Case Presentation 날짜: 장소: Sub-intern:
핸드폰은 진동 모드로 부탁합니다 ^_^
Chief Complaint C.C: Lt. wrist pain T : 30분 P : 공원 V : 넘어짐
I. PRIMARY SURVEY A: Airway C-spine immobilization B: Breathing Spontaneous breathing C: Circulation Skin color : Femoral/radial pulsation( / ) Active bleeding site: D: Disability : Brief Neurologic Examination Mental state : GCS score Eye Opening 4 / 3 / 2 / 1 Verbal Response 5 / 4 / 3 / 2 / 1 Motor Response 6 / 5 / 4 / 3 / 2 / 1 Pupil : Focal neurologic deficit : E: Exposure/Environment
II. Adjucts to Primary Survey and Resuscitation Trauma series Chest AP : C-spine Lat : Pelvis AP : EKG monitoring : Gastric catheter : Urinary catheter : FAST(Focused assessment with sonography for trauma):
III. SECONDARY SURVEY A. AMPLE History and Mechanism of Injury Allergies Medication currently used Past illnesses/Pregnancy Last meal Events/Environment related to the injury
III. SECONDARY SURVEY B. P/E
Question ? 환자에 대해 질문해 주시기 바랍니다.
Impression R/O Colle’s Fx. R/O Panperitonitis …
Diagnostic Plan Chest PA Amylase/Lipase Wrist AP/Lat
Therapeutic Plan IV Hydration Pain control 확진전에 우선적으로 치료할 내용을 적습니다.
LAB LAB을 시행했으면 결과를 적습니다.
Basic Study 필요하면 X-ray, ECG 등등…다운 받아서 붙여주세요.
Special Study 주요 부위만 다운 받아서 붙여주세요. (예: CT, EGD)
Diagnosis Colle’s Fx 진찰과 검사를 통해 결론지은 진단명을 씁니다.
Treatment Closed reduction Operation 진단에 따른 결정적인 치료를 씁니다.
Progress 수술기록, 기타 주요 경과 및 결과를 적습니다.