今回は、ノートについてもう少し詳しく。
まずはC.Cはこんな感じ。

C.C 43 yo F c/o 3 days of fever

HPIは
Pt states fever started 3 days ago and -----などと文章で書くこともできるが、私はほとんど箇条書きで書いた。日本人は英語のミスを減らすため、下記のように箇条書きにする人が多いようだ。

-Fever started 3 days ago
-Cough, runny nose and sore throat started 4 days ago
-Denies rash, n/v/c/d---

PEについては、鋳型を書いておく。 
これを何回も練習すればPEの順番や取るべき所見もわかるので、全てそらで書けるようにして欲しい。
もちろんこれは全てのPEのFullなので、前述のようにRoughを選択する場合は

Lung CTA B/L, no wheezes, no crackles, no rale
 
のみを書くことになる。
また、精神科症例では患者が服を着ていた場合実際の診察はしないが、下記のように問診による特別なPEが存在するため、留意してほしい。
 

HEENT: NC/AT, non tender. PERRLA, EOMI, Fundoscopy no papilledema. Visual acuity normal, No visual defect. TMs clear no redness no exudate. Nasal turbinate not congested. No nasal discharge. Oropharynx no tonsillar enlargement, erythema, exudate or vesicular lesion.

Neck: supple, no LAD. Thyroid not enlarged

Chest: Appears NL, non tender. Nl resp, excursion, fremitus equal and NL b/l. Lung CTA&P b/l, no wheezes, no crackles, no rales. No club

CV: RRR normal S1/S2, PMI not displaced, no MRG, no JVD. No clubbing or edema. No carotid artery bruits, peripheral arterial pulses 2 radial and dorsalis pedis b/l.

Abd: soft, not distended, BS 4()in 4Q, tympanic in 4Q, No tenderness, No CVA tenderness.  No hepatosplenomegaly. Negative murphy and obturator sign. No rebound, guarding or McBurney tenderness.

Back; No obvious deformities or signs of trauma. No spinous process or paraspinal tenderness.

LE; No obvious deformities or signs of trauma. No erythema or swelling. ROM WNL. Motor 5/5, DTR 2 b/l. Sensation intact to light touch and sharp pain. Peripheral artery pulses2 Radial and dorsal pedis. Negative McMurray, anterior drawer, and posterior drawer tests. Straight leg raise test negative.

Neuro: AAOx3, CN2-12 intact. Motor 5/5, DTR 2/4 in all 4 ext. Sensation to light touch, sharp pain, vibration sense and positional sense are intact in all ext. No Kernig or Brudzinski test. Coodination finger to nose intact. Gait stable, Romberg negative. Babinski NL b/l.

Psychiatric
Pt appears well-groomed.
A&Ox3.
Speech fluid and goal directed.
Remote and recent memory intact
Attention and concentration unimpaired
Mood euthymic. Affect c/w mood.
No hallucinations, delusions, or paranoia
No suicidal/homicidal ideation
Judgment are intact