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분야
hwp* Name : 0 0 0
* Gender / Age : F / 75세
* Dx. : Lt. Hemiplegia r/o cb-inf, r/o cb-hrr
* Onset: 2010. 8. 1
* height / weight : 150cm /50kg
* Mental status : Alert, time/place/person (+/+/+)
* Shoulder pain (-) Edema (+) Subluxation (-)
* C.C : 1. Lt. side weakness
2. Lt. facral palsy (H-B cr Ⅱ)
3. Mild Dysarthria
4. Lt. forearm numbness & Rt. 4,5th finger numbness
5. Dizziness
6. Dysphagia(물 종류만)
* P.I : 상기 Pt. 150cm 50kg 75세 여환으로 평소 벌무대병 중 2010.8.1 Lt. side weakness,
Mild dysarthria, Dizziness 발하였으며 별무처지 기료 중 증세호전 되지 않아 2010.8.4
local 내과 visit, HTN Dx. 받고 p.o.med 시작하였으며 상기일부터 Dysphagia(물 종류)
발생, 2010.8.5 local 한의원 visit, A-Tx 받았으며 큰 병원가서 CT 촬영하라는 권유 받고
본격적인 한방치료 받고자 2010.8.6 KOMC OHER경유 동 6A 3611호 (prof. 김진성 part)
로 adm함. (L/D: 8/5, Dysphagia:+)
* PHx. : 1. HTN: 2010년 8월 4일 local 내과 Dx. p.o.med 중
2. HTN(+) DM(-) Hepatitis B(-) Tb(-) Drug allery(-)
* Family Hx. : Nonspecific
