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(....EXAM DETAILS
on separate, linked pages)
This is a XX year
old man (or woman) ,
who looks about (younger or older than) his (her)
stated age. He appears comfortable ( restless,
pale, fatigued, agitated, in acute distress, discheveled, in severe pain, diaphoretic),
cooperative (uninterested, belligerent, combative,
intoxicated etc ) and is oriented x3 (is
disoriented, in which of the three spheres as to his person, time and place).
The patient is well developed, (short, miniature,
large framed, tall) well nourished ( thin,
anorexic, obese,
grossly overweight, cachectic, ematiated).
Height, weight
VITAL SIGNS are:
Temperature oral
(rectal,) XX C
(F) , Pulse XX / min, regular
(irregular, irregularly irregular, bounding, thin, faint, thready, frequent
extra beats),
Respiration XX/min, smooth (labored,
prolonged expiratory (inspiratory) phase, prominent stridor, croupy, ).
BP XXX / XX mmHg.
SKIN dry (sweaty,
diaphoretic, scaling, ) , normal color, (icteric, bronz,
few/frequent spider nevi, bruises) no leasions apparent.
HEAD
Normocephalic,
(microcephalic, hydrocephalic) no evidence of trauma
(describe as necessary. ) , no tenderness (tenderness
over frontal and maxillary sinuses )
FACE normal (edematous, cyanotic) color,
( yellow waxy deposits on eyelids, butterfly rash on
nose and cheeks, multiple waxy brown leasions a temporal skin ) no lesions
no tenderness (non-/pigmented mole, nevus, raised,
non-pigmented ulcerated leasion (size) on R/L nostril)
MOUTH lips are of normal color, (pale, cyanotic,
cherry red, swollen, cracked lips) oral mucous membrane non remarkable (dry,
pale, injected, petechial hemorrhages, covered with exudate, foul smelling,
white flaky exudate, aphtous spots, Koplik spots)
TONGUE normal, moist (dry, shrunken,
beefy red, swollen, covered with
yellow/white exudate, deviates to R/L side)
TEETH normal / in good repair (number
missing, in poor repair,
neglected, multiple fillings, partial/full dentures , removable / fixed )
GINGIVA normal (swollen, bleeding, neglected)
THROAT tonsils absent /
normal (enlarged
size, slightly / markedly enlarged, injected, flaming red, covered with exudate,
multiple vesicles, multiple
purulent crypts),
uvula in midline (swollen, hyperaemic, split ), pharynx clear,
normal color / not inflamed (covered with
exudate, postnasal drip, injected, markedly swollen erythematous)
NOSE
no obstruction, discharge or bleeding ( airway
appears blocked, partial onstruction, sonorous breathing, bleeding from the
nostril, discharge (color, character) )
EYES
Eyelids normal
(yellow deposits bilatearl, upper/lower eyelids,
yellow discharge)
PERRRLA, (Pupils Round, Regular,React to Light and Accomodation)
(Pupils are uneven, pinpoint, slugish reaction to
light, do not react to light),
sclera normal (injected, icteric) vision
grossly normal, EOM (ExtraOcular Movements) unrestricted, no
nystagmus.
EARS
Pinna no deformity (deformity from surgical
resection, cup ear, loop ear deformity, ulcerating leasion), ear
canals clear (obstructed with wax), TM normal
(tympanic membranes) (bright light reflexion,
shiny, injected, bulging, perforated, discharge -color, character-)
NECK
free movement, no
stiffness, no swelling, next veins flat,(restricted
movement, stiff neck, veins
distented in supine position, liver reflex positive) no masses,
(mass -location consistency fixation-, lymph nodes palpable bilateral supraclavicular area)
thyroid negative (thyroid diffusely enlarged
bilateraly, firm peanut size fixed non tender mass lower pole R thyroid),
trachea in midline
(trachea deviated to R/L)
CHEST
Normal shape (barrel chest, markedly
increased AP diameter, emphysematous, funnel chest (pectus excavatum),
pidgeon chest (pectus curinatum), scoliosis, kyphosis),
normal respiratory excursion both sides (assymetric
chest excursion R/L side restricted, diaphragm fixed on the R/L)
No surgical scars
(R/L
thoracotomy scar, anterior midline scar)
Both lungs are clear to
percussion no hyperresonance (R/L sided dullness posteriorly ) ,
Normal vesicular breath sounds
entire chest bilateraly by auscultation
(bilateral fine rales both sides inferiorly) no
rales or ronchi on inspiration or expiration (course rales both chest upon
inspiration, whistling sound on expiration, worse on R than on the L)
no pleural rub
LUNG EXAM DETAILS
BREASTS
Normal by inspection and
palpation, (gynecomastia, masses (location, size)
dimpling, discharge? implants Y/N ) no nipple deformity, no palpable
masses
BREAST EXAM
DETAILS
HEART
PMI (Point of Maximal Impact, apex) not visible
(if visible location) , apex palpable at the midclavicular line in
the fifth interspace, (apex palpable
X FB (fingerbreaths) lateral to MC line, palpable thrill at apex)
Heart
sounds are normal, (
(jól ékelt szivhangok???) split S1, S2) no murmurs,
(Gr I./IV systolic/diastolic murmur, soft, blowing
murmur, radiating into carotids) no rub (faint rub audible over entire
precordium)
CARDIAC EXAM DETAILS
ABDOMEN
No surgical scars ( well healed surgical
scar RLQ, well defined caput medusae, ), flat (obese, distended, ) , soft
(protected by guarding, boardlike) , nontender
(RLQ, RUQ, LLQ tendernes, rebound tendernes RLQ)
, no organs (liver palpable X FB below costal margin,
spleen enlarged by percussion, ) or masses
(large soft mass palpable in RL Quadrant,) , palpable. No fluid by
percussion (evidence of free fluid, fluid shift)
Bowel sounds normal (BS
absent, BS hypoactive, hyperactive, high tinkling, )
No bruit, no hernias
( mid abdominal bruit, umbilical / inquinal hernia
R/L, incisional hernia )
No CVA (CostoVertebral Angle) tenderness (R/L
tenderness, )
Murphy, McBurney signs negative
ABDOMINAL EXAM DETAILS
GENITALS
Normal female,
(pelvic exam deferred at this time )
Normal male external genitals
(penis infantile, R testicle atrophic, 5mm painless
ulcer on glans, marked hydrocele, varicocele L/R testicle, )
NEUROLOGICAL
Oriented X 3
( unable to tell day or time)
Cranial nerves intact
(double vision, visual field defect, nystagmus,
anosmia, R/L facial nerve paresys or paralysis, hoarseness, tongue deviation )
Speach normal
(dysphagia, aphasia )
Sensory exam and motor function
intact (decreased sensation in R ulnar nerve in
hand, paresys or paralysis, muscle weakness, ...)
Cerebellar function intact
(jerky fine tremor, intentional, unintentional tremor )
Gate normal
(weers to the R with closed eyes, ataxia, wide gate, )
DTR.s active and symmetrical
(slugish R knee jerk, absent R Achilles )
No pathological reflexes or signs
(Plantar reflex (Babinsky) (up, positive),
Kernig sign positive, Brudzinski positive )
NEUROLOGICAL EXAM DETAILS
****
LYMPH NODES
None palpable
( describe location, (axillary, inquinal, cervical,
postauricular, supraclavicular, occipital), size (pea size,
peanut size, walnut size, eggsize) number, consistency ( solid, soft),
mobility (freely mobile, fixed), painful )
MUSCULOSKELETAL
Muscle power is normal,
(weak, painful, masses palpable) no deformities
(congenital, aquired extremity deformity, kyphosis,
scoliosis), all joints full range of motion
(limitation of motion, -active, -passive, joint enlargement,
temperature, palpable fluid in joint, tenderness, erythema, muscle atrophy / symmetry, )
PERIFERAL VASCULAR
Periferal pulses normal and
symmetrical (carotid, radial, femoral, dorsalis
pedis, tibialis posteror, palpable or not or week, abdominal arteries.
bruit?, Stasis? Edema? Varicosities (location, extent, inflammation,
skin color, pain)? Ulceration? Calf tenderness? Homan's
sign?)
RECTAL EXAM
Sphincter tone normal
(sphincter loose, )
No hemorrhoids,
(moderate internal hemorrhoids, external hem..
bleeding, inflamed, ulcerated,
painful, thrombosed ) no palpable rectal masses,
(polyp, soft diffuse velvety mass,
constrictive ring like mass (at
X cm, at X o'clock) )
Prostate normal size
( enlarged x2), and consistency,
(soft, boggy, firm mass in
... lobe, tenderness, )
Stool normal
color, (clay colored, blood stained, tarry)
quaiac negative for occult
blood (1 -- 4 plus )
THE END
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dischevelt = zilált
belligerent = veszekedő
ematiated = összeaszott |
