{"id":46351,"date":"2026-07-13T09:01:09","date_gmt":"2026-07-13T00:01:09","guid":{"rendered":"https:\/\/blog.agentsoft.co.kr\/index.php\/2026\/07\/13\/46351\/"},"modified":"2026-07-13T09:01:09","modified_gmt":"2026-07-13T00:01:09","slug":"12-soap-note-traumatic-subdural-hemorrhage-%ed%99%98%ec%9e%90%eb%b6%84","status":"publish","type":"post","link":"https:\/\/blog.agentsoft.co.kr\/index.php\/2026\/07\/13\/46351\/","title":{"rendered":"12. SOAP note Traumatic Subdural hemorrhage \ud658\uc790\ubd84"},"content":{"rendered":"

<\/p>\n

\ubaa9\ucc28<\/strong><\/p>\n

1. Subjective information
\n2. Objective information
\n3. Assessment
\n4. Plan<\/p>\n

\ubcf8\ubb38\ub0b4\uc6a9<\/strong><\/p>\n

Dx
\nTraumatic Subdural hemorrhage, without open intracranial wound {S06, 50}
\nOnset
\n2024.5.15
\nC.C
\n\uc5b4\uc9c0\ub7fd\uace0 \ubab8\uc5d0 \ud798\uc774 \ubd80\uc871\ud55c \ub290\ub08c\uc774 \ub4e4\uc5b4\uc694
\nPI
\n\uc0c1\ud658 HTN, asprin+, \uacbd\ub3c4 \uc778\uc9c0\uc7a5\uc560 \uacfc\uac70\ub825 \uc788\ub294 \ubd84 1\/3 s\/d\ud558\uba70 \ubc1c\uc0dd\ud55c Head trauma\ub85c \ubcf8\uc6d0 EM \uc9c4\ub8cc \ubd04. \uc774\ud6c4 dizziness\uc5d0 \ub300\ud574 \ud611\uc870 \ubd88\uac00\ud558\uc5ec ENT(ear nose thorax) \uac80\uc0ac \uc9c4\ud589\ud558\uc9c0 \ubabb\ud558\uc600\uc73c\uba70, both convexity SDH \uc99d\uac00 \uc591\uc0c1 \ubcf4\uc5ec burr hole(\ucc9c\ub450\uc220) \uc704\ud574 \ub0b4\uc6d0\ud568<\/p>\n

<\uc911 \ub7b5><\/p>\n

MMSE
\n13\uc810 ( T-3, P-4, Cal-5, recall-3, penta-1 )<\/p>\n

1. \uc804\uccb4\uc801\uc778 \uadfc\ub825 \uac15\ud654
\n-Bridging: \ubc14\ub85c \ub204\uc6b4 \uc790\uc138\uc5d0\uc11c \ubc14\ub2e5\uc5d0 \uc190\ubc14\ub2e5\uc774 \ubc14\ub2e5\uc744 \ud5a5\ud558\uac8c \ud558\uace0 \ubb34\ub98e\uc744 \uad7d\ud788\uace0 \ubc1c\ubc14\ub2e5\uc744 \ub454 \uc790\uc138. hooklying\uc5d0\uc11c \uace8\ubc18 \ub4e4\uc5b4\uc62c\ub9ac\uae30 5\ucd08 \uc720\uc9c0\ud558\uace0 \ucc9c\ucc9c\ud788 \ub0b4\ub824\uc634. \uc774\ub97c 10\ud68c\uc529 3set \uc2dc\ud589<\/p>\n

1. \ubcf4\ud589\ud6c8\ub828
\n-\ud3c9\ud589\ubd09\uc744 \uc774\uc6a9\ud55c \ubc1c\ud310 \uc624\ub974\ub0b4\ub9ac\uae30 \uc6b4\ub3d9: \ud658\uc790\ub97c \ud3c9\ud589\ubd09 \uc0ac\uc774\uc5d0 \uc138\uc6b0\uace0 \uc758\uc790\ub97c \ub450\uc5b4 \ub099\uc0c1 \ub300\ube44\ud568. \ud658\uc790\uac00 \ud55c\ubc1c\uc529 \ub0b4\ubc00\uc5b4 \ub0b4\ubbfc \ubc1c\uc5d0 \uccb4\uc911\uc744 \uc2e3\uac8c \ud568. \uc704 \uc6b4\ub3d9\uc774 \ub2a5\uc219\ud574\uc84c\ub2e4\uba74 \ubc1c\ud310\uc744 \ud658\uc790 \uc55e\uc5d0 \ub450\uc5b4 \ud55c\ubc1c\uc529 \ubc88\uac08\uc544 \uac00\uba70 \ubc1c\ud310 \uc624\ub974\ub0b4\ub9ac\uae30\ub97c \ud568. \uc774\ub97c 10\ud68c\uc529 3set \uc2dc\ud589<\/p>\n

\ucd9c\ucc98 : \ud574\ud53c\ucea0\ud37c\uc2a4<\/a><\/p>\n","protected":false},"excerpt":{"rendered":"

\ubaa9\ucc28 1. Subjective information 2. Objective information 3. Assessment 4. Plan \ubcf8\ubb38\ub0b4\uc6a9 Dx Traumatic Subdural hemorrhage, without open intracranial wound {S06, 50} Onset 2024.5.15 C.C \uc5b4\uc9c0\ub7fd\uace0 \ubab8\uc5d0 \ud798\uc774 \ubd80\uc871\ud55c \ub290\ub08c\uc774 \ub4e4\uc5b4\uc694 PI \uc0c1\ud658 HTN, asprin+, \uacbd\ub3c4 \uc778\uc9c0\uc7a5\uc560 \uacfc\uac70\ub825 \uc788\ub294 \ubd84 1\/3 s\/d\ud558\uba70 \ubc1c\uc0dd\ud55c Head trauma\ub85c \ubcf8\uc6d0 EM \uc9c4\ub8cc \ubd04. \uc774\ud6c4 dizziness\uc5d0 \ub300\ud574 \ud611\uc870 \ubd88\uac00\ud558\uc5ec ENT(ear […]<\/p>\n","protected":false},"author":1,"featured_media":0,"comment_status":"open","ping_status":"open","sticky":false,"template":"","format":"standard","meta":{"footnotes":""},"categories":[1],"tags":[17127,42854,2296,56844,56845,40689,15497,41619,56834,56843],"class_list":["post-46351","post","type-post","status-publish","format-standard","hentry","category-uncategorized","tag-acase","tag-adhd-case-study","tag-soap-makes-bubbles","tag-tbi","tag-tsdh","tag-40689","tag-15497","tag-41619","tag-56834","tag-56843"],"_links":{"self":[{"href":"https:\/\/blog.agentsoft.co.kr\/index.php\/wp-json\/wp\/v2\/posts\/46351","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/blog.agentsoft.co.kr\/index.php\/wp-json\/wp\/v2\/posts"}],"about":[{"href":"https:\/\/blog.agentsoft.co.kr\/index.php\/wp-json\/wp\/v2\/types\/post"}],"author":[{"embeddable":true,"href":"https:\/\/blog.agentsoft.co.kr\/index.php\/wp-json\/wp\/v2\/users\/1"}],"replies":[{"embeddable":true,"href":"https:\/\/blog.agentsoft.co.kr\/index.php\/wp-json\/wp\/v2\/comments?post=46351"}],"version-history":[{"count":0,"href":"https:\/\/blog.agentsoft.co.kr\/index.php\/wp-json\/wp\/v2\/posts\/46351\/revisions"}],"wp:attachment":[{"href":"https:\/\/blog.agentsoft.co.kr\/index.php\/wp-json\/wp\/v2\/media?parent=46351"}],"wp:term":[{"taxonomy":"category","embeddable":true,"href":"https:\/\/blog.agentsoft.co.kr\/index.php\/wp-json\/wp\/v2\/categories?post=46351"},{"taxonomy":"post_tag","embeddable":true,"href":"https:\/\/blog.agentsoft.co.kr\/index.php\/wp-json\/wp\/v2\/tags?post=46351"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}