【 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 Activity   Hyperactive   good   not bad   not good   poor Humor/Mood   good   not bad   not good   poor   so so Appetite   good   not bad   not good   poor Water intake   good   not bad   not good   poor       polydipsia Final stool   with in 24 hours   this night   this evening   this noon   this morning   last night   yesterday   2days ago   3-4days ago   more than 5 days   unknown  ， normal   Diarrhea   watery Diarrhea   soft   hard   very hard  ， Color white   tarry   blood Urinary output   nl   half   none   polyuria Face color   not pale   pale   cyanotic   icteric   pink Head   Anterior fontanelle flat   sunken   bulging  ， Deformity ＋   － Eyes & Conjunctiva   nl   anemic   icteric   hyperemic   discharge Ear drums   Right intact   not visible   reddened   bulged   fluid   bleeding   perforation   tubing   Left   intact   not visible   reddened   bulged   fluid   bleeding   perforation   tubing Nose   np   serous rhinorrhea   mucous rhinorrhea   purulent rhinorrhea   bleeding Throat   Pharynx intact   reddened  ， Tonsils Right   Left  ， intact   reddened   swollen(enlarged)   purulent   abscess   pseudo membranous   adenoid   others Cervical Lymphnodes   Right --- not 1cm 2cm 3cm 4cm palpable，    --- 1 2 3 4 5 個， tenderness ＋   －  ，    pain ＋   －  ，    soft   hard   Left   --- not 1cm 2cm 3cm 4cm palpable，    --- 1 2 3 4 5 個， tenderness ＋   －  ，    pain ＋   －  ，    soft   hard Parotid gland   Right --- not 1cm 2cm 3cm 4cm palpable， tenderness ＋   －  ， pain ＋   －  ， soft   hard Left   --- not 1cm 2cm 3cm 4cm palpable， tenderness ＋   －  ， pain ＋   －  ， soft   hard Neck stiffness   ＋   ±   － Kernig sign   ＋   ±   － Lungs   Air entry good   not bad   so so   not good   poor  ， 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   Regular   irregular  ， S1 ～   ↑   ↓  ，    S2 ～   ↑   ↓   分裂  ，    S3 ＋   －  ，    S4 ＋   －   Gr --- 1 2 3 4 5 6 systolic   holosystolic   diastolic  ， rumble(lowpitch)   highpitch   harsh(white)   musical   to and fro   blowing   murmur  at ULSB   MLSB   LLSB Thorax deformities   np   Funnel chest   Pigeon’s chest   others Abdomen   Soft   Hard  ，      Flat   slightly distended   distended   depressed Bowel sound normal   hyperactive   hypoactive   absent   others  ， 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   Moist   Dry   Atopic   Eruption   Erythema   Papule   Pigmentation   Urticaria   others Extremities   Warm   Edema   Cyanosis   Reddish   Swelling   Clubbed finger  ， Capillary refilling time --- 1 2 3 4 5 sec， Peripheral pulse lt＝rt   lt＞rt   lt＜rt   Joints   np   pain   swelling   redness   inflammation Genitalia   normal male   normal female   intersex   pseudo-male   pseudo-female   type， Tanner’s staging Ⅰ   Ⅱ   Ⅲ   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   swelling   pain Neurological findings     CNS   w.n.l     　  I 　  II 　  III/IV/VI 　  V 　  VII 　  VIII 　  IX/X 　  XI 　  XII 　  Motor   w.n.l   Sensory   w.n.l   Dtr   w.n.l