보호자분께 뇌진탕의 가능성 및 기타 골절의 가능성과 검사의 필요성..

보호자분께 뇌진탕의 가능성 및 기타 골절의 가능성과
검사의 필요성 설명하였으나 보호자분께서 refuse하심

alcohol (-)
smoking (-)


- neurologic exam
motor - intact
LR (+/+) (+/+) CR (+/+)
EBP - neutral
EOM - well full conjugated
no facial palsy
Meningeal irritation sign - neck stiffenss (-)
Nystagmus (-)
Pathologic reflex (-)

발작

fever, O2-sat
st?
eyeball
LOC
URI
F/Hx

Abd pain

site:
onset:
nature :
mode :
duration :
Last NPO :
Last defecation :
Last gas-out time:

Dizziness

nature :
자세:
ear Sx :
nystagmus (-)
finger to nose (-)
rapid alternating movement (-)
Romgerg test (-)
tendem gait (-)
ass. sx :

Headache

attck:
site:
duration:
nature:
mode:
agg. factor:
rel. factor
ass. sx: URI Hx. (-) trauma Hx(-), vomiting(-), motor weakness(-)


Chest pain

nature :
site :
duration :
agg. factor :
relieving factor :
radiating pain :
ass. sx : dyspnea (-), palpitaion (-), cold sweating(-

Dyspnea

duration:
mode:
agg. factor:
rel. factor :
ass. sx: cough (-), coryza (-), pleuritic pain(-), cyanosis(-)

Vomiting & diarrhea

onset : ( times)
nature :
mode :
ass. sx : abdominal pain (), hematmesis(-), melena(-), myalgia(-

Motor weakness & dysarthria

attack
onest :
mode :
ass. sx : vomiting (-), dizziness(-), headache(-)

Laceration

cm L/W
depth -
bleeding (+)
swelling (+)
bruising (+)
motor & sensory - intact

OS P/E

resting pain (+)
tenderness (+)
swelling(-)
angulation(-)
ROM - limit d/t pain
motor - intact
sensory - intact
pulse - equal

비뇨기과

frequency: 회/시간
hematuria:
nocturia: 회/night
weak stream:
urgency:
difficulty:
tenemus


( - - - -)
PMP:
LMP:
last coitus:
질분비물:
bleeding: 여부, 양

DOA

last NR :
발견시각 :
발견장소(주소):
발견자 이름(연락처) :
발견당시 모습 :
평소거동상태 :
식이 :