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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