Status praesens

Internal
Conscious, fully mobile, cooperative, without impairment of orientation, verbal communication clear and understandable; normosthenic type, state of nutrition and musculature adequate; skin without pathological efflorescence, anicteric, non-cyanotic, without signs of bleeding, adnexa without deviations, mucous membranes moist without coating; eupnea; ameningeal, without abnormal movements, approximately neurologically normal; skin turgor not reduced, muscle tone appropriate for age, sores warm, patient afebrile.

Head: percussion painless; bulbs in medium position, movable in all directions; sclera anicteric, conjunctiva pink, pupil isochoric, reaction to light present; the tongue crawls through the middle.

Neck: nodes and thyroid gland not enlarged; pulsation of the carotid bodies symmetrical, aurally without a murmur; jugular vein filling not increased.

Thorax: symmetrical; heart action regular, sounds demarcated without murmurs, spike beat invisible, heart not enlarged on percussion; breathing clean, cellular, without secondary phenomena.

Breasts: soft, palpable, without pathological findings.

Abdomen: in niveau, peritoneal, painless on palpation; non-resistive peristalsis; liver and spleen not enlarged, tapotement negative bilaterally.

Lower limb: without swelling, inflammation, varicose veins; calf loose, painless; palpable pulsations in the periphery.

Per rectum: sphincter firm, ampoule loose with remains of brown stool, walls smooth without pathological findings , prostate elastic not enlarged.

Weight:   kg  Height:   cm  Heart pressure:   torr  HR: /min  BR:  /min

EKG:

Neurology
General condition: conscious; orientation by time, place and person; cooperates, speech without aphasia; without sphincter disorders.

Skin and adnexa: skin of normal color, without signs of cyanosis or jaundice.

Head: painless on percussion, atraumatic; I cannot feel the lymph nodes in typical locations, the thyroid gland is not enlarged.

Cranial nerves: pupil isochoric, direct and indirect photoreaction normal; bulbs free, nystagmus absent; values ​​and frowns symmetrically; the tongue crawls through the middle.

Neck: ameningeal neck, carotid pulsation without murmurs.

Chest: symmetrical, breathing is cellular, heart sounds are limited.

HCC: tone sym. in the norm, yr. C5–8 sym. moderate, in Mingazzini without decreases, taxa in normal sym., diadochokinesis in normal sym., tremor at rest, neither postural nor action absent.

Abdomen: palpable, painless on palpation, peritoneal, rr. skin abdominal sym. optional.

Lower limb: tonus sym. in the norm, yr. L2–S2 sym. medium, in Mingazzini without dips, Lasègue 90/90°, Babinski bilaterally unequipped, taxe sym. normal.

Spine: in axis, painless on percussion, free movement of C, Th and LS spine, Thomayer 0, free tilt.

Standing, walking: Romberg negative, Hautant without limb deviation.

Sensation: tactile and deep in the norm without gaps, perianogenital without pathological deviations.

Links

 * Dismissal report epicrisis template
 * Sample recommendation for dismissal reports