**Centent(목차) **
2-001-02 ① Past history
2-001-03 ② Review of system
2-001-04 ③ Physical exam
2-001-05 ④ Trauma exam
2-001-06 ⑤ Neurology
2-001-07 ⑥ Psychiatric
Recording style-General
이어지는 간단한 메모들은 (여기서는
medical recording style 라고 이름 붙였다.) 환자의 병력청취를 위해
빠짐없이 물어볼 만한 것들을 정리해둔 것이다. 별책으로 가지고 있거나 외워둔다면 면담을 효율적으로 진행하고
중요한 질문도 빠짐없이 할 수 있을 것이다.
물론 모든 환자에게, 특히 응급실에서 아래와 같은 내용을 체크할 수는
없다. 어디까지나 머리속에 넣어두고 꼭 필요한 상황에서 즉시 연달아 질문할 수 있도록 숙달해 두는 것이
필요하다.
①
Past history
DM(diabete mellitus)/HTN(hypertension)/Tb[1](tuberculosis)/Hepatitis
Malignancy/allergy/asthma/thyroid diz(disease)/Stroke
Op(operation)/admission Hx(History) :
Current medication : (oriental, herval / Health
Care Products 포함)
Occupation
Smoking:
Alcohol
Travel
Family history
Last oral intake
[1] -/ + 의 경우 언제 어느병원에서 HERZ 후 치료종결 되었는지, 복약 중이라면 언제 시작, 어떤 약제를 먹는지, active 인지, pulmonary Tb/extraP 여부
② Review of system
GW(general weakness)/EF(easy fatigue)/POI(poor
oral intake)/Insomnia2
NS(night sweating)/WC(weight change)/My(Myalgia)/Ar(arthralgia)
F(fever)/C(chilling) Sore throat/R(rhinorrhea)/C(cough)/S(sputum)
Hoarseness/Dysphagia
LOC(loss
of consciousness)/HA(headache)/DZ(dizziness) Wk(weakness)/(structural)rigidity
Blurry
vision/nyctalopia tinitus/hearing loss/aural fullness
Chest pain Palpitation
Dyspnea/Orthopnea/DOE(dyspnea on exertion)/PND(Paroxysmal
nocturnal dyspnoea)
Abdominal
pain A(anorexia)/N(nausea)/V(vomit)/D(diarreha)/C(constipation)
Hemoptysis/Hematemesis/Hematochezia/melena
residual
sense /frequency Dysuria/Frequency/Hematuria
2 If +, induction(일단 잠들면 푹 자는데 잠이 들기가 어려운지), endurance(잠에
들어도 쉽게 깨는지), narcolepsy(기면증), sleep
hygiene(낮에도 자주 자는지) 여부 확인
③ Physical exam
Vital sign :
GA(general
apperance) :
Mental
status (GCS15)Eye4Motor6Verval5
Alert
mental status / Responds to verbal order / Responds to
painful stimuli /Unresponds
HEENT(Head, Eyes, Ears, Nose, Throat) : not
i(anicteric/icteric) / a(anemic/anaemic) / dehydrated
PERRLA(pupils equal round reactive to light
accommodation)
Swing flashlight test : no RAPD(relative
afferent pupillary defect)
Carotid/Subclavian bruit (-/-)
CHEST : regular
HB clear / coarse BS
ABDOMEN :
Operation scar ( )
Distended/Flat/Obese
increased/normoactive/decreased Bowel sound :
Soft/Rigid
Tenderness
/ RT (
/ )
BACK & EXT.(extremity)
CVAT(costovertebral
angle tenderness) ( / )
PTPE(pretibial
pitting edema) ( / )
Flapping
tremor ( )
④ Trauma exam
SAMPLE
Symptom
AllergyFood-Drug /keloid
Medication
Past medical Hx
Last oral intake
Events, preceding, incident
LOC(loss of consciousness) / Headache / Dizziness
Neck pain / Hand paresthesia / toe movement
Chest pain / Dyspnea
Abdominal pain / Nausea / Vomiting
Back pain / Hematuria
Vital/Sign :
AVPU(Alert mental status / Responds
to verbal order / Responds to painful stimuli /Unresponds)
Airway : Not
choked airway /Clear
Breathing : equal rise & fall chest wall
Circulation :
carotid
(++/++)
radial
(++/++)
femoral pulse (++/++)
Skin color/temp : fine
Mental status :
GCS point (E
V M ) Orientation : Time/Place/Person( /
/ )
Head&Face
malocclusion, mouth opening limitation
( /
) No TMJ(temporomandibular
joint) tenderness
Oculocephalic
/ corneal reflex :
Ophthalmic exam :
normal
spontaneous venous pulsation
No papilledema,
subhyaloid hemorrhage
Abdomen :
soft / rigid
bowel
sound : increased / normoactive / decreased
tenderness/R.
tenderness
no
pelvic tenderness/instability
CHEST
symmetric
lung sound
rib
tenderness
regular
heart sound
Neck & Spine
Neck ROM(range of motion) : no limit
Spurling's test (-/-)
No Gait disturbance
Sensory
C3
|
100%/100%
S3
Motor
Shoulder Ab(abduction)
EF(elbow flexion)/WE(wrist
extension)/EE(elbow extension)/FA(finger)/FF
HF(hip)/KE(knee extension)/PF(plantar
flexion)
DTR
Extremity:
Swelling,
tenderness, ROM limit,hypoesthesia, circulation
⑤ Neurology
Seizure Risk Factors : perinatal problem /
congenital defect / tumor / vascular disease /
Hx. of febrile convulsion /Hx. of major
head trauma / Hx. of CNS infection
family Hx. of epilepsy
CVA Risk Factors
:
DM/HTN, Family Hx of stroke/Previous stroke
Hx.,
Hyperlipidemia/Homocystinemia/polycycemia ,
Smoking ( ) pack-year,
Menopause(
), Age ( ), Heart disease( )
Alert mentality
Orientation: Time/Person/Place ( /
/ )
Memory: immediate, recent, remote,
registration/recall
Speech:
fluency,comprehension,repetition,naming,write,read
3-step obey
CNE:
Normal VA/VF
PERRLA (pupil equal and reactive to light
and accommodation)
Swing flashlight test : no RAPD
Full EOM w nystagmus
Symmetric facial expression w palsy
Normal Gag reflex, no U/T Deviation, no
SCM/Trapezius weakness
Motor:
Rt/Lt Up/E
/
Rt/Lt Lo/E
/
Spasticity/rigidity ( / )
No Tremor/choreic
movement/athetosis/dystonia
Sensory:
pain(Temp)/Vibration(position)
: symmetric
Stereognosis/two
point discrimination : symmetric
Reflexes:
B/J (++/++) T/J (++/++) K/J
(++/++)
Babinski’s(/Chaddock’s) sign ( / )
Cerebellar Function Test:
Symmetric FTN/RAM/HTS
Gait & Station: not ataxic gait c
tandem, normal station c romberg
Neck
stiffness(Brudzinski sing/Kernig sign):
⑥ Psychiatric
GAGB :
키 170 체중 50의
건강해 보이는 체구, 나이보다 많아 보이며 검사자의 요구에 협조적
Speech : (slow-rapid) (emotional,
monotonous)
reaction time
rate of product
Mood & Affect :
(euthymic, elated-depressed) irritable,
fluctuation
inappropriate, inadequate (constricted blunted
flat)
vegetative symptom :
sleep
appetite loss ( )
wt. loss (
)
volition
Thought process :
incoherence/distractibility
Circumstantiality / tangentiality /clang
associations[1]
flight of ideas/neologism/perseveration
Thought content :
idea of reference
delusion (persecutory, paranoid, erotic,
jealousy, somatic delusion)
Thought broadcasting / insertion / leakage
Suicidal idea :
Perceptions :
Hallucination/illusion/Derealization
Sensorium & cogniation :
alertness(AAOx3) orientation concentration
memory (immediate, recent, long term)
calculations fund of knowledge
abstract reasoning
insight :
judgment :
[1] 우회증 (circumstantiality)
사고나 언어가 주어진 질문에 대한 답변과 관련이 있지만 지나치게 세밀하고 부수적임. 결국 결론에는 도달하지만 핵심적인 것과 그렇지 않은 것을 구별하지 못하는 증상
사고 이탈 (tangentiality)
우회성과 유사하지만 중심 주제에 돌아오지 못한다는 점과 원래의 질문에 대한 답을 하지 못한다는 점이
다르다
음향 현상 (Clang association)
소리가 비슷한 의미 없는 단어를 계속 반복해서 말하는 현상
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P(카카오플러스친구) @ermapinfo https://www.facebook.com/ERmap.info/
Decision-making; 진료지침; 응급의학, 응급의학과, 응급실, 응급센터, 가이드라인, ER Clinical Practice Guidelines, emergency medicine, emergency medicine department, Emergency room, emergency medical center
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