A+ 받은 SBAR 보고서(3개 포함)

문서 내 토픽

1. Pyelonephritis

이XX 선생님 환자 전XX님은 15일 Abdominal pain으로 입원했으며, APCT 상 Rt. pyelonephritis 소견이 있어 IV anti 치료를 받고 있습니다. 16일 3시부터 fever 40℃가 측정되어 연락드렸습니다. 오한 증상은 없으나 두통을 호소하고 있으며, ice pack 적용에도 불구하고 fever가 지속되고 있어 해열제 처방이 필요할 것 같습니다.
2. Appendicitis

서00님 환자는 19일 다회 diarrhea 이후 복통이 발생하여 내원했으며, Acute appendicitis로 Laparoscopic appendectomy and drainage 수술을 받았습니다. 24일 12시부터 속쓰림과 구역감을 호소하고 있으며, 피부 촉진 시 사지가 뜨겁게 느껴지고 오한 증상이 있어 Fentanyl fluid 중단 및 MXL 0.5@ 투여를 고려해야 할 것 같습니다.
3. Femur Neck Fracture

안XX님 환자는 13일 Lt. hip pain으로 입원했으며, X-ray와 CT 상 Lt. femur neck fracture가 확인되어 Open reduction Fractured Extremity-Femur 수술을 받았습니다. 20일 15시 50분부터 fever 38℃가 측정되어 연락드렸습니다. ice pack 적용에도 불구하고 fever가 지속되고 있어 해열제 처방이 필요할 것 같습니다.

Easy AI와 토픽 톺아보기

1. Pyelonephritis

Pyelonephritis is a serious kidney infection that can cause significant health problems if left untreated. It is typically caused by bacteria, such as Escherichia coli, that travel from the bladder up to the kidneys. Symptoms can include fever, chills, back pain, and nausea. Pyelonephritis requires prompt medical treatment, usually with antibiotics, to prevent complications like kidney damage or sepsis. Risk factors include diabetes, pregnancy, and urinary tract abnormalities. Prevention involves good hygiene, staying hydrated, and treating any underlying urinary tract infections. With proper treatment, most people with pyelonephritis can recover fully, but it's important to follow the doctor's instructions carefully and complete the full course of antibiotics. Ongoing monitoring may be necessary to ensure the infection has been fully resolved.
2. Appendicitis

Appendicitis is a medical emergency that requires prompt treatment to prevent the appendix from rupturing, which can be life-threatening. The appendix is a small, pouch-like structure attached to the first part of the large intestine. When the appendix becomes inflamed and swollen, it can cause severe abdominal pain, nausea, vomiting, and loss of appetite. Left untreated, the appendix can rupture and spill infectious material into the abdominal cavity, leading to a potentially fatal condition called peritonitis. Appendicitis is typically treated with surgery to remove the inflamed appendix, known as an appendectomy. This is usually done laparoscopically, which involves making small incisions and using a tiny camera to guide the procedure. Antibiotics may also be prescribed to prevent or treat any infection. Recovery time is usually fairly quick, with most people able to return to normal activities within a week or two. It's important to seek immediate medical attention if appendicitis is suspected, as a ruptured appendix can be extremely dangerous. With prompt diagnosis and treatment, however, appendicitis can be effectively managed, and the prognosis for a full recovery is generally excellent.
3. Femur Neck Fracture

A femur neck fracture is a serious injury that occurs when the upper part of the thigh bone, known as the femur, breaks near the hip joint. This type of fracture can be extremely debilitating and often requires surgical intervention to properly heal. Femur neck fractures are typically caused by high-impact trauma, such as a fall from a height or a car accident. They are more common in older adults, especially those with osteoporosis, as the bones become weaker and more brittle with age. Symptoms can include severe pain, swelling, and an inability to bear weight on the affected leg. Treatment for a femur neck fracture usually involves surgery to stabilize the bone and promote healing. This may involve the use of metal plates, screws, or a hip replacement, depending on the severity of the injury and the patient's overall health. Physical therapy is also an essential part of the recovery process, as it helps to restore strength, flexibility, and mobility. The prognosis for a femur neck fracture can vary widely, depending on factors such as the patient's age, overall health, and the extent of the injury. In some cases, the fracture may not heal properly, leading to complications such as avascular necrosis (death of the bone) or chronic pain. However, with prompt and appropriate treatment, many patients are able to regain a significant degree of function and return to their normal activities. Overall, a femur neck fracture is a serious and potentially life-altering injury that requires immediate medical attention and a comprehensive treatment plan. By working closely with their healthcare team, patients can maximize their chances of a successful recovery and minimize the long-term impact of this type of injury.

주제 연관 리포트도 확인해 보세요!