Medical write-up about normal Physical findings in English 11/07/00 Hisamatsu,M.D.
カルテの記入は日本語で書くことが望ましいですが、身体所見の記載に関しては、英語のほうがより
コンパクトにまとめられるのではと思います。正常所見の英語による記載方法例を作成してみました。
注）※の印は異常所見の書き方の例です。
身体所見=Physical examination
身体所見上異常認めず=
Physical examination reveals(shows,discloses) no abnormalities.
Physical examination are normal.
Physical findings are normal.
There are no abnormal findings on Physical examination
VS=Vital Signs
T36℃(36 degrees in Celsius or centigrade) , P88 , R14 , BP130/80(130 over 80と読む)
General appearance:
Development（体格）,nourishment（栄養）
well-developed, well-nourished, poorly developed,poorly nourished, fatty,obese,thin,lean
Degree of illness
be in distress, be acutely ill
appear to be in no distress, appear severely ill
appear to be in acute distress, appear to be in mild respiratory distress
seem to be in distress
Level of consciousness（意識レベル）
normal, lethargy,somnolence,drowsy, stupor, coma,
alert ,cooperative and oriented ×3 (oriented as to time,person,place)
Emotional state（感情）
look anxious, appear to be in depressed state
例）
General appearance:the pt is a well-developed, obese man. appears to be in no distress,but in
depressed state. consciousness alert ,cooperative, and oriented×3
HEENT(Head Eyes Ears Nose Throat)
Head: Normocephalic and atraumatic or Normal in size and shape, No tenderness
Eyes: PERRLA(Pupil equal, round,reactive to light and accommodation)
Visual acuity intact or Visual acuity is 1.2 on the right
EOM:intact
bulbar (palpebral) conjunctiva : not injected or congested, no icterus, no pallor
Optic funds:not visible（観察できず）, no abnormalities,no papilledema, exudate and bleeding
Ears:Hearing acuity intact or wnl (within normal limits)
Tympanic membranes (Eardrums) clear with good light reflex
Nose:No discharge,symmetrical,septum midline,mucous membranes are not injected or congested
patent (No obstruction)
Sinuses : No tenderness,discharge
Mouth / Throat: Teeth intact ,mucosa moist,gingiva normal
Tongue moist,well-papillated,midline
uvula midline, no injection,exudate of tonsil
no tonsillar enlargement
※All teeth are absent (missing), oral hygiene is poor
Neck: supple (not stiff, no stiffness,no nuchal rigidity)
trachea midline
No thyromegaly (No enlargement of thyroid, Not increased in size),
non-tender thyroid ,soft on palpation
No lymphadenopathy (no enlargement of cervical lymph node,lymph node not palpable,
not palpated)
Carotid (artery) equal and normal upstroke and in size,no bruit
Jugular vein is not distended ( Jugular venous pulsations are not visible, not distended, not
elevated)
※JVP are distended (elevated) to a level of 5 cm above sternum angle at 45 degrees of
elevation.
Back:No CVA tenderness, no deformity of the back and spine
CVS(cardiovascular system)
:Regular rate rhythm (RRR),Non-dislocated PMI ,normal in size and intensity
(PMI is visible and palpated in the 5th interspace at the LMCL (left midclavicular line)
inside ...
medial to ...
※outside ...
※lateral to ...
※IRIR(irregularly irregula rate rhythm)
Diffuse PMI is shifted (dislocated) toward the left and felt (palpated) in the 6th interspace.
S1 and S2 normal in intensity, normal split with inspiration
No murmur,gallops,rubs (No GMR)
※S3 heard at the apex, Grade 2/6 pansystolic murmur at the apex with radiation to axilla
or neck
Lung:Clear to auscultation and percussion (CTAP),
No wheeze,rhonchi, rales(crackles)
respiratory movement intact ,symmetrical
diaphragmatic excursion 5 cm,symmetrical (diaphragm descended to 4cm)
tactile (vocal) fremitus wnl
※dullness to percussion on the left side
vocal fremitus decreased (increased)
Abdomen: the wall flat and soft, normal active bowel sound (NABS), no masses,bruits
liver size normal by percussion in MCL
(10 cm by percussion in MCL or percussed at 9 cm in MCL)
normal liver edge
spleen size normal by percussion , kidney not palpated
※the wall distended or scapohid(depressed) ー 腹部は膨満もしくは陥凹
Liver palpated 2 cm below the right costal margin
Skin (integument) : no clubbing ,cyanosis,edema (No CCE)
Extremities :No deformity
Example
PMH),FH) unremarkable
Physical examination)
VS:T36℃ , P88 , R14 , BP130/80
General appearance:the pt is a well-developed, obese man. appears to be in no distress,but
in depressed state.
Consciousness alert ,cooperative, and oriented×3
HEENT
Head:Normocephalic and atraumatic, no tenderness
Eyes : PERRLA,Visual acuity intact, EOM :intact ,
bulbar and palpebral conjunctiva:not injected or congested, no icterus, no pallor
fundi:no papilledema, exudate and bleeding
Ears:Hearing acuity wnl ,Tympanic membranes clear with good light reflex
Nose:No discharge,symmetrical,septum midline,mucous membranes are not injected ,patent
Sinuses:No tenderness,discharge
Mouth / Throat :
Teeth intact ,mucosa moist,gingiva normal, Tongue moist,well-papillated,midline
uvula midline, no injection,exudate of tonsil
Neck : supple ,trachea midline, No thyromegaly,No lymphadenopathy
Carotid equal and normal upstroke and in size,no bruit, jugular venous pulsations are not
elevated)
Back:No CVA tenderness, no deformity of the back and spine
CVS : RRR,Non-dislocated PMI ,normal in size and intensity
S1 and S2 normal in intensity, normal split with inspiration, No murmur,gallops,rubs
Lung : Clear to auscultation and percussion , No wheeze,rhonchi, rales
respiratory movement intact ,symmetrical, diaphragmatic excursion 5 cm,symmetrical ,
tactile and vocal fremitus wnl
Abdomen :
the wall flat and soft, normal active bowel sound ,no masses,bruits
liver size normal by percussion in MCL ,normal liver edge
spleen size normal by percussion , kidney not palpated
Skin (integument) : no clubbing ,cyanosis,edema (No CCE)
Extremities : No deformity
Pulse:carotid brachial radial femoral popliteal post tibial dosalis pedis
Rt + + + + + + +
Lt + + + + + + +
最終更新：2006年08月28日 11:13
