Pattern status presence

Internal

Conscious, fully mobile, cooperates, without prejudice to orientation, verbal communication clear and understandable; normosthenic type, adequate nutritional and muscular condition; skin without pathological efflorescences, anicteric, non-cyanotic, without signs of bleeding, adnexa without deviations, mucous membranes moist without coating; eupnoea; ameningeal, without abnormal movements, approximately neurologically normal; turgor skin not reduced, muscle tone appropriate to age, acre warm, patient afebrile.
'Head:' knock painless; bulbs in middle position, movable in all directions; anterior sclera, pink conjunctiva, isoric pupils, exposure to exposure present; language crawls in the middle.
'Neck:' nodules and shields not enlarged; pulsations of the carotid arteries, symmetrical without murmur; jugular vein filling not increased.
'Chest:' symmetrical; regular heart action, sounds bounded without murmurs, point stroke invisible, heart not enlarged; breathing clean, atrial, without side effects.
'Breasts:' soft, palpable, free of disease.
'Abdomen:' in level, aperitoneal, palpably painless; non-resistive peristalsis; liver or spleen not enlarged, tapotement negative bilaterally.
'HD:' without swelling, inflammation, varicose veins; calves loose, painless; pulsation in the peripheral palpable.
'Per rectum:' firm sphincter, ampoule loose with remnants of brown stool, smooth walls without pathological finding , elastic prostate unhealed .
'Weight:' kg 'Height: cm 'HM:' torr 'AS:'/min 'DF:'/min
'ECG:'

Neurology

'Overall condition:' conscious; orientation by time, place and person; cooperates, speech without aphasia; without sphincter defects.
'Skin and adnexa:' skin of normal color, no signs of cyanosis or jaundice.
'Head:' painless, atraumatic; lymph nodes in typical sites do not touch, thyroid gland not enlarged.
'Cranial nerves:' isochoric pupils, direct and indirect photoreaction normal; bulbs free, nystagmus absent; appreciates and frowns symmetrically; language crawls in the middle.
'Neck:' ameningeal neck, carotid pulsation without murmurs.
'Chest:' symmetrical, ventricular respiration, heart sounds limited.
'HKK:' tone sym. in the norm, rr. C5–8 sym. medium, in Mingazzini without declines, taxa in the norm sym., diadochokinesis in the norm sym., tremor resting neither postural nor action absent.
'Abdomen:' palpable, palpably painless, aperitoneal, rr. skin abdominal sym. outfit.
'DKK:' tone sym. in the norm, rr. L2 – S2 sym. medium, in Mingazzini without dips, Lasègue 90/90 °, Babinski bilaterally unequipped, taxe sym. in the standard.
'Spine:' in axis, percussive, painless, momentum C, Th and LS spine free, Thomayer 0, tilt free.
'Stop, walk:' Romberg negative, Hautant without limb deviation.
'Feeling:' tactile and deep in the norm without outages, perianogenital without pathological abnormalities.

Source

• ws:Vzor status praesens

Odkazy

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