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분야
pptChief complaint
Present illness
Past history
Social history
Review of systems
Physical examination
Problem list
Assessment
Impression
Diagnostic plan
Laboratory Findings
Abdominal ultrasonography
Final diagnosis
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
