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분야
pptxChief complaint
Present Illness
Past medical history
Review of system1
Physical Examination2
Problem list
Initial assessment
Diagnostic plan
Initial Lab1
Ascites analysis
Esophagogastroduodenoscopy(EGD)
Liver CT
Final diagnosis
Therapeutic plan
Symmetric expansion
Breathing sound : clear breathing sounds
Crackle/wheezing/rhonchi/stridor(-/-/-/-)
Friction rub (-)
Heart sound : regular heart beat without murmur
Back & extremity
Deformity (-)
CVA tenderness (-)
Pretibial pitting edema (-)
Paresthesia
Abdomen
Soft and distension
Normoactive bowel sound
Shifting dullness (+)
Fluid wave(+)
Tenderness/Rebound tenderness(-/-)
Palpable mass (-), Organomegaly(-)
Abdominal distension with Shifting dullness, Fluid wave
Heavy alcoholics
General weakness, Poor oral intake
