Case Presentation 날짜: 장소: Sub-intern:.

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1 Case Presentation 날짜: 장소: Sub-intern:

2 핸드폰은 진동 모드로 부탁합니다 ^_^

3 Chief Complaint C.C: Lt. wrist pain          T : 30분          P : 공원          V : 넘어짐

4 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

5 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):

6 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

7 III. SECONDARY SURVEY B. P/E

8 Question ? 환자에 대해 질문해 주시기 바랍니다.

9 Impression R/O Colle’s Fx. R/O Panperitonitis …

10 Diagnostic Plan Chest PA Amylase/Lipase Wrist AP/Lat

11 Therapeutic Plan IV Hydration Pain control 확진전에 우선적으로 치료할 내용을 적습니다.

12 LAB LAB을 시행했으면 결과를 적습니다.

13 Basic Study 필요하면 X-ray, ECG 등등…다운 받아서 붙여주세요.

14 Special Study 주요 부위만 다운 받아서 붙여주세요. (예: CT, EGD)

15 Diagnosis Colle’s Fx 진찰과 검사를 통해 결론지은 진단명을 씁니다.

16 Treatment Closed reduction Operation 진단에 따른 결정적인 치료를 씁니다.

17 Progress 수술기록, 기타 주요 경과 및 결과를 적습니다.