{"id":7064,"date":"2023-04-03T12:00:29","date_gmt":"2023-04-03T03:00:29","guid":{"rendered":"https:\/\/wp.meccari.jp\/?p=7064"},"modified":"2023-12-25T12:16:34","modified_gmt":"2023-12-25T03:16:34","slug":"menu_49","status":"publish","type":"post","link":"https:\/\/wp.meccari.jp\/eigocafe\/menu_49\/","title":{"rendered":"Menu 49\u3000\u82f1\u8a9e\u3067\u306e\u75c7\u4f8b\u30d7\u30ec\u30bc\u30f3\u30c6\u30fc\u30b7\u30e7\u30f3\uff1a\u4e2d\u7d1a\u7de8"},"content":{"rendered":"

\"\"<\/p>\r\n\r\n

\u3053\u3093\u306b\u3061\u306f\u3002\u300c\u533b\u5b66\u82f1\u8a9e\u30ab\u30d5\u30a7<\/strong><\/span>\u300d\u306b\u3088\u3046\u3053\u305d\uff01<\/span><\/p>\r\n

\u3053\u3053\u306f\u300c\u30b3\u30fc\u30d2\u30fc1\u676f\u5206\u300d\u306e\u6642\u9593\u3067\u3001\u533b\u5b66\u82f1\u8a9e\u306b\u307e\u3064\u308f\u308b\u8a71\u3092\u6c17\u8efd\u306b\u697d\u3057\u3093\u3067\u3044\u305f\u3060\u304f\u30b3\u30fc\u30ca\u30fc\u3067\u3059\u3002<\/span><\/p>\r\n

\u672c\u65e5\u306e\u30c6\u30fc\u30de\u306f\u300c\u82f1\u8a9e\u3067\u306e\u75c7\u4f8b\u30d7\u30ec\u30bc\u30f3\u30c6\u30fc\u30b7\u30e7\u30f3\uff1a\u4e2d\u7d1a\u7de8<\/strong><\/span>\u300d\u3002<\/span><\/p>\r\n

\u533b\u7642\u306b\u304a\u3051\u308b\u82f1\u8a9e\u306e\u91cd\u8981\u6027\u304c\u9ad8\u307e\u308b\u4e2d\u3001\u6d77\u5916\u3067\u306e\u81e8\u5e8a\u5b9f\u7fd2\u3067\u306f\u3082\u3061\u308d\u3093\u3001\u65e5\u672c\u56fd\u5185\u306b\u304a\u3044\u3066\u3082\u300c\u82f1\u8a9e\u3067\u306e\u75c7\u4f8b\u30d7\u30ec\u30bc\u30f3\u30c6\u30fc\u30b7\u30e7\u30f3<\/strong>\u300dOral Case Presentation<\/strong> \u306e\u6a5f\u4f1a\u304c\u5897\u3048\u3066\u3044\u307e\u3059\u3002\u3057\u304b\u3057\u65e5\u672c\u306e\u533b\u5b66\u90e8\u3067\u306f\u82f1\u8a9e\u3067\u306e\u75c7\u4f8b\u30d7\u30ec\u30bc\u30f3\u30c6\u30fc\u30b7\u30e7\u30f3\u306e\u65b9\u6cd5\u3092\u7cfb\u7d71\u7684\u306b\u5b66\u3076\u6a5f\u4f1a\u306f\u305d\u3046\u591a\u304f\u306f\u3042\u308a\u307e\u305b\u3093\u3002<\/span><\/p>\r\n

\u305d\u3053\u3067\u4eca\u6708\u306f\u300cMenu 30\u82f1\u8a9e\u3067\u306e\u75c7\u4f8b\u30d7\u30ec\u30bc\u30f3\u30c6\u30fc\u30b7\u30e7\u30f3\uff1a\u57fa\u790e\u7de8<\/strong><\/span><\/a>\u300d\u306b\u5f15\u304d\u7d9a\u304d\u3001\u65e5\u672c\u306e\u533b\u5b66\u751f\u306b\u3088\u304f\u3042\u308b\u9593\u9055\u3044\u3068\u3001\u82f1\u8a9e\u3067\u306e\u75c7\u4f8b\u30d7\u30ec\u30bc\u30f3\u30c6\u30fc\u30b7\u30e7\u30f3\u306e\u57fa\u672c\u7684\u306a\u5b9a\u578b\u8868\u73fe\u3092\u3054\u7d39\u4ecb\u3057\u305f\u3044\u3068\u601d\u3044\u307e\u3059\u3002<\/span><\/p>\r\n

\u65e5\u672c\u306e\u533b\u5b66\u751f\u306b\u3088\u304f\u3042\u308b\u9593\u9055\u3044<\/strong><\/span><\/span>
\r\nMenu 30<\/strong><\/span><\/a> \u3067\u3082\u7d39\u4ecb\u3057\u305f\u3088\u3046\u306b\u3001\u82f1\u8a9e\u3067\u306e\u75c7\u4f8b\u30d7\u30ec\u30bc\u30f3\u30c6\u30fc\u30b7\u30e7\u30f3\u306b\u95a2\u3057\u3066\u4f55\u3082\u4e88\u5099\u77e5\u8b58\u306e\u306a\u3044\u533b\u5b66\u751f\u306e\u75c7\u4f8b\u30d7\u30ec\u30bc\u30f3\u30c6\u30fc\u30b7\u30e7\u30f3\u306b\u306f\u4e0b\u8a18\u306e\u3088\u3046\u306a\u7279\u5fb4\u304c\u3042\u308a\u307e\u3059\u3002<\/span><\/p>\r\n

\u3000<\/em>\u2022\u3000<\/em> \u7cfb\u7d71\u7acb\u3063\u3066\u3044\u306a\u3044<\/strong><\/span>
\r\n\u3000<\/em>\u2022\u3000<\/em> \u9451\u5225\u75be\u60a3\u304c\u60f3\u8d77\u3055\u308c\u306a\u3044<\/strong><\/span>
\r\n\u3000<\/em>\u2022\u3000<\/em> \u82f1\u8a9e\u8868\u73fe\u304c\u62d9\u3044<\/strong><\/span><\/p>\r\n

\u3067\u3059\u304b\u3089\u307e\u305a\u306f Menu 30<\/strong><\/span><\/a> \u3067\u3001\u4e0b\u8a18\u306e\u4e09\u3064\u306e\u30dd\u30a4\u30f3\u30c8\u3092\u78ba\u8a8d\u3057\u3066\u304f\u3060\u3055\u3044\u3002<\/span><\/p>\r\n

\u3000<\/em>\u2022\u3000<\/em> <\/strong>S<\/strong><\/span>tructure: \u82f1\u8a9e\u75c7\u4f8b\u30d7\u30ec\u30bc\u30f3\u30c6\u30fc\u30b7\u30e7\u30f3\u306e\u300c\u578b<\/strong>\u300d\u3092\u5b88\u308b<\/span>
\r\n\u3000<\/em>\u2022\u3000<\/em> <\/strong>A<\/strong><\/span>rgument: \u9451\u5225\u8a3a\u65ad\u3092\u300c\u8b70\u8ad6<\/strong>\u300d\u3059\u308b\u305f\u3081\u306b\u5fc5\u8981\u5341\u5206\u306a\u60c5\u5831\u3092\u63d0\u4f9b\u3059\u308b<\/span>
\r\n\u3000<\/em>\u2022\u3000<\/em> <\/strong>D<\/strong><\/span>elivery: \u82f1\u8a9e\u75c7\u4f8b\u30d7\u30ec\u30bc\u30f3\u30c6\u30fc\u30b7\u30e7\u30f3\u306b\u7279\u6709\u306e\u300c\u5b9a\u578b\u8868\u73fe<\/strong>\u300d\u3092\u4f7f\u3046<\/span><\/p>\r\n

\u3053\u308c\u3089\u4e09\u3064\u306e\u30dd\u30a4\u30f3\u30c8\u3092\u610f\u8b58\u3057\u305f\u75c7\u4f8b\u30d7\u30ec\u30bc\u30f3\u30c6\u30fc\u30b7\u30e7\u30f3\u304c\u3067\u304d\u308b\u6bb5\u968e\u3092\u300c\u521d\u7d1a<\/strong>\u300d\u3068\u5b9a\u7fa9\u3057\u307e\u3059\u3002\u3057\u304b\u3057\u3053\u308c\u3089\u306e\u30dd\u30a4\u30f3\u30c8\u3092\u610f\u8b58\u3057\u3066\u3082\u3001\u65e5\u672c\u306e\u533b\u5b66\u751f\u306b\u306f\u4e0b\u8a18\u306e\u3088\u3046\u306a\u9593\u9055\u3044\u304c\u3088\u304f\u898b\u3089\u308c\u307e\u3059\u3002<\/span><\/p>\r\n

\u2022\u3000<\/em> <\/strong>\u300c\u8074\u8846\u306e\u8996\u70b9\u300d\u3092\u6b20\u3044\u3066\u3044\u308b<\/span>
\r\n\u2022\u3000<\/em> <\/strong>\u300c\u73fe\u75c5\u6b74\u300d\u306e\u60c5\u5831\u304c\u4e0d\u8db3\u3057\u3066\u3044\u308b<\/span>
\r\n\u2022\u3000<\/em> <\/strong>\u300c\u73fe\u75c5\u6b74\u300d\u306e\u8a18\u8ff0\u304c\u6a5f\u68b0\u7684\u3067\u3042\u308b<\/span>
\r\n\u2022\u3000<\/em> <\/strong>\u300c\u9670\u6027\u3068\u306a\u308b\u95a2\u9023\u9805\u76ee\u300d\u3092\u8ff0\u3079\u3066\u3044\u306a\u3044<\/span>
\r\n\u2022\u3000<\/em> <\/strong>\u8907\u6570\u5f62\u3084\u6642\u5236\u3092\u6b63\u3057\u304f\u4f7f\u3063\u3066\u3044\u306a\u3044<\/span>
\r\n\u2022\u3000<\/em> <\/strong>\u4e00\u822c\u82f1\u8a9e\u3068\u533b\u5b66\u82f1\u8a9e\u3092\u6b63\u3057\u304f\u4f7f\u3044\u5206\u3051\u3066\u3044\u306a\u3044<\/span>
\r\n\u2022\u3000<\/em> <\/strong>\u85ac\u5264\u540d\u30fb\u30d0\u30a4\u30bf\u30eb\u30b5\u30a4\u30f3\u30fb\u691c\u67fb\u306a\u3069\u3092\u5177\u4f53\u7684\u306b\u8ff0\u3079\u3066\u3044\u306a\u3044<\/span><\/p>\r\n

\u300c\u4e2d\u7d1a<\/strong>\u300d\u3068\u306a\u308b\u305f\u3081\u306b\u306f\u3053\u308c\u3089\u3092\u610f\u8b58\u3057\u3066\u6e96\u5099\u3059\u308b\u5fc5\u8981\u304c\u3042\u308a\u307e\u3059\u3002\u3067\u306f\u3053\u308c\u3089\u306e\u3088\u304f\u3042\u308b\u9593\u9055\u3044\u3092\u4e00\u3064\u305a\u3064\u898b\u3066\u3044\u304d\u307e\u3057\u3087\u3046\u3002<\/span><\/p>\r\n

\u300c\u8074\u8846\u306e\u8996\u70b9\u300d\u3092\u6b20\u3044\u3066\u3044\u308b<\/strong><\/span><\/span>
\r\n\u300c\u521d\u7d1a<\/strong>\u300d\u306e\u6bb5\u968e\u3067\u306f\u75c7\u4f8b\u30d7\u30ec\u30bc\u30f3\u30c6\u30fc\u30b7\u30e7\u30f3\u306e\u6e96\u5099\u3092\u3059\u308b\u3060\u3051\u3067\u7cbe\u4e00\u676f\u3067\u3001\u300c\u305d\u306e\u75c7\u4f8b\u30d7\u30ec\u30bc\u30f3\u30c6\u30fc\u30b7\u30e7\u30f3\u3092\u81ea\u5206\u304c\u8074\u3044\u3066\u3082\u7406\u89e3\u3067\u304d\u308b\u304b\uff1f<\/strong>\u300d\u3068\u3044\u3046\u8996\u70b9\u3092\u6b20\u3044\u3066\u3044\u307e\u3059\u3002\u3042\u308b\u7a0b\u5ea6\u6e96\u5099\u304c\u3067\u304d\u305f\u3089\u300c\u305d\u306e\u75c7\u4f8b\u30d7\u30ec\u30bc\u30f3\u30c6\u30fc\u30b7\u30e7\u30f3\u3092\u81ea\u5206\u304c\u81e8\u5e8a\u73fe\u5834\u3067\u8074\u304f<\/strong>\u300d\u3068\u3044\u3046\u3053\u3068\u3092\u60f3\u50cf\u3057\u3066\u307f\u307e\u3057\u3087\u3046\u3002\u3082\u3057\u3082\u300c\u81ea\u5206\u304c\u8074\u3044\u3066\u3082\u9451\u5225\u75be\u60a3\u304c\u60f3\u8d77\u3055\u308c\u306a\u3044<\/strong>\u300d\u3068\u3044\u3046\u3082\u306e\u3067\u3042\u308c\u3070\u3001\u4e0a\u8a18\u306b\u7d39\u4ecb\u3057\u305f Structure, Argument, and\/or Delivery \u306e\u3069\u3053\u304b\u306b\u554f\u984c\u304c\u3042\u308b\u3068\u3044\u3046\u3053\u3068\u3067\u3059\u3002\u300c\u81ea\u5206\u304c\u8074\u3044\u3066\u3082\u7406\u89e3\u3067\u304d\u306a\u3044<\/strong>\u300d\u3068\u3044\u3046\u75c7\u4f8b\u30d7\u30ec\u30bc\u30f3\u30c6\u30fc\u30b7\u30e7\u30f3\u306f\u3001\u4ed6\u306e\u4eba\u306b\u3082\u7406\u89e3\u3067\u304d\u307e\u305b\u3093\u3002\u307e\u305a\u306f\u300c\u8074\u8846\u306e\u8996\u70b9<\/strong>\u300d\u3092\u6301\u3063\u3066\u81ea\u5206\u306e\u75c7\u4f8b\u30d7\u30ec\u30bc\u30f3\u30c6\u30fc\u30b7\u30e7\u30f3\u3092\u6279\u5224\u7684\u306b\u898b\u3066\u307f\u307e\u3057\u3087\u3046\u3002<\/span><\/p>\r\n

\u300c\u73fe\u75c5\u6b74\u300d\u306e\u60c5\u5831\u304c\u4e0d\u8db3\u3057\u3066\u3044\u308b<\/strong><\/span><\/span>
\r\n\u65e5\u672c\u306e\u81e8\u5e8a\u73fe\u5834\u3067\u306f\u691c\u67fb\u306e\u91cd\u8981\u6027\u304c\u5f37\u8abf\u3055\u308c\u3066\u3044\u308b\u305f\u3081\u304b\u3001\u65e5\u672c\u306e\u533b\u5b66\u751f\u304c\u884c\u3046\u75c7\u4f8b\u30d7\u30ec\u30bc\u30f3\u30c6\u30fc\u30b7\u30e7\u30f3\u3067\u306f\u300c\u533b\u7642\u9762\u63a5\u30fb\u75c5\u6b74\u8074\u53d6\u300dHistory Taking \u304c\u8efd\u8996\u3055\u308c\u308b\u50be\u5411\u304c\u3042\u308a\u307e\u3059\u3002\u3057\u304b\u3057\u82f1\u8a9e\u3067\u306e\u75c7\u4f8b\u30d7\u30ec\u30bc\u30f3\u30c6\u30fc\u30b7\u30e7\u30f3\u306b\u304a\u3044\u3066\u6700\u91cd\u8981\u9805\u76ee\u306f<\/strong>\u300c\u73fe\u75c5\u6b74<\/strong>\u300dHistory of Present Illness<\/strong> (HPI<\/strong>) \u3068\u8a00\u3048\u307e\u3059\u3002\u82f1\u8a9e\u3067\u306e\u75c7\u4f8b\u30d7\u30ec\u30bc\u30f3\u30c6\u30fc\u30b7\u30e7\u30f3\u3067\u306f HPI \u304c History Taking \u306e\u534a\u5206\u4ee5\u4e0a\uff08\u5c11\u306a\u304f\u3068\u30823\u5206\u306e1\u4ee5\u4e0a\uff09\u3068\u306a\u308b\u306e\u304c\u4e00\u822c\u7684\u3067\u3042\u308b\u3068\u3044\u3046\u3053\u3068\u3092\u8a8d\u8b58\u3057\u3066\u304f\u3060\u3055\u3044\u3002<\/span><\/p>\r\n

\u300c\u73fe\u75c5\u6b74\u300d\u306e\u8a18\u8ff0\u304c\u6a5f\u68b0\u7684\u3067\u3042\u308b<\/strong><\/span><\/span>
\r\n\u6b21\u306b\u591a\u3044\u9593\u9055\u3044\u304c\u3001\u3053\u306e HPI \u3092OPQRST<\/strong> (O<\/strong>nset, P<\/strong>rovoking & P<\/strong>alliating Factors, Q<\/strong>uality, R<\/strong>egion & R<\/strong>adiation, S<\/strong>everity, and T<\/strong>iming) \u306a\u3069\u306e\u300c\u8a9e\u5442\u5408\u308f\u305b<\/strong>\u300d mnemonics<\/strong> \u306e\u9805\u76ee\u3092\u4f7f\u3063\u3066\u300c\u6a5f\u68b0\u7684<\/strong>\u300d\u306b\u8ff0\u3079\u308b\u3068\u3044\u3046\u3053\u3068\u3067\u3059\u3002\u306a\u305c\u305d\u308c\u304c\u826f\u304f\u306a\u3044\u304b\u3068\u3044\u3046\u3068\u3001\u305d\u308c\u304c\u8074\u8846\u306b\u3068\u3063\u3066\u9451\u5225\u306e\u52a9\u3051\u3068\u306a\u3089\u306a\u3044\u3053\u3068\u304c\u591a\u3044\u304b\u3089\u3067\u3059\u3002<\/span><\/p>\r\n

\u4e0a\u8ff0\u3057\u305f\u3088\u3046\u306b HPI \u306fHistory Taking \u306b\u3068\u3063\u3066\u6700\u3082\u91cd\u8981\u3067\u3059\u3002\u3068\u8a00\u3046\u306e\u3082\u9069\u5207\u306a HPI \u306b\u3088\u3063\u3066\u8a3a\u65ad\u304c\u53ef\u80fd\u3068\u306a\u308b\u5834\u5408\u304c\u591a\u3044\u304b\u3089\u3067\u3059\u3002\u4f8b\u3048\u3070\u300c\u51a0\u52d5\u8108\u75be\u60a3\u300dcoronary artery diseases \u3067\u3042\u308b\u300c\u5fc3\u7b4b\u6897\u585e\u300dmyocardial infarction \u3084\u300c\u5b89\u5b9a\u72ed\u5fc3\u75c7\u300dstable angina pectoris\u3001\u300c\u4e0d\u5b89\u5b9a\u72ed\u5fc3\u75c7\u300dunstable myocardial infarction\u3001\u305d\u3057\u3066\u300c\u7570\u578b\u72ed\u5fc3\u75c7\u300dvariant angina pectoris \u306a\u3069\u306f\u3001\u9069\u5207\u306a HPI \u3060\u3051\u3067\u8a3a\u65ad\u304c\u3042\u308b\u7a0b\u5ea6\u60f3\u8d77\u3055\u308c\u307e\u3059<\/strong>\u3002\u3053\u3046\u3044\u3063\u305f\u9451\u5225\u75be\u60a3\u3092\u610f\u8b58\u305b\u305a\u306b\u305f\u3060\u300c\u6a5f\u68b0\u7684\u300d\u306b OPQRST \u3092\u9805\u76ee\u9806\u306b\u8ff0\u3079\u3089\u308c\u3066\u3082\u8074\u3044\u3066\u3044\u308b\u65b9\u306f\u9451\u5225\u75be\u60a3\u3092\u60f3\u8d77\u3059\u308b\u3053\u3068\u306f\u3067\u304d\u307e\u305b\u3093\u3002<\/span><\/p>\r\n

\u3067\u3059\u304b\u3089HPI \u3067\u306f OPQRST \u306a\u3069\u3092\u9805\u76ee\u9806\u306b\u8ff0\u3079\u308b\u306e\u3067\u306f\u306a\u304f\u3001\u201cDraw the picture of the patient\u2019s story<\/strong>\u201d \u3068\u3044\u3046\u3053\u3068\u3092\u610f\u8b58\u3057\u3066\u3001\u300c\u767a\u75c7\u524d<\/strong>\u300d\u300c\u767a\u75c7\u6642<\/strong>\u300d\u300c\u767a\u75c7\u5f8c<\/strong>\u300d\u306e\u3088\u3046\u306b\u6642\u7cfb\u5217<\/strong>\u3067\u75c7\u72b6\u306e\u5909\u5316\u3092\u8ff0\u3079\u3066\u3044\u304d\u307e\u3057\u3087\u3046\u3002OPQRST \u306e\u9805\u76ee\u306b\u95a2\u3059\u308b\u60c5\u5831\u306f\u3001\u3053\u306e\u6642\u7cfb\u5217\u3067\u8ff0\u3079\u3066\u3044\u304f\u4e2d\u3067\u9451\u5225\u75be\u60a3\u3092\u610f\u8b58\u3057\u3066\u8ff0\u3079\u308b<\/strong>\u3053\u3068\u3092\u5fc3\u304c\u3051\u3066\u304f\u3060\u3055\u3044\u3002<\/span><\/p>\r\n

\u300c\u9670\u6027\u3068\u306a\u308b\u95a2\u9023\u9805\u76ee\u300d\u3092\u8ff0\u3079\u3066\u3044\u306a\u3044<\/strong><\/span><\/span>
\r\n\u75c7\u4f8b\u30d7\u30ec\u30bc\u30f3\u30c6\u30fc\u30b7\u30e7\u30f3\u3067\u306f\u3001\u6307\u5c0e\u533b\u3082\u542b\u3081\u3066\u8074\u8846\u5168\u54e1\u304c\u982d\u306e\u4e2d\u3067\u8a3a\u65ad\u3092\u884c\u3044\u306a\u304c\u3089\u8074\u3044\u3066\u3044\u307e\u3059\u3002\u5f93\u3063\u3066\u8074\u8846\u306e\u533b\u5e2b\u3084\u533b\u5b66\u751f\u5168\u54e1\u304c\u7d0d\u5f97\u3057\u3066\u8a3a\u65ad\u306b\u5230\u9054\u3067\u304d\u308b\u306e\u304c\u826f\u3044\u75c7\u4f8b\u30d7\u30ec\u30bc\u30f3\u30c6\u30fc\u30b7\u30e7\u30f3\u3068\u8a00\u3048\u307e\u3059<\/strong>\u3002<\/span><\/p>\r\n

\u305d\u306e\u305f\u3081\u306b\u306f\u300c\u967d\u6027\u3068\u306a\u308b\u95a2\u9023\u9805\u76ee<\/strong>\u300dpertinent positives<\/strong><\/span> \u3068\u300c\u9670\u6027\u3068\u306a\u308b\u95a2\u9023\u9805\u76ee<\/strong>\u300dpertinent negatives<\/strong><\/span> \u3092\u8ff0\u3079\u308b\u5fc5\u8981\u304c\u3042\u308b\u306e\u3067\u3059\u304c\u3001\u3053\u308c\u3089\u306e\u4e21\u65b9\u3001\u7279\u306b pertinent negatives<\/strong> \u3092\u8ff0\u3079\u306a\u3044\u533b\u5b66\u751f\u304c\u591a\u3044\u306e\u3067\u3059\u3002<\/span><\/p>\r\n

\u305f\u3068\u3048\u3070\u60a3\u8005\u3055\u3093\u306e\u4e3b\u8a34\u304c chest pain \u3067\u3001\u305d\u306e\u8a3a\u65ad\u304c myocardial infarction \u3067\u3042\u3063\u305f\u3068\u3057\u307e\u3057\u3087\u3046\u3002\u305d\u3057\u3066 myocardial infarction \u306b\u306f chest pain \u4ee5\u5916\u306b\u3082\u3001\u300c\u547c\u5438\u56f0\u96e3<\/strong>\u300d dyspnea<\/strong> \u3084\u300c\u5410\u304d\u6c17<\/strong>\u300d nausea<\/strong> \u306e\u3088\u3046\u306a\u95a2\u9023\u75c7\u72b6\u304c\u3042\u308a\u307e\u3059\u306e\u3067\u3001\u305d\u308c\u304c\u8a8d\u3081\u3089\u308c\u308b\u5834\u5408\u306b\u306f pertinent positives<\/strong><\/span> \u3068\u3057\u3066\u3001\u305d\u3057\u3066\u305f\u3068\u3048\u305d\u308c\u3089\u304c\u8a8d\u3081\u3089\u308c\u306a\u304f\u3066\u3082 pertinent negatives<\/strong><\/span> \u3068\u3057\u3066\u8ff0\u3079\u3066\u3044\u304f\u5fc5\u8981\u304c\u3042\u308a\u307e\u3059\u3002\u307e\u305f myocardial infarction \u4ee5\u5916\u306e\u9451\u5225\u75be\u60a3\u3067\u3042\u308b\u300c\u80ba\u708e<\/strong>\u300dpneumonia<\/strong> \u306b\u306f\u3001\u300c\u54b3<\/strong>\u300dcough<\/strong> \u3084\u300c\u75f0<\/strong>\u300dsputum<\/strong> \u3068\u3044\u3063\u305f\u95a2\u9023\u75c7\u72b6\u304c\u3042\u308a\u307e\u3059\u3002\u305d\u3057\u3066\u3053\u3046\u3044\u3063\u305f\u95a2\u9023\u75c7\u72b6\u304c\u8a8d\u3081\u3089\u308c\u306a\u3044\u5834\u5408\u306b\u3082\u3001\u305d\u308c\u3089\u3092 pertinent negatives<\/strong><\/span> \u3068\u3057\u3066\u8ff0\u3079\u3066\u3044\u304f\u5fc5\u8981\u304c\u3042\u308b\u306e\u3067\u3059\u3002<\/span><\/p>\r\n

\u8074\u8846\u3067\u3042\u308b\u6307\u5c0e\u533b\u3084\u4ed6\u306e\u533b\u5b66\u751f\u304b\u3089\u8ffd\u52a0\u306e\u8cea\u554f\u3092\u3055\u308c\u306a\u3044\u306e\u304c\u826f\u3044\u75c7\u4f8b\u30d7\u30ec\u30bc\u30f3\u30c6\u30fc\u30b7\u30e7\u30f3\u306e\u6761\u4ef6<\/strong>\u3067\u3059\u3002\u81ea\u5206\u304c\u8003\u3048\u308b\u8a3a\u65ad\u3084\u9451\u5225\u75be\u60a3\u3067\u306f\u4e3b\u8a34\u4ee5\u5916\u306b\u3069\u306e\u3088\u3046\u306a\u75c7\u72b6\u3084\u30ea\u30b9\u30af\u30d5\u30a1\u30af\u30bf\u30fc\u304c\u3042\u308b\u306e\u304b\u3092\u8003\u3048\u3001\u305d\u308c\u3089\u304c\u8a8d\u3081\u3089\u308c\u308b\u5834\u5408\u306b\u306f pertinent positives \u3068\u3057\u3066\u3001\u305d\u3057\u3066\u8a8d\u3081\u3089\u308c\u306a\u3044\u5834\u5408\u306b\u306f pertinent negatives \u3068\u3057\u3066\u8ff0\u3079\u308b\u3088\u3046\u306b\u3057\u3066\u304f\u3060\u3055\u3044\u3002<\/span><\/p>\r\n

\u8907\u6570\u5f62\u3084\u6642\u5236\u3092\u6b63\u3057\u304f\u4f7f\u3063\u3066\u3044\u306a\u3044<\/strong><\/span><\/span>
\r\n\u8907\u6570\u5f62\u3084\u6642\u5236\u3082\u591a\u304f\u306e\u5b66\u751f\u3055\u3093\u306f\u9593\u9055\u3063\u3066\u4f7f\u3063\u3066\u3044\u307e\u3059\u3002
\r\n\u4e0b\u8a18\u306e\u8868\u73fe\u306f\u5168\u3066\u9593\u9055\u3044\u306a\u306e\u3067\u3059\u304c\u3001\u7686\u3055\u3093\u306f\u6b63\u3057\u3044\u8868\u73fe\u304c\u308f\u304b\u308a\u307e\u3059\u304b\uff1f<\/span><\/p>\r\n

\u2022\u3000<\/em> <\/strong>The patient is a 48-years<\/strong><\/span>-old woman, who presented with two-hours<\/strong><\/span>-history<\/span>
\r\n\u2002\u3000<\/em> <\/strong>of intermittent chest pain.<\/span>
\r\n\u2022\u3000<\/em> <\/strong>His vital sign<\/strong><\/span> is<\/strong><\/span> within normal limit<\/strong><\/span>.<\/span>
\r\n\u2022\u3000<\/em> <\/strong>His weight was<\/strong><\/span> 67 kilogram<\/strong><\/span>.<\/span><\/p>\r\n

\u8907\u6570\u306e\u540d\u8a5e\u3092\u30cf\u30a4\u30d5\u30f3\u3067\u7e4b\u3052\u3066\u5f62\u5bb9\u8a5e\u3068\u3059\u308b\u5834\u5408\u3001\u305d\u308c\u305e\u308c\u306e\u540d\u8a5e\u306f\u5358\u6570\u5f62\u306b\u3059\u308b\u5fc5\u8981\u304c\u3042\u308a\u307e\u3059\u3002\u3057\u305f\u304c\u3063\u3066 \u201c48-years<\/strong>-old woman\u201d \u3084 \u201ctwo-hours<\/strong>-history\u201d \u3067\u306f\u306a\u304f\u3001 \u201c48-year<\/strong><\/span>-old woman\u201d \u3084 \u201ctwo-hour<\/strong><\/span>-history\u201d \u3068\u3059\u308b\u5fc5\u8981\u304c\u3042\u308a\u307e\u3059\u3002<\/span><\/p>\r\n

\u65e5\u672c\u8a9e\u306b\u3082\u306a\u3063\u3066\u3044\u308b\u300c\u30d0\u30a4\u30bf\u30eb\u30b5\u30a4\u30f3<\/strong>\u300d\u3067\u3059\u304c\u3001\u3053\u308c\u306b\u306f\u8907\u6570\u306e\u9805\u76ee\u304c\u542b\u307e\u308c\u308b\u306e\u3067\u3001\u82f1\u8a9e\u3067\u306f vital signs<\/strong><\/span> \u306e\u3088\u3046\u306b\u5fc5\u305a\u8907\u6570\u5f62\u306b\u306a\u308a\u307e\u3059\u3002\u307e\u305f\u300c\u6b63\u5e38\u7bc4\u56f2\u5185\u300d\u306f upper limit \u3068lower limit \u3068\u3044\u3046\u4e8c\u3064\u306e limits \u306e\u9593\u306b\u3042\u308b\u308f\u3051\u3067\u3059\u304b\u3089\u3001within normal limits<\/strong><\/span> \u306e\u3088\u3046\u306b\u5fc5\u305a\u8907\u6570\u5f62\u306b\u306a\u308a\u307e\u3059\u3002\u305d\u3057\u3066\u3053\u306e withing normal limits (WNL) \u306f\u300c\u6570\u5024<\/strong>\u300d\u306b\u5bfe\u3057\u3066\u4f7f\u3048\u308b\u8868\u73fe\u3067\u3059\u306e\u3067\u3001\u753b\u50cf\u691c\u67fb\u306a\u3069\u306b \u201cThe chest X-ray is within normal limits.\u201d \u306e\u3088\u3046\u306b\u4f7f\u3046\u3053\u3068\u306f\u3067\u304d\u307e\u305b\u3093\u3002\u6b63\u3057\u304f\u306f \u201cThe chest X-ray is unremarkable for pathology<\/strong><\/span>.\u201d \u306e\u3088\u3046\u306b\u8868\u73fe\u3057\u307e\u3059\u3002<\/span><\/p>\r\n

\u307e\u305f\u82f1\u8a9e\u306e\u5358\u4f4d\u306f\u6570\u5b57\u304c1\u4ee5\u5916\u306e\u5834\u5408\u3001\u5fc5\u305a\u8907\u6570\u5f62\u306b\u306a\u308a\u307e\u3059\u3002\u5f93\u3063\u3066\u300c\uff11\u30ad\u30ed\u30b0\u30e9\u30e0<\/strong>\u300d\u306f\u82f1\u8a9e\u3067\u306f one kilogram<\/strong><\/span> \u3068\u306a\u308a\u307e\u3059\u304c\u3001\u300c67\u30ad\u30ed\u30b0\u30e9\u30e0<\/strong>\u300d\u306f sixty seven kilograms<\/strong><\/span> \u306e\u3088\u3046\u306b\u8907\u6570\u5f62\u306b\u306a\u308a\u307e\u3059\u3002<\/span><\/p>\r\n

\u8eab\u4f53\u8a3a\u5bdf\u306e\u6240\u898b\u3092\u8ff0\u3079\u308b\u5834\u5408\u306b\u300c\u8eab\u4f53\u8a3a\u5bdf\u3092\u3057\u305f\u306e\u306f\u904e\u53bb\u306a\u306e\u3060\u304b\u3089\u904e\u53bb\u5f62\u3092\u4f7f\u3046\u3079\u304d\u3060\u300d\u3068\u3044\u3046\u7406\u5c48\u306f\u7406\u89e3\u3067\u304d\u308b\u306e\u3067\u3059\u304c\u3001\u3053\u308c\u3089\u3092\u904e\u53bb\u5f62\u3067\u8868\u73fe\u3059\u308b\u3068\u300c\u4eca\u306e\u8eab\u4f53\u6240\u898b\u306f\u305d\u306e\u6642\u306e\u6240\u898b\u3068\u306f\u9055\u3046<\/strong>\u300d\u3068\u3044\u3046\u30a4\u30e1\u30fc\u30b8\u3092\u4e0e\u3048\u3066\u3057\u307e\u3044\u307e\u3059\u3002\u3067\u3059\u304b\u3089\u300c\u8eab\u4f53\u8a3a\u5bdf\u3092\u3057\u305f\u306e\u306f\u904e\u53bb\u3060\u304c\u3001\u4eca\u3082\u305d\u306e\u8eab\u4f53\u6240\u898b\u306f\u5909\u308f\u3063\u3066\u3044\u306a\u3044<\/strong>\u300d\u3068\u3044\u3046\u5834\u5408\u306b\u306f\u3001 \u201cHis weight is<\/strong><\/span> 67 kilograms.\u201d \u306e\u3088\u3046\u306b\u73fe\u5728\u5f62\u3092\u4f7f\u3046\u306e\u304c\u4e00\u822c\u7684<\/strong>\u3067\u3059\u3002<\/span><\/p>\r\n

\u4e00\u822c\u82f1\u8a9e\u3068\u533b\u5b66\u82f1\u8a9e\u3092\u6b63\u3057\u304f\u4f7f\u3044\u5206\u3051\u3066\u3044\u306a\u3044<\/strong><\/span><\/span>
\r\n\u3053\u308c\u306b\u95a2\u3057\u3066\u306f\u7d76\u5bfe\u7684\u306a\u57fa\u6e96\u304c\u3042\u308b\u308f\u3051\u3067\u306f\u3042\u308a\u307e\u305b\u3093\u304c\u3001\u300c\u4e3b\u8a34<\/strong>\u300dChief Complaint<\/strong> \u3084\u300c\u73fe\u75c5\u6b74<\/strong>\u300dHistory of Present Illness<\/strong> \u306b\u304a\u3044\u3066\u306f\u60a3\u8005\u3055\u3093\u304c\u4f7f\u3063\u305f\u8868\u73fe\u3092\u4e00\u822c\u82f1\u8a9e\u3067\u305d\u306e\u307e\u307e\u4f7f\u3046\u3053\u3068\u304c\u4e00\u822c\u7684\u3067\u3059\u3002\u300c\u529b\u304c\u5f31\u3044\u300dweakness \u3068\u3044\u3046\u75c7\u72b6\u304c\u4e3b\u8a34\u3067\u3042\u308b\u5834\u5408\u3001\u305d\u306e weakness \u304c neurological weakness \u306a\u306e\u304b functional weakness \u306a\u306e\u304b\u306e\u533a\u5225\u3092\u73fe\u75c5\u6b74\u3067\u8a18\u8ff0\u3059\u308b\u5fc5\u8981\u304c\u3042\u308a\u307e\u3059\u3002\u300c\u7b4b\u529b\u4f4e\u4e0b\u306e\u533b\u5b66\u82f1\u8a9e\u306f paresis \u306a\u306e\u3060\u304b\u3089\u3001\u4e3b\u8a34\u3084\u73fe\u75c5\u6b74\u3067\u3082 paresis\u3068\u3044\u3046\u533b\u5b66\u82f1\u8a9e\u3092\u4f7f\u3046\u300d\u3068\u3044\u3046\u3053\u3068\u3092\u3057\u3066\u3057\u307e\u3046\u3068\u3001\u305d\u308c\u3092\u8074\u3044\u3066\u3044\u308b\u8074\u8846\u306f\u9593\u9055\u3063\u305f\u524d\u63d0\u3067\u9451\u5225\u8a3a\u65ad\u3092\u9032\u3081\u308b\u53ef\u80fd\u6027\u304c\u3042\u308a\u307e\u3059\u3002<\/span><\/p>\r\n

\u3053\u3046\u3044\u3063\u305f\u3053\u3068\u3092\u9632\u3050\u305f\u3081\u3001\u300c\u65e2\u5f80\u6b74<\/strong>\u300dPast Medical History \u4ee5\u964d\u306e\u9805\u76ee\u3067\u306f\u533b\u5b66\u82f1\u8a9e\u3092\u4f7f\u3046\u3079\u304d<\/strong>\u3067\u3059\u304c\u3001Chief Complaint \u3068History of Present Illness \u306b\u304a\u3044\u3066\u306f\u60a3\u8005\u3055\u3093\u304c\u4f7f\u3063\u305f\u8868\u73fe\u3092\u305d\u306e\u307e\u307e\u4e00\u822c\u82f1\u8a9e\u3068\u3057\u3066\u4f7f\u3046<\/strong><\/span>\u3053\u3068\u3092\u5fc3\u304c\u3051\u3066\u304f\u3060\u3055\u3044\u3002<\/span><\/p>\r\n

\u85ac\u5264\u540d\u30fb\u30d0\u30a4\u30bf\u30eb\u30b5\u30a4\u30f3\u30fb\u691c\u67fb\u306a\u3069\u3092\u5177\u4f53\u7684\u306b\u8ff0\u3079\u3066\u3044\u306a\u3044<\/strong><\/span><\/span>
\r\n\u6700\u5f8c\u306b\u6307\u6458\u3057\u3066\u304a\u304d\u305f\u3044\u3088\u304f\u3042\u308b\u9593\u9055\u3044\u306f\u3001\u300c\u85ac\u5264\u540d<\/strong>\u300d\u300c\u30d0\u30a4\u30bf\u30eb\u30b5\u30a4\u30f3<\/strong>\u300d\u300c\u691c\u67fb<\/strong>\u300d\u306a\u3069\u3092\u5177\u4f53\u7684\u306b\u8ff0\u3079\u3066\u3044\u306a\u3044\u3068\u3044\u3046\u3053\u3068\u3067\u3059\u3002<\/span><\/p>\r\n

\u300c\u85ac<\/strong>\u300dMedications<\/strong> \u306e\u9805\u76ee\u3067 \u201cMedications: The patient is currently on antihypertensives<\/strong>.\u201d \u306e\u3088\u3046\u306a\u66d6\u6627\u306a\u8a18\u8ff0\u306f\u75c7\u4f8b\u30d7\u30ec\u30bc\u30f3\u30c6\u30fc\u30b7\u30e7\u30f3\u3067\u306f\u4e0d\u5341\u5206\u3067\u3059\u3002\u300c\u964d\u5727\u5264<\/strong>\u300dantihypertensive<\/strong> \u3067\u3042\u308b\u306a\u3089\u3070\u3001\u305d\u306e\u964d\u5727\u5264\u306e\u85ac\u5264\u540d\u3092\u5177\u4f53\u7684\u306b\u8ff0\u3079\u308b\u3053\u3068\u304c\u5fc5\u8981<\/strong>\u3067\u3059\u3002<\/span><\/p>\r\n

\u300c\u30d0\u30a4\u30bf\u30eb\u30b5\u30a4\u30f3<\/strong>\u300dVital Signs<\/strong> \u3082 \u201cThe vital signs are within normal limits.\u201d \u306e\u3088\u3046\u306b\u8ff0\u3079\u308b\u3053\u3068\u306f\u907f\u3051\u307e\u3057\u3087\u3046\u3002\u82f1\u8a9e\u3067\u306f \u201cVital signs are vital<\/strong>.\u201d \u3068\u3044\u3046\u8868\u73fe\u304c\u3042\u308b\u3088\u3046\u306b\u3001vital signs \u306f\u305d\u308c\u305e\u308c\u306e\u9805\u76ee\u306b\u91cd\u8981\u306a\u610f\u5473\u304c\u3042\u308a\u307e\u3059\u3002\u305f\u3068\u3048\u6b63\u5e38\u3067\u3042\u3063\u305f\u3068\u3057\u3066\u3082 vital signs \u306f\u305d\u308c\u305e\u308c\u306e\u9805\u76ee\u3092\u5177\u4f53\u7684\u306b\u8ff0\u3079\u308b<\/strong>\u3088\u3046\u306b\u3057\u3066\u304f\u3060\u3055\u3044\u3002<\/span><\/p>\r\n

\u305d\u3057\u3066\u300c\u691c\u67fb<\/strong>\u300dWorkup<\/strong> \u3067\u3082\u305d\u308c\u305e\u308c\u306e\u9805\u76ee\u3092\u5177\u4f53\u7684\u306b\u8ff0\u3079\u308b\u3088\u3046\u306b\u3057\u307e\u3057\u3087\u3046\u3002\u3088\u304f\u300c\u8840\u6db2\u691c\u67fb<\/strong>\u300d\u3068\u3044\u3046\u610f\u5473\u3067 Blood Tests<\/strong>\uff08\u3053\u308c\u306f\u5fc5\u305a\u8907\u6570\u5f62\u3067\u3059\uff09\u3068\u3044\u3046\u8868\u73fe\u3092\u4f7f\u3046\u5b66\u751f\u3055\u3093\u304c\u3044\u307e\u3059\u304c\u3001\u3053\u308c\u306f\u66d6\u6627\u3059\u304e\u308b\u8868\u73fe\u3067\u3059\u3002\u3069\u306e\u3088\u3046\u306a\u8840\u6db2\u691c\u67fb\u3092\u3057\u305f\u3044\u306e\u304b\u3001\u5177\u4f53\u7684\u306b\u4e0b\u8a18\u306e\u3088\u3046\u306a\u9805\u76ee\u3092\u8ff0\u3079\u308b\u3053\u3068\u304c\u5fc5\u8981<\/strong>\u3067\u3059\u3002<\/span><\/p>\r\n

\u2022\u3000<\/em> <\/strong>\u5168\u8840\u7b97\uff1aComplete Blood Count (CBC)\/Full Blood Count (FBC)<\/span>
\r\n\u2022\u3000<\/em> <\/strong>\u751f\u5316\u5b66\u691c\u67fb\uff1aBlood Chemistry Tests<\/span>
\r\n\u2022\u3000<\/em> <\/strong>\u809d\u6a5f\u80fd\u691c\u67fb\uff1aLiver Function Tests (LFT)\/Liver Panel\/Liver Enzymes<\/span>
\r\n\u2022\u3000<\/em> <\/strong>\u51dd\u56fa\u691c\u67fb\uff1aCoagulation Tests\/Coagulations Panel<\/span>
\r\n\u2022\u3000<\/em> <\/strong>\u52d5\u8108\u8840\u30ac\u30b9\u5206\u6790\uff1aArterial Blood Gas (ABG)<\/span><\/p>\r\n

\u3053\u308c\u307e\u3067\u591a\u304f\u306e\u5b66\u751f\u3055\u3093\u306e\u75c7\u4f8b\u30d7\u30ec\u30bc\u30f3\u30c6\u30fc\u30b7\u30e7\u30f3\u3092\u6307\u5c0e\u3057\u3066\u304d\u307e\u3057\u305f\u304c\u3001\u3053\u308c\u3089\u304c\u4ee3\u8868\u7684\u306a\u9593\u9055\u3044\u3067\u3059\u3002\u300c\u57fa\u790e<\/strong>\u300d\u7de8\u3067\u7d39\u4ecb\u3057\u305f\u5185\u5bb9\u306b\u52a0\u3048\u3066\u3053\u308c\u3089\u300c\u3088\u304f\u3042\u308b\u9593\u9055\u3044\u300d\u3092\u610f\u8b58\u3059\u308c\u3070\u3001\u82f1\u8a9e\u3067\u306e\u75c7\u4f8b\u30d7\u30ec\u30bc\u30f3\u30c6\u30fc\u30b7\u30e7\u30f3\u306b\u304a\u3044\u3066\u300c\u4e2d\u7d1a<\/strong>\u300d\u3068\u547c\u3079\u308b\u30ec\u30d9\u30eb\u306b\u5230\u9054\u3059\u308b\u3053\u3068\u304c\u3067\u304d\u308b\u3067\u3057\u3087\u3046\u3002<\/span><\/p>\r\n

\u82f1\u8a9e\u3067\u306e\u75c7\u4f8b\u30d7\u30ec\u30bc\u30f3\u30c6\u30fc\u30b7\u30e7\u30f3\u306e\u5b9a\u578b\u8868\u73fe<\/strong><\/span><\/span>
\r\n\u3055\u3066\u3001\u305d\u308d\u305d\u308d\u30ab\u30c3\u30d7\u306e\u30b3\u30fc\u30d2\u30fc\u3082\u6b8b\u308a\u308f\u305a\u304b\u3067\u3059\u3002\u6700\u5f8c\u306b\u300c\u82f1\u8a9e\u3067\u306e\u75c7\u4f8b\u30d7\u30ec\u30bc\u30f3\u30c6\u30fc\u30b7\u30e7\u30f3\u306e\u5b9a\u578b\u8868\u73fe<\/strong>\u300d\u3068\u3057\u3066\u57fa\u672c\u7684\u306a\u3082\u306e\u3060\u3051\u3092\u307e\u3068\u3081\u3066\u304a\u304d\u307e\u3059\u3002\u3082\u3061\u308d\u3093\u3053\u308c\u304c\u5168\u3066\u3067\u306f\u3042\u308a\u307e\u305b\u3093\u306e\u3067\u3001First Aid for the USMLE Step 2 CS<\/strong> \u306a\u3069\u306e\u82f1\u8a9e\u570f\u306e\u533b\u5b66\u6559\u6750\u3082\u53c2\u7167\u3057\u3066\u304f\u3060\u3055\u3044\u3002<\/span><\/p>\r\n

1. Patient Information<\/strong><\/span>
\r\n\u2022\u3000<\/em> <\/strong>The patient is a\/an (age)-year-old (man\/woman) with (pertinent risk factors),<\/span>
\r\n\u2002\u3000<\/em> <\/strong>who presented with a (duration)-history of (chief complaint).<\/span><\/p>\r\n

2. History Taking<\/strong><\/span>
\r\nHistory of Present Illness (HPI)<\/strong><\/span>
\r\nOnset<\/strong><\/span>
\r\n\u2022\u3000<\/em> <\/strong>The patient had been in her\/his usual state of health until (\u3000\u3000)<\/span>
\r\n\u2002\u3000<\/em> <\/strong>days\/weeks\/months prior to the presentation, when she\/he noticed (\u3000\u3000). <\/span>
\r\nProvoking & Palliating Factors<\/strong><\/span>
\r\n\u2022\u3000<\/em> <\/strong>The (symptom) is aggravated by (\u3000\u3000).<\/span>
\r\n\u2022\u3000<\/em> <\/strong>The (symptom) is alleviated by (\u3000\u3000).<\/span>
\r\nQuality<\/strong><\/span>
\r\n\u2022\u3000<\/em> <\/strong>The patient describes the pain as (\u3000\u3000).<\/span>
\r\nRegion & Radiation<\/strong><\/span>
\r\n\u2022\u3000<\/em> <\/strong>The pain is located in (\u3000\u3000).<\/span>
\r\n\u2022\u3000<\/em> <\/strong>The pain is localized in (\u3000\u3000) and does not move anywhere else.<\/span>
\r\n\u2022\u3000<\/em> <\/strong>The pain is located in (\u3000\u3000) and moves to (\u3000\u3000).<\/span>
\r\nSeverity<\/strong><\/span>
\r\n\u2022\u3000<\/em> <\/strong>The patient rates the pain as (\u3000\u3000) out of 10.<\/span>
\r\n\u2022\u3000<\/em> <\/strong>The pain was initially rated as (\u3000\u3000) out of 10, but it progressed to (\u3000\u3000) out of 10<\/span>
\r\n\u2002\u3000<\/em> <\/strong>over (\u3000\u3000) minutes.<\/span>
\r\nTime<\/strong><\/span>
\r\n\u2022\u3000<\/em> <\/strong>The pain lasted for (\u3000\u3000) minutes.<\/span><\/p>\r\n

Past Medical History (PMH)<\/strong><\/span>
\r\n\u2022\u3000<\/em> <\/strong>Her\/His past medical history is unremarkable\/noncontributory.<\/span>
\r\n\u2022\u3000<\/em> <\/strong>Her\/His past medical history is significant\/remarkable for (\u3000\u3000) years of<\/span>
\r\n\u2002\u3000<\/em> <\/strong>(disease).<\/span>
\r\n\u2022\u3000<\/em> <\/strong>Besides a (\u3000\u3000)-year history of (\u3000\u3000), her\/his past medical history is <\/span>
\r\n\u2002\u3000<\/em> <\/strong>unremarkable\/noncontributory.<\/span>
\r\n\u2022\u3000<\/em> <\/strong>The patient was hospitalized for (disease) (\u3000\u3000) at the age of (\u3000\u3000).<\/span><\/p>\r\n

Past Surgical History (PSH)<\/strong><\/span>
\r\n\u2022\u3000<\/em> <\/strong>The patient underwent (\u3000\u3000) at the age of (\u3000\u3000).<\/span><\/p>\r\n

Medications (Meds)<\/strong><\/span>
\r\n\u2022\u3000<\/em> <\/strong>She\/He is currently on (\u3000\u3000) milligrams per day of (\u3000\u3000).<\/span>
\r\n\u2022\u3000<\/em> <\/strong>The patient takes no medications or nutritional supplements.<\/span><\/p>\r\n

Allergies<\/strong><\/span>
\r\n\u2022\u3000<\/em> <\/strong>The patient has known allergies to (\u3000\u3000), and it caused (\u3000\u3000).<\/span>
\r\n\u2022\u3000<\/em> <\/strong>The patient has no known allergies (NKA).<\/span>
\r\n\u2022\u3000<\/em> <\/strong>The patient has no known drug allergies (NKDA).<\/span><\/p>\r\n

Family History (FH)<\/strong><\/span>
\r\n\u2022\u3000<\/em> <\/strong>Her\/His family history is significant\/remarkable for (\u3000\u3000) in her\/his<\/span>
\r\n\u2002\u3000<\/em> <\/strong>(family member).<\/span>
\r\n\u2022\u3000<\/em> <\/strong>Her\/His family history is unremarkable\/noncontributory.<\/span>
\r\n\u2022\u3000<\/em> <\/strong>Her\/His parents are alive and well.<\/span>
\r\n\u2022\u3000<\/em> <\/strong>Her\/His maternal\/paternal grandmother\/grandfather died of (\u3000\u3000) at the<\/span>
\r\n\u2002\u3000<\/em> <\/strong> age of (\u3000\u3000).<\/span><\/p>\r\n

Social History (SH)<\/strong><\/span>
\r\n\u2022\u3000<\/em> <\/strong>The patient is married and lives with her\/his husband\/wife and her\/his<\/span>
\r\n\u2002\u3000<\/em> <\/strong>child\/children.<\/span>
\r\n\u2022\u3000<\/em> <\/strong>The patient works as a (\u3000\u3000).<\/span>
\r\n\u2022\u3000<\/em> <\/strong>The patient does not drink alcohol.<\/span>
\r\n\u2022\u3000<\/em> <\/strong>The patient drinks (\u3000\u3000) milliliters of (\u3000\u3000) per day.<\/span>
\r\n\u2022\u3000<\/em> <\/strong>The patient drinks (\u3000\u3000) glass(es) of (\u3000\u3000) on a social basis.<\/span>
\r\n\u2022\u3000<\/em> <\/strong>The patient has had (\u3000\u3000) can(s) of (\u3000\u3000) per day for the past (\u3000\u3000) years.<\/span>
\r\n\u2022\u3000<\/em> <\/strong>The patient has smoked (\u3000\u3000) packs of cigarettes per day for the past (\u3000\u3000)<\/span>
\r\n\u2002\u3000<\/em> <\/strong>years.<\/span>
\r\n\u2022\u3000<\/em> <\/strong>The patient has smoked one pack per day (PPD) for (\u3000\u3000) years.<\/span>
\r\n\u2022\u3000<\/em> <\/strong>The patient has a (\u3000\u3000) pack-year history of smoking.<\/span>
\r\n\u2022\u3000<\/em> <\/strong>The patient does not smoke.<\/span><\/p>\r\n

Review of Systems (ROS)<\/strong><\/span>
\r\n\u2022\u3000<\/em> <\/strong>Review of systems is negative except as mentioned in the history of present<\/span>
\r\n\u2002\u3000<\/em> <\/strong>illness.<\/span><\/p>\r\n

3. Physical Examination (PE)<\/strong><\/span>
\r\nVital Signs<\/strong><\/span>
\r\n\u2022\u3000<\/em> <\/strong>Her\/his temperature is (\u3000\u3000) degrees Celsius. <\/span>
\r\n\u2022\u3000<\/em> <\/strong>Her\/his blood pressure is (\u3000\u3000) over (\u3000\u3000) millimeters of mercury.<\/span>
\r\n\u2022\u3000<\/em> <\/strong>Her\/his heart rate is (\u3000\u3000) per minute with a sinus rhythm.<\/span>
\r\n\u2022\u3000<\/em> <\/strong>Her\/his respiratory rate is (\u3000\u3000) per minute.<\/span>
\r\n\u2022\u3000<\/em> <\/strong>Her\/his oxygen saturation is (\u3000\u3000) percent on room air.<\/span><\/p>\r\n

General Appearance (GA)<\/strong><\/span>
\r\n\u2022\u3000<\/em> <\/strong>The patient is in acute distress.<\/span>
\r\n\u2022\u3000<\/em> <\/strong>The patient is in no acute distress (NAD).<\/span>
\r\n\u2022\u3000<\/em> <\/strong>She\/He is well developed and well nourished. (Pediatrics)<\/span><\/p>\r\n

Mental Status (Mental)<\/strong><\/span>
\r\n\u2022\u3000<\/em> <\/strong>She\/He is alert, awake, and oriented times four (AAOx4).<\/span>
\r\n\u2022\u3000<\/em> <\/strong>She\/He is alert, awake, and oriented to name, place, time, and purpose.<\/span><\/p>\r\n

Head, Eyes, Ears, Nose and Throat (HEENT)<\/strong><\/span>
\r\n\u2022\u3000<\/em> <\/strong>The head is normocephalic and atraumatic (NC\/AT).<\/span>
\r\n\u2022\u3000<\/em> <\/strong>The extraocular muscles are intact (EOMI) bilaterally (b\/l).<\/span>
\r\n\u2022\u3000<\/em> <\/strong>The pupils are equal and round, react to light and accommodation (PERRLA)<\/span>
\r\n\u2002\u3000<\/em> <\/strong>bilaterally (b\/l).<\/span>
\r\n\u2022\u3000<\/em> <\/strong>No conjunctival pallor.<\/span>
\r\n\u2022\u3000<\/em> <\/strong>No conjunctival icterus.<\/span>
\r\n\u2022\u3000<\/em> <\/strong>The bilateral (b\/l) tympanic membranes (TM) are intact.<\/span>
\r\n\u2022\u3000<\/em> <\/strong>The mucous membranes are moist (MMM). <\/span>
\r\n\u2022\u3000<\/em> <\/strong>The neck is supple.<\/span>
\r\n\u2022\u3000<\/em> <\/strong>No jugular venous distention (JVD)<\/span>
\r\n\u2022\u3000<\/em> <\/strong>No cervical lymphadenopathy (LAD)<\/span>
\r\n\u2022\u3000<\/em> <\/strong>No carotid bruits<\/span>
\r\n\u2022\u3000<\/em> <\/strong>No goiter<\/span><\/p>\r\n

Cardiovascular (CV)<\/strong><\/span>
\r\n\u2022\u3000<\/em> <\/strong>Regular rate and rhythm (RRR)<\/span>
\r\n\u2022\u3000<\/em> <\/strong>Normal S1 and S2<\/span>
\r\n\u2022\u3000<\/em> <\/strong>No murmurs, rubs, or gallops (m\/r\/g)<\/span>
\r\n\u2022\u3000<\/em> <\/strong>Point of maximal intensity (PMI) is not displaced or not sustained.<\/span>
\r\n\u2022\u3000<\/em> <\/strong>Apical impulse is not displaced.<\/span>
\r\n\u2022\u3000<\/em> <\/strong>No hepatojugular reflux (HJR)<\/span>
\r\n\u2022\u3000<\/em> <\/strong>Capillary refill time (CRT) is less than 2 seconds.<\/span><\/p>\r\n

Pulmonary Exam (Chest)<\/strong><\/span>
\r\n\u2022\u3000<\/em> <\/strong>Clear to auscultation bilaterally (CTAB)<\/span>
\r\n\u2022\u3000<\/em> <\/strong>No wheezes, rhonchi, or crackles (w\/r\/c)<\/span>
\r\n\u2022\u3000<\/em> <\/strong>No egophony<\/span>
\r\n\u2022\u3000<\/em> <\/strong>No tactile fremitus <\/span>
\r\n\u2022\u3000<\/em> <\/strong>Resonant to percussion<\/span><\/p>\r\n

Abdominal Exam (Abdomen)<\/strong><\/span>
\r\n\u2022\u3000<\/em> <\/strong>Soft<\/span>
\r\n\u2022\u3000<\/em> <\/strong>Non-distended<\/span>
\r\n\u2022\u3000<\/em> <\/strong>Non-tender<\/span>
\r\n\u2022\u3000<\/em> <\/strong>No rebound or guarding<\/span>
\r\n\u2022\u3000<\/em> <\/strong>No pulsatile masses<\/span>
\r\n\u2022\u3000<\/em> <\/strong>Positive bowel sounds in all four quadrants<\/span>
\r\n\u2022\u3000<\/em> <\/strong>No high pitched or tinkling sounds<\/span>
\r\n\u2022\u3000<\/em> <\/strong>Resonant to percussion<\/span>
\r\n\u2022\u3000<\/em> <\/strong>No costovertebral angle (CVA) tenderness<\/span>
\r\n\u2022\u3000<\/em> <\/strong>No hepatosplenomegaly (HSM)<\/span><\/p>\r\n

Neurological Exam (Neuro)<\/strong><\/span>
\r\n\u2022\u3000<\/em> <\/strong>Cranial Nerve (CN) II through XII are intact.<\/span>
\r\n\u2022\u3000<\/em> <\/strong>No focal deficit<\/span>
\r\n\u2022\u3000<\/em> <\/strong>Deep tendon reflexes: symmetric 2+ in all extremities<\/span>
\r\n\u2022\u3000<\/em> <\/strong>Sensation: intact to pinprick and soft touch<\/span>
\r\n\u2022\u3000<\/em> <\/strong>Manual muscle test (MMT): 5 out of 5<\/span><\/p>\r\n

Extremities (EXT)<\/strong><\/span>
\r\n\u2022\u3000<\/em> <\/strong>Normal range of motion (ROM)<\/span>
\r\n\u2022\u3000<\/em> <\/strong>No joint swelling or erythema<\/span>
\r\n\u2022\u3000<\/em> <\/strong>No cyanosis<\/span>
\r\n\u2022\u3000<\/em> <\/strong>No clubbing<\/span>
\r\n\u2022\u3000<\/em> <\/strong>No edema<\/span><\/p>\r\n

Skin<\/strong><\/span>
\r\n\u2022\u3000<\/em> <\/strong>Intact<\/span>
\r\n\u2022\u3000<\/em> <\/strong>No lesions<\/span>
\r\n\u2022\u3000<\/em> <\/strong>Macule\/Patch\/Papule\/Plaque\/Nodule\/Pustule\/Vesicle\/Bulla<\/span><\/p>\r\n

4. Summary<\/strong><\/span>
\r\n\u2022\u3000<\/em> <\/strong>In summary, the patient is a\/an (age)-year-old (man\/woman) with (pertinent<\/span>
\r\n\u2002\u3000<\/em> <\/strong>risk factors), who presented with a (duration)-history of (chief complaint +<\/span>
\r\n\u2002\u3000<\/em> <\/strong>significant HPI), associated with (pertinent positives).<\/span><\/p>\r\n

5. Differential Diagnosis<\/strong><\/span>
\r\n\u2022\u3000<\/em> <\/strong>My list of differential diagnoses includes (#1 diagnosis), (#2 diagnosis), and<\/span>
\r\n\u2002\u3000<\/em> <\/strong>(#3 diagnosis).<\/span>
\r\n\u2022\u3000<\/em> <\/strong>My top differential diagnosis at this time would be (#1 diagnosis), because\u2026<\/span>
\r\n\u2022\u3000<\/em> <\/strong>(#2 diagnosis) is a diagnosis we would need to consider, because\u2026<\/span>
\r\n\u2022\u3000<\/em> <\/strong>(#3 diagnosis) is a diagnosis we would need to exclude, because\u2026<\/span><\/p>\r\n

6. Plan<\/strong><\/span>
\r\n\u2022\u3000<\/em> <\/strong>I would like to order (\u3000\u3000), because\u2026<\/span><\/p>\r\n

\u3067\u306f\u3001\u307e\u305f\u306e\u3054\u6765\u5e97\u3092\u304a\u5f85\u3061\u3057\u3066\u304a\u308a\u307e\u3059\u3002<\/span><\/p>\r\n

\u300cDr. \u62bc\u5473\u306e\u533b\u5b66\u82f1\u8a9e\u30ab\u30d5\u30a7\u300d\u3067\u306f\u7686\u3055\u3093\u304b\u3089\u6271\u3063\u3066\u6b32\u3057\u3044\u30c8\u30d4\u30c3\u30af\u3092\u52df\u96c6\u3044\u305f\u3057\u307e\u3059\u3002\u3053\u3061\u3089\u306e\u30ea\u30f3\u30af<\/strong><\/span><\/a>\u304b\u3089\u3053\u306e\u30ab\u30d5\u30a7\u3067\u6271\u3063\u3066\u6b32\u3057\u3044\u3068\u601d\u3046\u533b\u5b66\u82f1\u8a9e\u306e\u30c8\u30d4\u30c3\u30af\u3092\u3054\u81ea\u7531\u306b\u8a18\u8f09\u304f\u3060\u3055\u3044\u3002<\/span><\/p>\r\n

\u56fd\u969b\u533b\u7642\u798f\u7949\u5927\u5b66\u533b\u5b66\u90e8 \u533b\u5b66\u6559\u80b2\u7d71\u62ec\u30bb\u30f3\u30bf\u30fc \u6559\u6388\u3000\u62bc\u5473 \u8cb4\u4e4b<\/p>\r\n","protected":false},"excerpt":{"rendered":"\u3053\u3093\u306b\u3061\u306f\u3002\u300c\u533b\u5b66\u82f1\u8a9e\u30ab\u30d5\u30a7\u300d\u306b\u3088\u3046\u3053\u305d\uff01 \u3053\u3053\u306f\u300c\u30b3\u30fc\u30d2\u30fc1\u676f\u5206\u300d\u306e\u6642\u9593\u3067\u3001\u533b\u5b66\u82f1\u8a9e\u306b\u307e\u3064\u308f\u308b\u8a71\u3092\u6c17\u8efd\u306b\u697d\u3057\u3093\u3067\u3044\u305f\u3060\u304f\u30b3\u30fc\u30ca\u30fc\u3067\u3059\u3002 \u672c\u65e5\u306e\u30c6\u30fc\u30de\u306f\u300c\u82f1\u8a9e\u3067\u306e\u75c7\u4f8b\u30d7\u30ec\u30bc\u30f3\u30c6\u30fc\u30b7\u30e7\u30f3\uff1a\u4e2d\u7d1a\u7de8\u300d\u3002 \u533b\u7642\u306b\u304a\u3051\u308b\u82f1\u8a9e\u306e\u91cd\u8981","protected":false},"author":1,"featured_media":6876,"comment_status":"closed","ping_status":"closed","sticky":false,"template":"onecolumn-960.php","format":"standard","meta":{"_acf_changed":false,"_jin_ogp_image_url":"","_jin_last_featured_id":0,"footnotes":""},"categories":[63],"tags":[],"class_list":["post-7064","post","type-post","status-publish","format-standard","has-post-thumbnail","hentry","category-eigocafe"],"acf":[],"_links":{"self":[{"href":"https:\/\/wp.meccari.jp\/api\/wp\/v2\/posts\/7064","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/wp.meccari.jp\/api\/wp\/v2\/posts"}],"about":[{"href":"https:\/\/wp.meccari.jp\/api\/wp\/v2\/types\/post"}],"author":[{"embeddable":true,"href":"https:\/\/wp.meccari.jp\/api\/wp\/v2\/users\/1"}],"replies":[{"embeddable":true,"href":"https:\/\/wp.meccari.jp\/api\/wp\/v2\/comments?post=7064"}],"version-history":[{"count":2,"href":"https:\/\/wp.meccari.jp\/api\/wp\/v2\/posts\/7064\/revisions"}],"predecessor-version":[{"id":7071,"href":"https:\/\/wp.meccari.jp\/api\/wp\/v2\/posts\/7064\/revisions\/7071"}],"wp:featuredmedia":[{"embeddable":true,"href":"https:\/\/wp.meccari.jp\/api\/wp\/v2\/media\/6876"}],"wp:attachment":[{"href":"https:\/\/wp.meccari.jp\/api\/wp\/v2\/media?parent=7064"}],"wp:term":[{"taxonomy":"category","embeddable":true,"href":"https:\/\/wp.meccari.jp\/api\/wp\/v2\/categories?post=7064"},{"taxonomy":"post_tag","embeddable":true,"href":"https:\/\/wp.meccari.jp\/api\/wp\/v2\/tags?post=7064"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}