환자기본정보

• 진료일 :

  2022-01-18

• 병원명 :

  전주병원

• 환자명 :

  박연옥

• 성별/ :

  여/

• 생년월일 :

  1949-02-10

• 작성일 :

  2022-01-18

• :

• :

치료사항및계획

• 입원여부 :

  Y

• 진단내역 :

  파킨슨병 척추협착 등

• 검사결과내역 :

  -▣ (처방일자:2022/01/17 검사일자:2022/01/17 판독일자:2022/01/17 판독의사:김상원 ) ▣-
  검사명 : L-Spine Series 6View(AP,LAT,EXT,FLX,BOTH OBLIQUE) 판독의사:김상원
  
  < Gross >
  LUMBAR SPINE
  
  r/o Lumbar sprain
  - loss of lumbar lordotic curve & straightening.
  
  Osteoporosis.
  Degenerative spondylosis.
  Degenerative disc disease of L4/5/S1.
  
  rec.) clinical correlation.
  
  
  -▣ (처방일자:2022/01/17 검사일자:2022/01/17 판독일자:2022/01/17 판독의사:김상원 ) ▣-
  검사명 : Brain CT 판독의사:김상원
  
  < Gross >
  BRAIN CT WITHOUT ENHANCEMENT:
  
  no acute hemorrhage or acute mass effect.
  no hydrocephalus or mass.
  no pathologic brain atrophy.
  
  IMP: nonspecific finding.
  
  
  ■ 신현준 NR[2022.01.17 18:28]
  S: 입원
  O: bradykinesia(3<3) rigidity(1/3) masked face(2) Lt resting tremor + b/l postural tremor
  brain CT (0222.1.17) n/s
  RF (2022.1.17) 118.7 (>15)
  A: Pdism naive Lt onset
  - baseilne UPDRS 64 H&Y 4
  P: Pdism w/u
  UPDRS, 산정특례