【 Physical Examination 】   （←クリックするとさらに追加して大項目を選択出来るようになります）      English     日本語

Vital signs     体温 ℃  脈拍 回/分  呼吸数 回/分  SpO2 ％  (  room air  /  O2  L)  左右別  血圧  / mmHg  血圧 (左) / mmHg   (右) / mmHg  Measurements     体重  kg  /  g    頭囲 cm  身長 cm 胸囲 cm General condition   good   not bad   not good   poor   Well   poorly nourished   Well   poorly developed   Activity   good   not good   poor Humor/Mood   good   not good   poor   Appetite   good   not good   poor Water intake   good   not good   poor   Final stool   this evening   this noon   this morning   last night   yesterday   2days ago   3-4days ago   more   Diarrhea   watery Diarrhea   soft   hard   very hard   Urinary output   nl   half   none   Face color   not pale   pale   cyanotic   icteric   Neck stiffness   ＋   ±   － Kernig sign   ＋   ±   － Eyes   np   anemic   icteric   hyperemic   Pupils Right mm   , Left mm Light reflex prompt   sluggish   none   ( direct   / indirect   ) Ear drums   Right intact   not visible   reddened   Left   intact   not visible   reddened   Nose   np   serous rhinorrhea   mucous rhinorrhea   purulent rhinorrhea   Throat   Pharynx intact   reddened  ， Tonsils   intact   reddened   swollen(enlarged)   purulent   abscess   pseudo membranous   adenoid   etc Cervical Lymphnodes   Right --- not 1cm 2cm 3cm 4cm palpable，    --- 1 2 3 4 5 個， soft   hard   Left   --- not 1cm 2cm 3cm 4cm palpable，    --- 1 2 3 4 5 個， soft   hard Lungs   Air entry symmetrical   lt＞rt   lt＜rt  ，     bilateral clear   Retraction ＋   －   Right Stridor   Wheezing  ， Dry rales at UL   ML   LL   Wet ( fine   med   large   ) rales at UL   ML   LL   Left   Stridor   Wheezing  ， Dry rales at UL   ML   LL   Wet ( fine   med   large   ) rales at UL   ML   LL Heart   np   Regular   irregular  ， S1 ～   ↑   ↓  ，    S2 ～   ↑   ↓   分裂  ，    S3 ＋   －  ，    S4 ＋   －   Gr --- 1 2 3 4 5 6 systolic   holosystolic   diastolic  ， rumble(lowpitch)   highpitch   harsh(white)   musical   murmur  at ULSB   MLSB   LLSB Abdomen   Soft and Flat        slightly distended   distended   Bowel sound normal   hyperactive   hypoactive   absent   etc  ， Tenderness ＋   －  ， Defense ＋   －  ， Rebound ＋   －  ， Mass ＋   －  ， Ascites ＋   －  ， Scar ＋   －  ， Hernia ＋   －  ， McBurney’s point ＋   －  ， Lanz’s point ＋   －  ， Liver --- not 1cm 2cm 3cm 4cm 5cm 6cm 7cm 8cm 9cm 10cm palpable below RCM ，   Spleen --- not 1cm 2cm 3cm 4cm 5cm 6cm 7cm 8cm 9cm 10cm palpable below LCM Back   Scoliosis ＋   －  ， CVA tenderness ＋   －   Skin   Smooth and Moist   Atopic   Eruption   Erythema   Papule   Pigmentation   Urticaria   etc Extremities   Warm   Edema   Cyanosis   Reddish   Swelling   Clubbed finger  ， Peripheral pulse lt＝rt   lt＞rt   lt＜rt   Joints   pain   swelling   redness   inflammation Genitalia   normal male   normal female   intersex   pseudo-male   pseudo-female   type， Testis nl   retained    Size --- 1 2 3 4 5 6 ml Color red   pink   black   Penis Size nl   micropenis   megalopenis   Color red   pink   black             posthitis   pustule   ulcer   Scrotum hydrocele   nl   Superficial Lymph Nodes   not palpable   inguinal   axillary   Comments   Neurological findings     CNS   w.n.l     　  I 　  II 　  III/IV/VI EOM full and smooth   No nystagmus   Light reflex bil prompt   sluggish   absent   ( rt   / lt   ) V facial touch normal   VII be able to close eyes tightly   NLF symmetrical   asymmetrical   Wrinkle Forehead symmetrical   asymmetrical   VIII 　  IX/X 　  XI 　  XII 　  Motor   w.n.l   Sensory   w.n.l   Dtr   w.n.l