• Title/Summary/Keyword: Patient History

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A Study on the Level of Medical Record Documentation and Agreement in the Information on the Patient's Past History (과거력 의무기록 정보의 기재정도 및 일치도 분석)

  • Seo, Jung-Sook;Yu, Seung-Hum;Oh, Hyohn-Joo;Kim, Yong-Oock
    • Korea Journal of Hospital Management
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    • v.13 no.1
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    • pp.42-64
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    • 2008
  • This study was conducted to evaluate the quality in medical records by analyzing its completeness through setting up the level of record on the patient's past history and through examining the actual medial records. Targeting the information on the patient's past history in interns' records, residents' records and nurses' records toward 403 inpatients who were admitted first in 2004 at an university hospital due to stomach cancer. We analyzed whether the charts were recorded or not, recording level, the satisfaction with the expectant level of the records in the hospital targeted for a research and the level of agreement. The results were as follows; first, as for the rate of recording those each items, they were high in the chief complaint & present illness and the past illness history. Depending on the group of recorders, the recording rate showed big difference by items. Second, as a result of measuring the level after dividing the recording level of items for the patient's past history from Level 1 to Level 4 by each item, the admission history, the past illness history, and the family history were about Level 3, and the smoking history, the medication history, the chief complaint & present illness, the drinking history and allergy were about Level 2. In the admission department, it was excellent in the interns' records for the medical department. Third, as a result of its satisfactory level by comparing the expect level of a record and the actual record by item in information on the patient's past history, which was expected by the medical-record committee members of the hospital targeted for a study. And forth, we analyzed the level of agreement with Kappa score in the level of 'Yes' or 'None' related to the corresponding matter in Level 1, in terms of information on the past history in the intern's record, the resident's record, and the nurse's record. The level of agreement in the resident's record & the nurse's record, and in the intern's record & the resident's record was from "excellent" to "a little good". There were differences in the level of completeness and in reliability for the information on the past history by the recorder group or by the admission department. The encounter process that was performed by the admission department or the recorder group, indicated the result that was directly reflected on the quality of medical records, thus it was required further study about the medical record documentation process and quality of care. The items that showed the high recording rate quantitatively were rather low, consequently we'd should develop the tool for the qualitative inspection and evaluate the medical records further. And the items were needed to be detailed in the record level were rather low, and hence there needed to be a documentation guideline and education by the clinical departments.

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Paroxysmal kinesigenic dyskinesia in a patient with a PRRT2 mutation and centrotemporal spike discharges on electroencephalogram: case report of a 10-year-old girl

  • Seo, Sun Young;You, Su Jeong
    • Clinical and Experimental Pediatrics
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    • v.59 no.sup1
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    • pp.157-160
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    • 2016
  • Coexistence of paroxysmal kinesigenic dyskinesia (PKD) with benign infantile convulsion (BIC) and centrotemporal spikes (CTS) is very rare. A 10-year-old girl presented with a 3-year history of frequent attacks of staggering while laughing and of suddenly collapsing while walking. Interictal electroencephalogram (EEG) revealed bilateral CTS, but no changes in EEG were observed during movement. The patient's medical history showed afebrile seizures 6 months after birth, while the family history showed that the patient's mother and relatives on the mother's side had similar dyskinesia. Genetic testing demonstrated that the patient had a heterozygous mutation, c.649_650insC, in the PRRT2 gene. To our knowledge, this constitutes only the second report of a patient with PKD, BIC, CTS, and a PRRT2 mutation.

Clinical study on one patient with oculomotor nerve palsy accompanied by Diabetes mellitus complication history (당뇨 합병증의 과거력이 있는 동안 신경마비 환자1례에 대한 임상적 고찰)

  • Yun, Cheol;Yun, Chae-Sung;Lee, Dong-Hyo;Seong, Eun-Jin;Kim, Hwan-Young;Hwang, Chung-Yeon
    • Herbal Formula Science
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    • v.17 no.2
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    • pp.233-238
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    • 2009
  • Objective : To carry out the oriental medicine treatment on a patient with oculomotor nerve palsy accompanied by Diabetes mellitus complication history Methods : We conducted one patient with oculomotor nerve palsy at Won-Kwang University Kwang-Ju Oriental Medical Hospital. We treated patient by herbal medicine, acupuncture, etc. Results : We had an effect that one patient's symptom had improved. Conclusion : We suggest that the oriental medical treatment and management have an effect with oculomotor nerve palsy accompanied by DM complication history.

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Developing a Standardized Patient Program using Internal Damage Fever Cases in Korean Medical Education (한의학 교육에서 내상발열(內傷發熱) 증례를 이용한 표준화환자 프로그램 개발 연구)

  • Jo, Hak-jun;Jo, Na-young
    • Journal of Korean Medical classics
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    • v.33 no.4
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    • pp.33-56
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    • 2020
  • Objectives : The objective of this paper is to develop a standardized patient program with a focus on diagnosis and treatment of internal damage fever in Korean Medical education. Methods : First, cases of diagnosis and treatment of internal damage fever were collected from various classical texts, then a module was developed according to pre-existing standardized patient program's protocols based on selected cases. Careful consideration was given to developing evaluation criteria on history taking and physical examination that are necessary to accurately differentiating the 9 types. Results : Nine types of differentiation models on internal damage fever were selected, which are qi deficiency from overexertion/fatigue and famish; blood deficiency from overexertion/fatigue, famish and fullness; fire stagnation from excessive eating and cold foods; food damage; yang deficiency; yin deficiency; phlegm; stagnated blood; liver qi stagnation. For each type, evaluation criteria in regards to history taking, physical examination, communication with patient, and patient education were developed. Conclusions : When developing a standardized patient program using internal damage fever cases, it would better reflect the characteristics of Korean Medicine in clinical education of Korean Medicine if the program is based on classical texts. It would also be useful in evaluating students' graduation competence in exams such as CPX.

FCST, Its Foundation and Early History (FCST의 초기 역사)

  • Yin, Chang Shik;Lee, Young-Jun
    • Journal of TMJ Balancing Medicine
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    • v.1 no.1
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    • pp.9-12
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    • 2011
  • Objectives: Functional Cerebrospinal Therapy (FCST) is a rather new physiologic therapeutics. It has passed about two decades since its basic idea was founded. This study briefly reviewed its early history. Methods: The first FCST patient was a stroke patient in the year 1992. Basic ideas of FCST was devised one by one and later developed into a systematic clinical application. The first official lecture was held in the year 2004. Yinyang balance in the meridian-system-based network over the whole body was a mainstay idea. Results: As other stories on newly-developed therapeutics, there was an effort to make a breakthrough for difficult clinical problems, and followed by a creative initial idea along with incessant refinement in the early history of FCST. Conclusions: Patient-centered approaches was a mainspring in the development and refinement of FCST. History of FCST hereafter may well follow the trace.

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A Psychological Analysis of the Orofacial Pain Patients Through SCL-90-R (간이정신진단검사를 이용한 구강안면동통환자의 심리학적 분석)

  • Noh, Chang-Se;Ko, Myung-Yun;Park, June-Sang
    • Journal of Oral Medicine and Pain
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    • v.24 no.4
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    • pp.467-477
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    • 1999
  • Personality characteristics of orofacial pain patients was analyzed psychologically by means of the SCL-90-R. 36 TMD patients, 20 burning mouth syndrome(BMS) patients, 31 trigeminal neuralgia(TN) patients, 20 control I and 28 control II were subjected at Orofacial pain clinic, Department of Oral Medicine and Health Promotion Center, Pusan National University Hospital during the period from 1998 to 1999. The obtained results were as follows: 1. Mean values of T-scores on 9 basic scales in all the groups were within normal range. 2. The T-scores of SOM, O-C, ANX and HOS in TMD patient group were significantly higher than those in control I group, but there was no significant difference in all scales between TMD patient group and control II group. 3. The T-scores of SOM in BMS patient group was significantly higher than those in control I group, but there was no significant difference in all scales between BMS patient group and control II group. 4. The T-scores of SOM in TN patient group was significantly higher than those in control II group. 5. As compared with present and absent of the history of systemic diseases, there was no significant difference of the scales in TMD, BMS and TN patient groups but the T-scores of the patient groups with the history of systemic diseases tended to higher than those of the patient group without the history of systemic diseases. 6. As compared with acute and chronic groups, the T-scores of O-C, I-S, PAR, PSY in chronic BMS patient group were significantly higher than those in acute BMS patient.

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Study of Standardized Patient Program Using Case Report of Atopic Dermatitis (아토피 피부염 증례를 이용한 표준화환자 프로그램 연구)

  • Lee, Hyun-Woo;Hong, Seung-Ug
    • The Journal of Korean Medicine
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    • v.32 no.5
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    • pp.78-89
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    • 2011
  • Objectives: The purpose of this study was to design a standardized questionnaire for patients with atopic dermatitis in oriental dermatology. Methods: We selected atopic dermatitis from the evaluation of students' satisfaction conducted by the Department of Oriental Dermatology, Dong-guk University College of Oriental Medicine in 2011. To design the questionnaire for atopic dermatitis, we made up descriptive materials consisting of history of the present illness, patient risk factors, past medical history, personal history, and physical examination. Results: Standardized patients (SP) were used in teaching and practicing interviewing and physical examination skills for students. The SP offers a readily available tool for teaching and evaluating the clinical performance and interpersonal skills of medical students. However, the SP program needs to be more thoroughly researched and developed. Research of pattern identification in atopic dermatitis is needed to design the questionnaire. Conclusions: Using an SP program is strongly recommended to teach and evaluate in oriental medicine clinical clerkships.

A Case Report on Patient of Acute paralyic ileus with past history of mild depressive episode (급성 마비성 장폐색 환자 치험 1례)

  • Mok, Na-rae;An, Hun-Mo;Lee, Gi-Seung
    • Journal of Korean Medical Ki-Gong Academy
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    • v.13 no.1
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    • pp.19-35
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    • 2013
  • Objective : The purpose of this case is to report the improvement of a patient with acute paralytic ileus with past history of mild depressive episode after acupuncture therapy and herbal medicine. Methods : We treated the patient, who had acute abdominal pain and were diagnosed as paralytic ileus, with acupuncture, herbal medicine and manipulation therapy. We observed changes of chief symptoms and abdominal states. Results : We treated the patient who had severe abdominal pain, constipation and anorexia caused by acute paralytic ileus. For about one month of the treatment, we had the improvement of the symptoms. Conclusions : This study suggests that Conservative korean medical treatment might be useful for abdominal pain caused by acute paralytic ileus, and make a patient feel psychological stability.

A Study on Lee Jae Won's Application of the Sa-am Acupuncture Method (소곡(小谷) 이재원(李在元)의 사암침법(舍岩鍼法) 운용(運用)에 관(關)한 연구(硏究))

  • Jung, Yoo-Ong;Cha, Woongseok;Kim, Namil
    • The Journal of Korean Medical History
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    • v.23 no.2
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    • pp.89-101
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    • 2010
  • Lee Jae Won is a scholar who wrote the most in Euirim, a representative Oriental Medical magazine after the liberation of Korea, on the Sa-am Acupuncture Method. In order to understand the principles of this method, he proposed rather distinctive theories called the Comparative Pulse Diagnosis and the Five Constitutions. Lee Jae Won distinguished the deficiency and exuberance of the Five Phases through the Comparative Pulse Diagnosis, and set harmonizing the Five Phases by tonifying the deficient and purging the exuberant as the object of the Sa-am Acupuncture Method. He took pulses from both the patient's hands and distinguished the deficiency and exuberance of the five viscera. Then, he balanced the Five Phases by tonifying the weakest viscus and purging the strongest viscus. Lee Jae Won argued that because the Five Constitutions are something that one has innately, people suffer from differnet diseases according to their constitutions. Therefore, he argued, when treating a patient, one should first decide the constitution of the patient and then treat the patient according to his/her deficiency or exuberance. From the late 50's to early 60's, Lee Jae Won wrote Acupuncture and Moxibustion According to Yin-Yang and the Five Phases, explaining the principles of the Sa-am Acupuncture Method and its applications. Seen from this, Lee Jae Won is a person from whom we can confirm the historical lineage of the Sa-am Acupuncture Method after the liberation of Korea.

Bisphosphonate-related osteonecrosis of the jaw in a patient with osteoporosis following treatment of testicular cancer: a case report

  • Kim, Do-Sup;Kim, Jung-Ho;Ohe, Joo-Young;Lee, Jung-Woo;Choi, Byung-Jun;Lee, Baek-Soo;Kwon, Yong-Dae
    • Journal of the Korean Association of Oral and Maxillofacial Surgeons
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    • v.41 no.6
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    • pp.327-331
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    • 2015
  • Bisphosphonate-related osteonecrosis of the jaw (BRONJ) occurs mainly in female patients. In males the occurrence rate is low, which seems to be related to the low incidence of osteoporosis in men. Unfortunately, BRONJ tends to be ignored in general dental clinics in male patients with a history of osteoporosis treatment. BRONJ occurred in a male patient due to the clinician's lack of interest in the patient's history. In this case, the male patient was on bisphosphonate therapy because of a orchiectomy, and a dental treatment was performed without consideration of his medical history, resulting in BRONJ. We performed careful examinations and treatment with antibiotics and surgical operations. The postoperative healing was successful. In light of this particular case, we concluded that careful listening to the patient's history is very important.