2-002 Recording style-special

2-002 Recording style-special
**Centent(목차) **
2-002-02 A. CPR note(Cardiopulmonary Resuscitation)
2-002-03 B. Poisoning note
2-002-04 C. Laceration note
2-002-05 D. Abdominal pain note
2-002-06 E. Chest pain note
2-002-07 F. Headache note
2-002-08 G. Dizziness note
2-002-09 H. Forensic note
2-002-10 I. Opthalmic note
2-002-11 Delium note
2-002-12 paraspinal lumbar pain note

Recording style-special

A.   CPR note(Cardiopulmonary Resuscitation)

Onset :

Collapse/witmess time     initial ECG time

EMS(emergency medical services) CPR time  AED shock time

Intubation time              ROSC time

ED arrive time   

Intubation time              shock time

vasopressor time            ROSC time

End CPR time

Place :

Etiology : cardiogenic(       )/trauma/drowning/asphyxia/hemorrhage

Pre-arrest Sx : syncope/mental change/HA/Dizzi/Cp/Dyspnea

pre-hospital ACLS(Advanced Cardiovascular Life Support)

bystander CPR/ pre-hospital CPR (  /  )

intubation / IV access (  /  )

shock / vasopressor (  /  )

Initial ECG : VF / VT / Asystole / PEA / Bradycardia

At visit Vital sign: MS(A/V/P/U/S) Spo2:      BST

Pre-existing condition

Echo finding :

B.   Poisoning note

(when)   onset : lastwellbeing:

detect:

(who)    body weight:    kg

(why)    accidental / intentional

(what)  

(how amount)

Pre-hospital vomiting (   )

Last meal :

TOXIDROME

Hyper/HypoTENSION Tarchy/BradyCARDIA Tarchy/BradyPNEA

Hyper/HypoTHERMIA Mydriasis/Miosis

SalivationLacrimationUrinationDefecationGIupsetEmesis

Previous suicide Hx (  )

Suicide idea / plan / trial (   /   /   )

Psychiatric hx / FHx (   /   )

Drug use

IN SAD CAGES(Interest, Sleep, Appetite, Depressed Mood, Concentration, Activity, Guilt, Energy, Suicide)

Cause of suicide

           Healthy/occupational/marriage/affection/economic/social

Socio-economic status

C.   Laceration note

Onset

Cause

DM/valve diz/aspleen/im. Deficiency

position

object

mechanism : shearing / crush / tensile

forign body sensation / fragile / bite

contaminated/delayed

Tender/swelling/parathesia/loss of function

Assault / accidental / intentional

D. Abdominal pain note

PQRST

Provocation

Quality

Radiation

Severity

Timing / Treatment

Effect of Diet/defecation

Tenesmus/bloody or mucose diarrhea

E. Chest pain note

Onset

Duration, Time course, frequency

Nature

Severity

Location

Radiation

time of occurrence

alleviate/relief factor

aggravate factor  / effort-related

association factor

risk factor : DM/HTN/Hyperlipidemia

                      Smoking/alcohol

                      Postmenopausal/ F/Hx of premature CAD

                      Cocaine use

                      Vascular diz

F.    Headache note

chronology

Onset/frequency

Duration

Associated Sx     N/V

                                 Photophobia/phonophobia

                                 Lacrimation/conj. Injection

Severity/aggravating factor/relieving factor/triggering factor

Location/nature

(pulsatile-throbbing/pressing/squeezing/tight/heavy/stabbing)

Aura or prodrome/mense/diet

URI Hx/familial Hx/analgic response/substance use

Temporal a. pulse/sinus tenderness

G.   Dizziness note

           Long (c URI)       Short term dizz

c hearing loss     labyrinthitis        Meniere’s diz

w hearing loss    Vestibular neuronitis       BPPV

Onset/recurrent

Duration

           Sec: seizure, BPPV

           Min: TIA

           Hr: meniere’s diz

           Day: labyrinthitis, vestibular neuronitis, stroke

Nature rotation sense/imbalance-disequilibrium/presyncopal faintness

Autonomic- N/V/paleness

Cochlear- Hearing loss/tinnitus/aural fullness/otalgia/autophony

Neurologic- dysphagia/dysarthria/Diplopia/facial palsy/perioral numbness/headache

Recent URI Hx/underlying diz

Positional aggravation

Nystagmus

H.   Forensic note

도착시간 :

사망일시 : ~ 이전으로 추정

Hx :      unable ambulation

           unable intake

           unable talking

P/Exam :

Self respiration

Carotid pulse

Spontaneous movement

Pain response

L/R (-/-)

Pupil size

Skin color : NL/pale/dark-red

Skin temp :        trunk warm/cool

                      Extremity warm/cool

Sacrum/buttock/scapular bedsore

Livor motis/rigor mortis

Trauma survey :

Laceration/Stab wound/Avulsion/Abrasion

Contusion/Patechiae/Fracture

Amputation/Penetrating

Hanging mark/Needle mark/Burn

I.     Opthalmic note

Use glassed/contact lens

Foreign body sensation

Visual disturbance

blurring

Diplopia

Eyelid swelling

RAPD

VFD

Infraorbital hypothesia

Normal VA/VF

PERRLA (pupil equal and reactive to light and accommodation)

Swing flashlight test : no RAPD

Full EOM w nystagmus

iris/pupil

Conjunctiva

Cornea

Lid

Fundus

lacrimal

ocular muscle

Delium note

I watch DEATH

Infection pul,uro,biliary,mengitis,septis

Withdrawal alcohol, sedative

Acute metabolic acidosis, eletro, liver failure, kidney failure

Trauma, head

CVA, seizure, tumor

Hypoxia

Deficiencies B1 B12 folic acid

Endocrine&environment diz, DM Thyroid diz, adrenal hyperthermia/hypothermia

Acute vascular MI AD PE SAH

Toxin&Drug poisoning adverse effect

Heavy metal

paraspinal lumbar pain note

trauma

mechanism

pain relieving/aggravating/position

radiation

claudication

weight loss

fever/chilling/night sweating

tender point      spinous process,paravertebral muscle,iliac creast,sacrum

SLRT straight leg rising test 

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