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Department of Dental hygiene, Gachon University College of Health Science
Prof. Hee-Eun Kim
Social history
Family history
Relevant medical history
Drug and allergy history
History taking (병력검사)
History of present complaint
Medical records (의무기록)
Chief complaint
Basic information
진료기록부를 구성하는 내용
환자에 대한 기본자료
주소 및 기왕력
과거 의과적 병력
사회적 및 가계적 병력
기관별 검사
신체검사
검사실 및 방사선적 검사
문진표
개인 병력 청취 및 가족력 등의 필요한 정보를 효과적
으로 기록하기 위해 활용
History of the presenting complaint _ 1
This is the patient’s opportunity to tell the
surgeon about the problem.
It is important to avoid prompting with leading
questions.
Some patients will give a really good account
of their problem but many will need guidance.
Time-scale of the illness
Chronological order
History of the presenting complaint _2
When was the problem first noted?
What is the location?
Are the symptoms continuous or intermittent?
Does anything make the problem better or
worse?
Is the problem getting better or worse?
Relevant medical history _ 1
The opportunity
to elaborate on any points in the history that the
surgeon felt were unclear.
to enquire from the patient any aspect of his or her
health that might otherwise influence the treatment
plan.
Relevant medical history _ 2
Cardiovascular system (심혈관계)
is important when general anaesthesia is required.
Upper respiratory tract infection (상기도 감염)
is a relative contra-indication to surgery.
‣ productive cough with sputum
Gastrointestinal system (위장관계, liver disease)
hepatitis, coagulation
Locomotive system (운동계, arthritis, rheumatoid disease)
problems with the cervical spine, Down syndrome
Neurological system (신경계)
trauma
Family history
Is there a genetic family problem?
blood-related problem (haemophilia, 혈우병)
heart disease
stroke
cancer
Has any member of the family had any
problem with anaesthetics, especially muscle
relaxants (근이완제) ?
Social history
The patient’s occupation might be relevant to
the complaint or the opportunity for recovery.
Home support for patients
Smoking, alcohol consumption
Drug and allergy history
It is critical to know about certain drugs prior
to performing any surgery.
Possible interactions between drugs need to be
assessed.
‣ corticosteroid medication
‣ anticoagulant therapy
A history of asthma and anaphylaxis is
important.
아나필락시스(anaphylaxis)
과민성 쇼크
항원항체반응
급성 알레르기
히스타민 자가면역질환
아나필락시스(anaphylaxis)
에피네프린!! 강력하게 혈관수축을 시켜 후두부종이나 기관지부종을 신속하게 없애고 혈관을 수축시켜 혈압을
회복시킨다.
Physical examination _ 1
Vital sign (생징후 검사)
Blood pressure, BP (혈압)
‣ 120/80 mmHg
Pulse rate, PR (맥박)
‣ 성인 60~100 회/분, 소아 90~110회/분
Respiration rate, RR (호흡)
‣ 성인 14~18(20)회/분, 소아 (20~)30회/분
Body temporature, BT (체온)
‣ 36.5℃ (구강 내 체온)
Carotid (경동맥)
20
Radial artery (요골동맥)
21
Physical examination _ 2
Head & neck examination
Physical examination
general appearance and mental status (전반적인 외모
의 평가 및 인지능력 검사)
head and neck & facial region (두경부 및 안면부 검사)
chest (흉부 검사)
abdomen (복부 검사)
spine & urogenital system (등 및 비뇨기계 검사)
Physical examination _ 3
Laboratory procedure
Radiographic examination
Pathologic examination
Biopsy
Important clinical feature of a swelling
1. Position
2. Size
3. Shape
4. Colour and temperature
5. Tenderness
6. Movement
7. Consistency
8. Surface texture
9. Ulceration
10.Margin
11. Associated swelling
Systemic disease
Hypertention (고혈압)
Angina (협심증)
Myocadial infarction (심근경색)
Cerebrovascular accident, CVA (뇌혈관 질환, 뇌
졸중)
Bleeding disease (출혈성 질환)
Diabetes mellitus (당뇨)
고혈압
고혈압 관련 합병증
뇌졸중
당뇨병
과호흡 응급처치
30
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