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분야
pptxChief complaint
Present Illness
Past medical history
Review of system1
Physical Examination1
Initial Lab
Left hand AP(#HD 1)
Problem list
Initial assessment
Diagnostic plan
Laboratory findings
Assessment
Therapeutic plan
Deformity (-) CVA tenderness (-) Pretibial pitting edema (-)
Left thumb laceration
Transverse, IP joint 근처, 1.5cm, clear margin
Distal phalanx, vertical incision scar (0.5cm)
Left hand and wrist
Swelling (+) : forearm의 distal part 1/3 까지
Color change (+) : palm
Bullae (-), Erythema (+)
Tenderness(+) : 특히 joints
Paresthesia (-)
Heatness (+)
Pitting edema (-)
local infection - Left hand and wrist
pain, swelling, heatness, tenderness, arthralgia
칼에 의한 상처, 상처를 깨끗하게 유지하지 못함
Fever : 38.3 ℃, Febrile sensation, myalgia
Elevated WBC, hs CRP
Initial X-ray : soft tissue swelling
Laboratory study
CBC, Serum electrochemistry
Pus Gram stain and culture
Blood Gram stain and culture
Urine Gram stain and culture
Redness and swelling 확장시 – further image study
Tetanus에 대한 예방접종력
예방접종이 나오기 전에 출생
