의학과응급의학과 신경외과 사례(54세 남성환자)
목차 1.Review of System 2.PhysicalExamination(10:00am) 3.EKG 4.Impression (10:00am) 5.Plan 6.Laboratory findings 7.Diagnosis 8.Plan 본문 Glucose288 mg/dL BUN/Cr 9.2/1.3 mg/dL AST/ALT 154/36 IU/L CK 1903 IU/L CK-MB238.8 ng/mL Tn-I 40.72 ug/L ABGA pH7.11-pCO2 49mmHg-pO2 86mmHg-HCO3 15mmol/L-SaO2 93% CBC WBC 15200/uL (43.4%) Hb15.4g/dL Plt151000/uL Electrolyte Na 142mmol/L- K 6.7 mmol/L –Cl 104mmol/L CPR stop Ventilator apply Cold N/S, head ice cooling Dopamin Calcium, insulin+glucose, bicarbonate Chest X-ray, Brain CT Heparin, aspirin, clopidogrel Coronary angiography Cardiac arrest due to acute myocardial infarction of anterior, lateral wall R/O Hypoxic brain damage 본문내용 전일 저녁부터 chest discomfort 호소하다가 내원 당일 아침 일어나서 화장실 2회 다녀온 후 수면 중 mental change 보여 CPR 시행하며 ER 내원 (아들이 발견 후 10분 정도 CPR 시행) PAGE:3 Past History HTN/DM/Tbc/Hepatitis (+/-/-/-) Social History Alcohol (-) Smoking (-) Family History Not specific PAGE:4 General Uncheckable HEENT Uncheckable Chest Uncheckable Abdomen Uncheckable Urinary Uncheckable Genital & Back & Extremities Uncheckable PAGE:5 Vi |
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