英語の症例発表のときにも
略語って必要ですから、
USMLEを取らなくても
最低限の書き方は知っておきましょう！
■病歴
CC
HPI ● yo M/F
OPDCSFLIQRAAA を記載→OPQRSTの方が覚え易いですかね。
Onset
Progression
Duration
Constant
Setting
Frequency
Location
Intensity
Quality
Radiation
Abbreviating factor
Aggracating factor
Associated started
ROS: denies
PMH: none
PSH（手術歴）: none
Meds: none, (OTC) none
Allergy: NKDA
FH: noncontributory, father died of ● at age ●, father with ●
SH: no smoking/1 PPD × 10 yrs, no EtOH/1 beer per day, no drug use, sexually active with ● with condoms all the time
OB/Gyn: G0P0A0, menarche: age ●, LMP 4 wks ago, normal, lasts ● days
■身体所見
GA
NAD: No acute distress
Anxious and restless
Speech fluent
Talkative
Mood euphoric
Behavior inappropriate
Cooperative
Appearance disheveled
VS
WNL: Within normal limits
WNL except for
No orthostatic changes
HEENT
No conjunctival pallor
No conjunctival congestion
EOMI: Extra ocular movement intact
NCAT: Normocephalic/Atraumatic (Head Not Injured)
MMM: Moist Mucous Membranes
OP cl: oral-pharyngeal clear
PERRLA: pupils equal, round, react to light, accommodation
TMs nl: tympanic membranes normal
No funduscopic abnormalities
No cerumen
Neck
supple
No thyromegaly
No carotid bruits
No JVD: No Jugular vein distention
LAD: Lymphadenopathy
Anterior cervical chain with LAD
Neg Lhermitte and Spurling tests
Tenderness on cervical spinous processes
CV
RRR: Regular Rate and Rhythm
nl S1/ S2: normal S1/ S2
no m/r/g: no murmurs/ rubs/ gallops
Tachycardiac
Chest
CTAB: Clear To Auscultation Bilaterally
No tenderness on percussion
VFT nl: Vocal tactile fremitus normal
Decreased breath sounds over lt lung field
No rhonchi, rales, or wheezing
Abd
S: Soft
ND: Nondistended
NT: Nontenderness
+BS x 4Qs: positive bowel sound in 4 quadrants
No organomegaly
No rebound tenderness
Neg murphy’s sign: negative murphy’s sign
C-section scar
HSM: Hepatosplenomegaly
Ext
No c/c/e: no cyanosis/ clubbing/ edema
Palpable pulse on popliteal, posterior tibialis, and dorsalis pedis
Nontender ROM b/l
Restricted ROM on flexion and extension of lt knee
Neuro
Mental status: A and O x3: alerted and oriented x3
AAO in person and place, disorientated in time
Cranial 2-12 grossly intact
MMT: 5/5 throughout
DTRs: symmetric 2 + in all extremities
Decreased pinprick and vibration sense on left arm
Intact to pinprick and light touch
Romberg neg: Romberg negative
Nl gait: Normal gait
Weber w/o lateralization: Weber test without lareralization
Rinne pos: Rinne test positive
覚えることは沢山ですね^^;
日本語 カルテと対比すると分かり易いです♪
よろしければ応援クリックお願いします！
にほんブログ村
