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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    +    +    +    +    +    +     +