분야
docDate of Care Patient Initials Age Gender Date of Admission 2012-11-29 남** 0(10M) Female 2012.11.23
A. ASSESSMENT:
I. REASON FOR HOSPITALIZATION:
a. Describe reason for hospitalization: Rigidity aggravation for 7 days
b. Medical Diagnosis : Epilepsy, unspecified, With intractable epilepsy
Congenital malformation of brain, unspecified
c. All signs and symptoms : vomiting, coughing, seizure & rigidity, stridor, cyanosis
II. HISTORY OF PRESENT ILLNESS
Known #Pontocerebellar hypoplasia # Hearing defect # Convulsive disorder # High arch palate로 Phenobarbital ~2.5mg/kg/d, keppra ~0.2ml/kg/d med하는 환아로 평소에도 feeding(FF,160-200cc*4/day) 시마다 chocking(#4/day, 대개 먹는 동안 #2-3) regurgitation(#4/day, not bloody, not bilous) rigidity on whole body(intermittent,
