분야
hwp1) concept map
Date of care:
11-06-01
POD:
patient initials:
K.Y.S
Age
(face sheet):
78
Growth and Development
: Ego integrity vs Despair
Gender
(face sheet):
F
Admission Date:
11-05-23
Reason for hospitalization(face sheet):
*Describe reason for hospitalization
: 내원 1일전 저녁식사 후 watery diahea, vomiting develop 되면서 whole abd.pain develop 되어 자가약(소화제) 복용하였으나 밤새 diahea#10, vomiting#10 develop 되었고 내원 당일 fever develop 되어 LMC ER 방문하여 시행한 abd.CT상 Lt. UT stone 소견 보이며 BP 70/40 check되어 본원 ER로 transfer, Lt APN, Lt hydronephresis 동반 된 상태로 APN sepsis asess 하여 PCN insertion 후 empirical anti 사용하여 입원함.
*Medical Dx:
: Acute tubulo - intestitial nephritis
*Pathophysiology:
: 뒷장첨부
*All signs and symptoms: Highlight those your patient exhibits: abd.pain, fever(37.7), diahea, vomiting.
Chronic illnesses, History, Family History
(physicians history and physical notes in chart; nursing intake assessment and Kardex) :
*Chronic illnesses : 1991년 HTN 진단
*History : 2010년 2월 Slip down 으로 Lt. femur neck fx
