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분야
ppt2.Review of System(2010/3/4)
3.Physical Examination
4.Lab(2010/3/2)
5.X-ray
6.Endoscopy
7.Pathology
8.Diagnosis
9.Plan
- Abdominal pain (onset : 1month ago)
Present Illness
상기 52세 남환은 평소 특이 과거력 없는 환자로 지난 2010년 2월 초부터 abdominal pain, discomfort, constipation 지속되어 2월 18일 시행한 abdomen X-ray에서 bowel dilatation 소견보였다. 이후 시행한 APCT에서 rectal cancer로 인한 bowel obstruction 소견보여 sigmoidscopy 시행하여 stent insertion 시행 후 보호자가 본원 치료 원해 내원함.
General weakness (-)
Fever / chill (-/-)
Easy fatigue (-)
Headache/dizziness(-/-)
Insomnia (-)
Cough/sputum (-/-)
Dyspnea / DOE (-/-)
Chest pain / palpitation(-/-)
Hemoptysis (-)
Hematemesis (-)
Anorexia (-)
Nausea (-)
Vomiting (-)
Dysphagia (-)
Constipation (+-)
Diarrhea (-)
Abdominal pain (+-)
Abdominal discomfort (+-)
Hematochezia (-)
Melena (-)
Tenesmus (-)
Dysuria (-)
Oliguria (-)
Hematuria (-)
Poor oral intake (-)
Weight gain/loss (-)
178cm/75kg
Vital sign (3/2일 8시 시행)
- BP 136/85mmHg, PR 67회/분
- RR 20회/분, BT 36.9℃
General Appearance
- Not so ill-looking appearance
- Mental status alert
- No nutrient deficiency
Skin
- Warm, wet
HEENT
- no icteric Sclera
- no pale Conjunctiva
- normocephaly without deformity
Neck
- Supple
- no palpable cervical nodes
Chest
- Symmetric expansion without retraction
- No wheezing, no rhonchi
Heart
- Regular Heart Beat
- No murmur, thrill
Abdomen
- Not distended
- No tenderness
- Normative bowel sound
- No palpation of organ
Back and Extremity
- LOM(-)/Pitting edema(-)
- Paresthesia (-) numbness(-)
