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