B. Objective 客观资料 1. General statement 一般陈述
Age, race, gender, general appearance, weight, height, body mass index, vital signs (including orthostatic if applicable)
年龄、种族、性别、外观、体重、身高民、身体质量指数、生命体征（有用的话还包括直立性低血压） 2. Mental status 精神状态
Physical appearance, behavior, facial expression and body language, appropriate eye contact, level of consciousness (alertness and awareness and ability to interact appropriately with the environment), response to questions, reasoning, emotion, speech and language
身体表征，行为，面部表情和肢体语言，适当的眼神接触，意识清醒程度（警觉，清醒，能与环境适当互动），提问响应，推理，情绪，言语和语言 3. Skin皮肤
Color, texture, temperature, turgor, uniformity, hygiene, scars, tattoos, moisture, edema, odor, lesions, trauma, hair texture and distribution, nail configuration
肤色，质地，温度，充盈，均匀度，卫生，疤痕，纹身，湿度，肿，气味，损伤，创伤，毛发质地和分布，指甲形状 4. Head头部
Size, contour, scalp, facial features, facies, edema, temporal arteries
尺寸，轮廓，头皮，面部特征，面容，肿，颞动脉 5. Eyes眼睛
Acuity, visual fields, edema, conjunctiva and sclera, eyebrows, extraocular movements, corneal light reflex, cover-uncover test, nystagmus, pupils equal, round, react to light, accommodation (PERRLA) both direct and consensual, fundoscopic findings
视敏度，视野，肿，结膜和巩膜，睫毛，眼外运动，角膜光反射，遮与不遮试验，眼球震颤，瞳孔等大，圆，对光反射，调节（PERRLA）包括直接和间接，眼底镜检查结果 6. Ears 耳
Configuration, position, alignment, tenderness, nodules, hearing, otoscopic findings
外形，位置，定位，触痛，根瘤，听力，耳镜检查结果 7. Nose鼻
Appearance, patency, discharge, polyps, turbinates, septum, sinus tenderness, odors
外形，通畅，分泌，息肉，鼻甲，鼻隔，窦痛，气味 8. Throat and mouth 喉、口腔
Teeth, lips, tongue, buccal and oral mucosa, floor of mouth, appearance of palate, tonsils, tonsil grade, gag reflex, phonation of “Ah," voice, taste
牙，唇，舌，颊和口腔粘膜，口底，颚粘膜，扁桃体，扁桃体分级，咽反射，“阿”发声，声音，味觉 9. Neck颈
Fullness, mobility, strength, trachea, thyroid size, shape, nodules, tenderness, bruits, masses, lymphadenopathy
发胀，可动性，强度，气管，甲状腺大小，形状，结节，触痛，擦伤，肿块，淋巴结病 10. Chest胸
Size, shape, anterior and posterior (AP) and transverse diameter, respiration, tenderness on bones, retractions/accessory muscle use
大小，形状，前、后、横径，呼吸，骨触痛，收缩、辅助肌使用 11. Lungs肺
Respiration rate, depth, work of breathing, regularity, tactile fremitus, percussion notes, breath sounds, friction rub
呼吸率，呼吸深度，呼吸功，规则，触觉语颤，叩诊音，呼吸音，摩擦音 12. Breasts乳房
Size, symmetry, contour, lesions, masses, tenderness, retractions, dimpling, nipple discharge, nipple retraction
大小，对称性，轮廓，损伤，肿块，触痛，回缩，凹陷，乳头溢液，乳头内陷 13. Heart心脏
Apical impulse, pulsation, heart rate, rhythm, thrills, heaves, lifts, heart tones, murmurs, rubs, gallops
心尖脉，搏动，心率，节律，震颤，气喘，抬举感，心音，杂音，摩擦音，奔马律 14. Vasculature脉管系统
Pulses, jugular venous distention or pulsations, carotid, abdominal aortic, temporal, renal, iliac, femoral artery bruit, temperature, color, skin texture, hair distribution, edema, nail beds, tenderness
脉搏，颈静脉扩张或搏动，颈动脉，腹主动脉，颞、肾、髂、股动脉杂音，体温，颜色，皮肤质地，毛发分布，浮肿，甲床，触痛 15. Abdomen腹部
Shape, contour, pulsations, bowel sounds, masses, organomegaly, tenderness, distention, costovertebral angle tenderness
形状，轮廓，搏动，肠鸣音，肿块，器官巨大症，触痛，膨胀，肋椎角压痛 16. Genitalia生殖器
Male: Symmetry, circumcision, color, urethral opening, discharge, lesions, hair distribution, palpation of penis, testes, epididymides, vasa deferentia, tenderness, masses, hernia, scrotal swelling, transillumination
男性：对称性，包皮环切术，颜色，尿道口，分泌，损伤，毛发分布，阴茎触诊，睾丸，附睾，输精管，触痛，肿块，疝，阴囊肿，透照法
Female: Tenderness, discharge, inflammation, lesions, polyps, vaginal mucosa, cervix, discharge, odor, size and contour of uterus, mobility of cervix, adnexa, ovaries
女性：压痛，分泌，炎症，损伤，息肉，阴道粘膜，宫颈，排出物，气味，子宫形状与大小，宫颈活动性，附件，卵巢 17. Anus and rectum 肛门与直肠
Hemorrhoids, fissures, skin tags, inflammation, excoriation, sphincter tone and control, prostate size, contour, consistency, mobility, color and consistency of stool
痔疮，龟裂，皮赘，炎症，脱皮，括约肌紧张性和控制力，前列腺大小，轮廓，硬度，移动性，粪便颜色与硬度 18. Lymphatics淋巴管
Presence of palpable lymph nodes, size, shape, warmth, tenderness, mobility, consistency
是否可以扪及淋巴结，大小，形状，热度，压痛，移动性，硬度 20. Musculoskeletal肌肉骨骼
Posture, alignment, symmetry, spasms, active and passive range of motion, deformities, tenderness, swelling crepitus, muscle strength
姿势，定位协调，对称性，痉挛，主动、被动活动范围，变形，压痛，浮肿，肌力 21. Neurologic神经学
Cranial nerves, gait, balance, coordination with rapid alternating movements, sensory function with pain, touch, fibration, superficial and deep tendon reflexes
颅神经，步态，平衡，快速交替运动协调，疼痛感官功能，触觉，纤维化，浅表和深腱反射 C. Assessment 评估
▪ Diagnosis with rationale 诊断及说明
▪ Rationale derived from subjective and objective data 主、客观资料说明
▪ Symptoms can be listed as diagnoses 症状可以列为诊断
▪ There may be a list of differential diagnoses, which are suspected diagnoses that are yet to be confirmed
可能会有鉴别诊断清单，属于需要确认的可疑诊断
▪ May include anticipated problems such as progression of disease or complications
可包括预期问题，如疾病进展或并发症 D.Plan 计划
▪ Typically denoted in the following order. 主要以下列顺序列出
▪ Diagnostic tests, treatment plan with rationale 诊断试验，治疗计划及说明
▪ Client education and counseling 患者宣教与咨询
▪ Referrals 转诊
▪ Follow-up or dates for re-evaluating results of plan 随访或计划结果再评价日期
★Vocabulary for Today ★
mental status -- 精神状态
physical appearance – 外表
facial expression – 面部表情
uniformity – n. 均匀度，一致性
configuration – n. 结构，格局
contour – n. 轮廓
facial features – 面部特征
facies – n. 相，面容
nystagmus – n. 眼球震颤
fundoscopy – n. 眼底镜检查
otoscopy – n. 耳镜检查
turbinate – n. 鼻甲
septum -- n. 鼻隔
phonation – n. 发声
tactile fremitus –触觉语
breath sounds -- 呼吸音
dimpling – n. 凹陷
organomegaly – n. 器官巨大症
costovertebral – a. 肋椎的
circumcision – n. 包皮环切
epididymides – n. 附睾
vasa deferentia – n. 输精管
transillumination – n. 透照法
adnexa – n. 附件
fissure – n. 龟裂，裂缝
excoriation – n. 脱皮
★Video ★
SOAP Notes
★Test ★
1. The nurse notes documentation that a client is exhibiting Cheyne-Stokes respirations. On assessment of the client, the nurse should expect to note which finding?
A. Rhythmic respirations with periods of apnea
B. Regular rapid and deep, sustained respirations
C. Totally irregular respiration in rhythm and depth
D. Irregular respirations with pauses at the end of inspiration and expiration 2. A client diagnosed with conductive hearing loss asks the nurse to explain the cause of the hearing problem. The nurse plans to explain to the client that this condition is caused by which problem?
A. A defect in the cochlea
B. A defect in cranial nerve VIII
C. A physical obstruction to the transmission of sound waves
D. A defect in the sensory fibers that lead to the cerebral cortex
答案 Key to Questions
1. A
Rationale: Cheyne-Stokes respirations are rhythmic respirations with periods of apnea and can indicate a metabolic dysfunction in the cerebral hemisphere or basal ganglia. Neurogenic hyperventilation is a regular, rapid and deep, sustained respiration that can indicate a dysfunction in the low midbrain and middle pons. Ataxic respirations are totally irregular in rhythm and depth and indicate a dysfunction in the medulla. Apneustic respirations are irregular respirations with pauses at the end of inspiration and expiration and can indicate a dysfunction in the middle or caudal pons. 2. C
Rationale: A conductive hearing loss occurs as a result of a physical obstruction to the transmission of sound waves. A sensorineural hearing loss occurs as a result of a pathological process in the inner ear, a defect in cranial nerve VIII, or a defect of the sensory fibers that lead to the cerebral cortex.
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