3. 의무기록 사용 약어 PH – past history Hx – History CC – Chief complaint FH – Family history Sx – SymptomROS – Review of system PE – Phsical examination HEENT – Head, eyes, ears, nose, throat PERRLA – pupils equals, round, reactive to light, accommodation WNL – Within normal limits
1. 환자 기본 정보이 할머니는 2014년 7월 21일부터 남구 돌봄의 집에 다니고 계시다. 주 5회 나오시고 계시며 2013년 알쯔하이머 치매 진단을 받으셨다. 2013년도와 2014년도 각각 고열 및 어지러움증으로 OOO 병원에 입원한 과거력이 있다.2. 인터뷰 내용 및 사정 자료1) 근골격계 & 낙상경험: 스스로 앉기, 서기, 걷기 등을 할 수 있으며 계단을 오르락내리락 하는 것은 난간을 잡고 천천히 이동하신다. 걸음걸이가 허약하시고, 낙상의 과거력은 없다.2) 수면: 매일 잠을 잘 자며, 잠을 자는데 문제없다고 대답하셨다. <중 략>4. 복용약도네필정1) 1회 투여량: 10mg2) 투여 경로: 경구3) 1일 투여 횟수: 1회, 저녁 식후 30분4) 부작용: 설사, 구역, 식욕부진, 두통, 어지러움, 감기5) 투여 목적: 치매 증상을 완화시키기 위하여
General appearance and behaviourMr.Kwon is a 73-year-old man and he is 155cm and 59kg. He is walking well and walks fast. He looks healthy. He is not spontaneously admitted to hospital. His hair is organized well. He often walks in a hospital hall. When he talks with staff, he doesn't avoid to talk, and take an active parti in talking. When talking with staff or watching TV, He sometimes says “... bright Korea, bright future which is we go toward.” rising his arms and being high his pich and tone. He maintained eye contact. sometime smiles. but He tends to talk about himself. His posture is comfortable.Attitude to examinerHe is cooperative to staffs.SpeechHe usually speaks at normal tone, speed, pich but When he watches TV, He often says “... Yes..It is beautiful. bright Korea, bright future which is we go toward.” repeatedly. that time, He talk like an orator having hight pich and tone.He speak well.