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[의학] Case-Abdominal pain

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    [의학] Case-Abdominal pain에 대한 자료입니다.
    목차
    Patient Identification
    Chief complaint
    Present illness
    Obstetric History
    Past History (cont.)
    Review of system
    Physical examination(cont.)
    Physical examination
    Pelvic examination
    Problem List
    Impression
    Diagnostic Plan
    Laboratory Test
    TV Ultrasonography
    Diagnostic assessment
    Therapeutic Plan
    Operation Record
    Final Diagnosis
    Definition
    Epidemiology
    Site and Incidence
    Risk Factors
    Symtoms and signs
    Diagnosis 2 (1)
    Diagnosis 2 (2)
    Treatment (1) - Medical
    Treatment(2) – surgical
    Reference
    본문내용
    Pelvic examination

    Cervix : vaginal spotting
    no active bleeding
    no erosion
    motion tenderness
    Adnexa : nonspecific
    Parametrium : nonspecific



    R/O Ectopic pregnancy
    (#1, #2, #3, #4, #10 )
    R/O PID
    (#2, #3, #4, #6, #7 )
    R/O Ovarian torsion
    (#2, #3, #6)
    R/O Surgical abdomen
    (#2, #8)


    Skipped mense
    RLQ – Td/RTd +/+
    Rt. Flank pain
    Vaginal spotting
    Cold sweating
    Nausea, vomiting
    Dysuria
    S/p D&C
    S/p appendectomy
    smoking


    Operation Record


    Operation date : 2010. 05. 18
    Preoperation Diagnosis: R/O Rt. Tubal pregnancy
    Findings : 1. Pelvic adhesion (+)
    2. Uterus : 7cm size -> non specific
    3. Both adnexa
    Rt.: ectopic focus at ampulla
    Lt : fimbrio obstruction
    Operation name : Laparoscopic Rt. Salphingotomy, Lt. fimbrioplasty, adhesiolysis


    참고문헌
    1. Williams OBSTETRICS 23rd edition
    p. 238-256
    2. Berek & Novak’s GYNECOLOGY 14Th
    edition, Jonathan S. Berek, LWW,
    p. 602-637
    #CaseAbdominal#Case#Abdominal#pain#의학