カルテの書き方

●カルテ
CC, PI, PH, Med, Fa, SH
嘔吐、下痢、食事、月経、周囲、HT, DM, IHD, asthma,allergy,TB,tabaco,alcohol
●身体所見
BP, HR, BT, RR, SpO2
level: clear
general status: consciousness clear, understanding well, not doing well, not so bad, so so, good
eye: not anemic, not icteric, quick light reflex, round and iso coria
conj(conjunctiva) b(bulbar): not icteric
conj(conjunctiva) p(palpebral): not anemic
throat: no swelling and redness, not red, slt red
chest: clear to ausculation bilaterally, no rale, regular rate and rhythm, normal S1S2, no S3S4, no murmur
chest: Hs no murmur, systolic murmur, diastolic murmur
Ls no rale, wheeze, rhonchi, fine(coarse) crackles
abdomen: bowel sound active, no tenderness, no mass, no defense, no rebound tenderness, no murphy sign, no McBurney tenderness
abd: b/s moderate, hyper, hypo, soft and flat
extrimities: no cyanosis and clubbing and edema and erosion and rashu
●神経所見
意識声明
失行・失語・失認(-)
眼底正常、瞳孔正円同大、対光反射敏、
眼位正常、眼球運動正常、眼振(-)、
顔面筋左右差(-)、軟口蓋運動偏奇(-)、
舌運動偏奇(-)、筋力上肢下肢、筋緊張、
Mingazzini(-,-)、Barre(-,-)、
diadocho(正、正)、H-K-T（正、正）、F-N-T
立位　閉眼開脚可
Hoffman(-,-), Tromrer(-,-)
Babinski(-,-),　腱反射bi, branchio, tri, PTR, ATR
MMT12345
●レントゲン
CTR=0.48
CPA: sharp
niveau(-)