カルテは簡潔に（２）

カルテは記号だらけで、独特の言語である。Physical examなんて正常ならば、殆ど文字の羅列で書くことができる（一応、翻訳つき）:

VITALS T 36°C Tm 36.5°C HR 80 BP 120/80 (115-125/75-85) RR 20 SPO2 98% (RA)　(temperature (24 hour max), heart rate, respiratory rate, blood pressure (24 hour range), O2 saturation on room air)
GEN WDWN NAD　(well developed, well nourished, no acute distress)
HEENT NCAT　(Head, Ears, Eyes, Nose, Throat, normocephalic, atraumatic)
　　 PERRLA (Pupils equally round and reactive to light and accommodation)
　　MMM (Mucous membranes moist)
　　EOMI (Extra ocular movements intact)
NECK supple, full ROM (range of motion)
　　ØJVD, ØLAD (no juglar venous distension, no lymphadenopathy)
CV RRR ØM/R/G (regular rate and rhythm, no murmurs, rubs, or gallops)
PULM CTAB (clear to auscultation bilaterally)
ABD NTND NABS (abdomen nontender nondistended, normoactive bowel sounds)
EXT Øc/c/e (extremities no cyanosis/clubbing/edema
NEURO CN II-XII intact (Cranial Nerves)