소개글
[소화기 내과] Case Study-Fever, Chill, Nausea에 대한 자료입니다.
목차
Identifying data
Chief complaint
Present illness
Past history
Social history
Review of systems
Physical examination
Problem list
Assessment
Impression
Diagnostic plan
Laboratory Findings
Abdominal ultrasonography
Final diagnosis
본문내용
Review of systems
Urogenital
Dysuria (-), Frequency (-), Nocturia (-)
Urgency (-), Oligouria(-), Hematuria (-)
Musculoskeletal
Muscle or joint pain (-), Limitation in motor activity (-)
Backache (-)
Skin
Rashes (-), Eruption (-), Jaundice (-), Itching (-), Lumps (-), Changes in hair or nails (-)
General status
V/S
BP : 110/80mmHg – PR : 64/min – RR : 20/min – BT : 36.8℃
General appearance : Acute ill looking appearance
Mental status : alert
Head & neck
Normocephalus
Icteric sclera(+)
Pinkish conjuctivae
No palpable neck mass
No neck stiffness
No palpable supraclavicular node