的距离与身高基本一致坐高等于下肢的长度巨人症巨人症侏儒症侏儒症呆小症呆小症佝偻病佝偻病成年人体型均称型/正力型(ortho-sthenic type)瘦长型/无力型(asthenic type)矮胖型/超力型(sthenic type)体型 身体各部发育的外观表现,包括骨骼,肌肉的成长与脂肪分布的状态 营养状态1.根据皮肤,毛发,皮下脂肪,肌肉的发育情况2.检测体重的变化营养状态的分类:良好 中等 不良营养状态异常1 营养不良:1)消瘦:体重减轻至低于正常的10%2)恶病质:极度消瘦者2 营养过度:1)外源
4、性肥胖:为摄入过多热量所致 2)内源性肥胖:主要为某些内分泌疾病所致CushingCushing综合症综合症facial features and expression face of acute ill chronic disease face critical facies/Hippocratic face mitral facies anemic face acromegaly facies moon facies hyperthyroid faciesposition active positionpassive positioncompulsive position 强 迫 体 位强迫仰卧位强迫俯卧位强迫侧卧位强迫坐位(端坐呼吸)强迫蹲位强迫停立位辗转体位角弓反张位posture and gaitdisturbance of consciousness嗜睡(somnolence)意识模糊(confusion)昏睡(stupor)昏迷(coma)