年 月...
TRANSCRIPT
-
1. 2.
/
()
1./ 2./ 3. 4. 5.
6. 7.
8. ()
1.
2.
1./ 2./ 3. 4. 5.
6. 7.
8. ()
104 1 12
-
2
3
20
6
()
3 20
4
(104.4.17
)
1. 2. 3. 4. 3 5. 3 6. 7.
1. () ( 3 2.( 3) 3.(_____________) 4. () ( 3)
( 4)
21 22
104 1 12
-
3
( ICD)
104 7
21
2()
6
()
( )
( )
-
4
()()
() 1. ()(1)
(1)( 4-1) 2. ()(5)(1
)( 4-1) 3.
()
( 4-1)
1. ()( 45)
2.
3.
()
b110() 4 (ICD-9-CM 780 780.09ICD-10-CM R40.2 R40.3) (1)(2)
(/)ICD-9-CM 296ICD-10-CM F30~34
b117() 2(2) (1 )(10)
b144() b164() 3(3)() (1 )(10)
b167()b16700() b16710() 2(2)() (1 )(10)
b210() 3(ICD-9-CM360.41ICD-10-CM H44521H44522H44523 H44529)(ICD-9-CM 743.00ICD-10-CM Q111) (1 )
s220() 3 (1)
b230() 3 (ICD-9-CM 388.5ICD-10-CM H933x3) (1)
s260() 3 (1)
s320s330 s340 (1)
s430 (1)
s530s540 s560 (1 )
b730()b730ab730bb735 b765 b730.2 1( 1 ) 2(2)(5 )(2 )
s730 s750 (1 )
s810 (1)
-
(16)(8)
1 2
2 2
3 2
4 1
3
5 7
6 1
7 4
5
4
6
5
5
5
6
4
8 8
9 1
10 1
11 1
12 1
13 1-8 ICD
14 1
15
1 8 ICD
16
1 8 ICD
()
1
4-1
-
5
1.
b110 Consciousness functions
()
b110.0
b110.1()
b110.4
b117 Intellectual functions
()
()
1.
b117.0
b117.1 69 55
b117.2 54 40
b117.3 39 25
b117.4 24
2. (mental age)
b117.0
b117.1(mental quotient) 69 55
b117.2(mental quotient) 54 40
b117.3(mental quotient) 39 25
b117.4(mental quotient) 24
3.CDR
b117.0
b117.1 1
b117.2 2
b117.3 3
b117.4 3
-
6
b122 Global psychosocial functions ()
(Global Assessment of Functioning)
b122.0
b122.1 41 50
b122.2 31 40
b122.3 21 30
b122.4 20()
b140 Attention functions ()
b140.0
b140.1
(
)
b140.2
(
)
b140.4
(
)
b144 Memory functions ()
b144.0
b144.1
b144.2
b144.3
b147 Psychomotor functions ()
(Global Assessment of Functioning)
b147.0
b147.1 41 50
b147.2 31 40
b147.3 21 30
b147.4 20()
-
7
b152 Emotional functions
()
(Global Assessment of Functioning)
b152.0
b152.1 41 50
b152.2 31 40
b152.3 21 30
b152.4 20()
b160 Thought functions
()
(Global Assessment of Functioning)
b160.0
b160.1 41 50
b160.2 31 40
b160.3 21 30
b160.4 20()
b164 Higher-level Cognitive functions
()
()
1.
b164.0
b164.1
b164.2
b164.3
2.
b164.0
b164.1()()
b164.2
3.
b164.0
b164.1 1
b164.2 2
b164.3 3
-
8
b16700 Reception of spoken language ()
b16700.0
b16700.1
b16700.2
b16700.3
b16710 Expression of spoken language ()
b16710.0
b16710.1
b16710.2
b16710.3
b16701 Reception of written language ()
b16701.0
b16701.11.
2.
b16711 Expression of written language ()
b16711.0
b16711.11.
2.
-
9
2.
b210 Seeing functions
()
b210.0
b210.11. 0.3 0.3 0.1
() 0.4 0.05()
2. 20
3. 30 10dB()
b210.21. 0.1 0.1
0.05()
2. 30 15dB()
b210.31. 0.01( 50)
2. 30 20dB()
b230 Hearing functions
()
3 ~ 5
1. PTA = ( 500Hz + 1kHz + 2kHz + 4kHz ) /4
PTA = ( + + + ) /4=
PTA = ( + + + ) /4=
2. ( 100% 100%)
( PTA - 25 ) x 1.5% = % ( PTA - 25 ) x 1.5% = %
3. = ( % x 5 + % x 1) /6 = %
b230.0
b230.1 50.0% 70.0%
b230.2 70.1% 90.0%
b230.3 90.0%
3 ~ 5
b230.0
b230.1(ABR) 55 69
b230.2(ABR) 70 90
b230.3(ABR) 90
-
10
b235 balance functions
()
b235.0
b235.1
b235.2
b235.3
s220 Structure of eyeball
()
s220.0
s220.3
s260 Structure of inner ear
()
s260.0
s260.3
3.
b310 Voice functions
(
)
b310.0
b310.1
b310.3
b320 Articulation functions
(
)
b320.0
b320.1
b320.3
-
11
b330 Fluency and rhythm of speech functions
(
)
b330.0
b330.1
b330.3
s320 Structure of mouth
()
s320.0
s320.1 25mm
14
s320.2 15 mm
6
s320.3 5 mm
s330 Structure of pharynx
s330.0
s330.1 25% 49%
s330.2 50% 95%
s330.3 96% 100%
s340 Structure of larynx
s340.0
s340.1 25% 49%
s340.2 50% 96%
s340.3
-
12
4.
b410 Heart functions
() *
b410.0
b410.11.
2. 85% 90%
3.
b410.21.
2. 80% 84%
3.
b410.31.
2. 70% 79%
3.
b410.41.
2.
3.
4. couplets
5. 40
50%
6.QT 480 QT
7. 35%
8. 70%
9.
10. 70%
11.
12.
b415 Blood vessel functions ()
b415.0
b415.1
b415.2
b415.3
-
13
b430 Haematological system functions
()
b430.0
b430.11. 8g/dL 2000/uL 500/uL
50,000/uL
2. 5% 30%
3.
4.()
5.(Protein C Protein S
Antithrombin)
b430.21. 8g/dL 2000/uL
500/uL 50,000/uL
2. 1% 5%
3.
4. vWF 25%
5.Protein CProtein SAntithrombin
6.(
)
b430.31.
2. 1%
3.
4.(vWF 5%)
5.Protein CProtein SAntithrombin
6.(
)
b430.41.
2. 1%
3.
4.(Protein CProtein SAntithrombin)
(
)
5.(
)
-
14
b440 Respiration functions (
)
b440.0 b440.11.PaO2 60 65 mmHg SpO2 93% 96% (
) 2.FEV1 30% 35% 3.FEV1/FVC 40% 45% 4.DLco 30% 35% 5.Apnea-hypopnea index (AHI) 40/hr
6. PaCO2 50 55mmHg
b440.21.PaO2 55 59.9 mmHg SpO2 89% 92% ()
2.FEV1 25% 29.9% 3.FEV1/FVC 35% 39.9% 4.DLco 25% 29.9% 5. PaCO2 56 60mmHg
b440.31.PaO2 50 54.9 mmHg SpO2 85% 88% ()
2.FEV1 25% 3.FEV1/FVC 35% 4.DLco 25% 5. 6 6. PaCO2 61 65mmHg
b440.41.PaO2 50 mmHg SpO2 85% ( )
2.(Ventilator-dependent) 3. PaCO2 65mmHg
s430 Structure of respiratory system s430.0
s430.1
s430.21.
2. 70%
s430.3()
5.
b510 Ingestion functions
()
b510.0 b510.1 b510.2
s530 Structure of stomach s530.0 s530.1 75%
-
15
s540 Structure of intestine
s540.0
s540.1
s540.3
75%
s560 Structure of liver *()
s560.0
s560.1 Pugh's modification of
Child-Turcotte criteria Child's class B
s560.21. Pugh's modification of Child-Turcotte criteria Child's
class B
2.
3.
s560.31.
2.
3.
4.
5.
s560.41. Pugh's modification of Child-Turcotte criteria Child's
class C
2.
6.
b610 Renal functions
() *
b610.0
b610.1(eGFR)
31 60
b610.2
(eGFR)
16 30
b610.3
(eGFR) 15
b610.4
-
16
b620 Urination functions ()
b620.0
b620.21.
2.
3.
7.
b710a () Mobility of joint functions (Upper limbs)
()
b710a.0
b710a.11. 70%
2. 70%
3. 70%
4.
5. 70%
6.
7.()
8. b710a.21.
2.
3. 70%
4.
5.()
b710a.3
b710b () Mobility of joint functions (Lower limbs) ()
b710b.0
b710b.11. 70%
2. 70%
3. 70%
4.
5. 70%
b710b.21.
2.
3. 70%
b710b.3
-
17
b730a ()Muscle power functions (Upper limbs) ()
b730a.0
b730a.11.
2.
3.
4.
5.
6.()
7.()()
8.()
b730a.21.
2.
3.
4. ()
5. ()()
b730a.3
b730b ()Muscle power functions (Lower limbs) ()
b730b.0
b730b.11. 2 3. 4. 5.
b730b.21. 2.
3. b730b.3
-
18
b735 Muscle tone functions ()
b710b730/
b735.0
b735.1 modified Ashworth scale
b735.2 modified Ashworth scale
b735.3 modified Ashworth scale
b765 Involuntary movement functions
b710b730/
b765.0
b765.11. Modified Hoehn-Yahr Stage
2.
b765.21. Modified Hoehn-Yahr Stage
2.
b765.31. Modified Hoehn-Yahr Stage
2.
s730 Structure of upper extremity
s730.0
s730.11.
2.
3.()
4.
s730.21.
2.
3.()
s730.31.
2.
-
19
s750 Structure of lower extremity
s750.0
s750.11.
2.
3 X
()
_____________________
s750.21.
2.
s750.31.
2.
s760 Structure of trunk
s760.0
s760.11. X
2. X X
Cobb 70
3. X Schober 2
4. Schober 2
s760.21. X
X Cobb 70
2. X
Schober 2
s760.3 X
X Cobb 70 X
Schober 2
8.
b810 Protective functions of the skin
()
b810.0
b810.1
-
20
b830 Other functions of the skin
b830.0
b830.1(
)
s810 Structure of areas of skin
s810.0
s810.11.
30% 39%
2. 31% 50%
s810.21. 40% 59%
2. 51% 70%
s810.31. 60%
2. 71%
*
()(
)()()()
-
21
14
( 4 )
14
( 4 )
14
( 4 )
14
( 4 )
14
( 4 )
1. 14
2.
3. ()(
4-1)
(1)(1
)
(5)(>1 )
4.
-
22
()101 7 11() 101
7 10 ()
()(
4-1)
(1)
(1)
(5)(>1)
()
(
)( 45)(
4-1)
()
() ()
()
-
23
(18 )
H4
0 1 2 3 4
5 6 7 8 ()
A5
0 1 2 ()3
4 ()5 6.1 ()
6.2 () 7 /()
8 ()
F5
0()
1()
2()
H5 H6
/
H7
H8
0 1 2 3
4 5 6 7
8 9
0
() 1
() 2
() 3
()
4 (/
)
9 ()
1
D1.1 10
0 1 2 3 4 9
D1.2 0 1 2 3 4 9
D1.3 0 1 2 3 4 9
D1.4 0 1 2 3 4 9
D1.5 0 1 2 3 4 9
D1.6 0 1 2 3 4 9
P1.1 ?
0()1()2() ( 2)
D1.1 10
0 1 2 3 4 9
D1.2 0 1 2 3 4 9
D1.3 0 1 2 3 4 9
D1.4 0 1 2 3 4 9
D1.5 0 1 2 3 4 9
D1.6 0 1 2 3 4 9
-
24
0
() 1
() 2
() 3
()
4 (/
)
9 ()
2
D2.1
0 1 2 3 4 9
D2.2 0 1 2 3 4 9
D2.3 0 1 2 3 4 9
D2.4 0 1 2 3 4 9
D2.5 0 1 2 3 4 9
P2.1 ?
0()1()2() ( 3)
D2.1
0 1 2 3 4 9
D2.2 0 1 2 3 4 9
D2.3 0 1 2 3 4 9
D2.4 0 1 2 3 4 9
D2.5 0 1 2 3 4 9
0
() 1
()
2 ()
3 ()
4 (/
)
9 ()
3
D3.1
0 1 2 3 4 9
D3.2 0 1 2 3 4 9
D3.3 0 1 2 3 4 9
D3.4 0 1 2 3 4 9
P3.1 ?
0()1()2() ( 4)
D3.1
0 1 2 3 4 9
D3.2 0 1 2 3 4 9
D3.3 0 1 2 3 4 9
D3.4 0 1 2 3 4 9
0
() 1
()
2 ()
3 ()
4 (/
)
9 ()
4
D4.1
0 1 2 3 4 9
D4.2 0 1 2 3 4 9 D4.3 0 1 2 3 4 9
D4.4 0 1 2 3 4 9 D4.5 0 1 2 3 4 9
P4.1 ?
0()1()2() ( 5)
D4.1
0 1 2 3 4 9
D4.2 0 1 2 3 4 9 D4.3 0 1 2 3 4 9 D4.4 0 1 2 3 4 9
D4.5 0 1 2 3 4 9
-
25
0
() 1
()
2 ()
3 ()
4 (/
)
9 ()
51
D5.1
0 1 2 3 4 9
D5.2 0 1 2 3 4 9
D5.3 0 1 2 3 4 9
D5.4 0 1 2 3 4 9
P5.1 ?
0()1()2() ( 5 2)
D5.1
0 1 2 3 4 9
D5.2 0 1 2 3 4 9
D5.3 0 1 2 3 4 9
D5.4 0 1 2 3 4 9
()/() D5.5-5.10
6
0
() 1
()
2 ()
3 ()
4 (/
)
9 ()
52
D5.5 /
0 1 2 3 4 9
D5.6 0 1 2 3 4 9
D5.7 0 1 2 3 4 9
D5.8 0 1 2 3 4 9
D5.9
?
(0) (1) 9()
0 1 9
D5.10
?
0 1 9
P5.3 ?
0()1()2() ( 6)
D5.5 /
0 1 2 3 4 9
D5.6 0 1 2 3 4 9
D5.7 0 1 2 3 4 9
D5.8 0 1 2 3 4 9
D5.9
?
(0) (1) 9()
0 1 9
D5.10
?
0 1 9
-
26
0
() 1
()
2 ()
3 ()
4 (/
)
9 ()
6
D6.1
0 1 2 3 4 9
D6.2 0 1 2 3 4 9
D6.3 0 1 2 3 4 9
D6.4 0 1 2 3 4 9
D6.5 0 1 2 3 4 9
D6.6 0 1 2 3 4 9
D6.7 0 1 2 3 4 9
D6.8 0 1 2 3 4 9
P6.1 ?
0()1()2() ( 7)
D6.1
0 1 2 3 4 9
D6.2 0 1 2 3 4 9
D6.3 0 1 2 3 4 9
D6.4 0 1 2 3 4 9
D6.5 0 1 2 3 4 9
D6.6 0 1 2 3 4 9
D6.7 0 1 2 3 4 9
D6.8 0 1 2 3 4 9
7
D7.1 (0) (8)
D7.2 (0) (8)
D7.3 (0)/ (8)
D7.4 (0)/ (8)
D7.5 (0)/ (8)
D7.6 (0)/ (8)
D7.7 (0) (8)
D7.8 (0)/ (8)
-
27
8
0
()
1
()
2
()
3
()
4
()
D8.1
0 1 2 3 4
D8.2 0 1 2 3 4
D8.3 0 1 2 3 4
D8.4 0 1 2 3 4
D8.5 0 1 2 3 4
D8.6 3 0 1 2 3 4
D8.7 0 1 2 3 4
Pd1.1 ?0()1()2()
D8.1
0 1 2 3 4
D8.2 0 1 2 3 4
D8.3 0 1 2 3 4
D8.4 0 1 2 3 4
D8.5 0 1 2 3 4
D8.6 3 0 1 2 3 4
D8.7 0 1 2 3 4
() ()
()
-
28
(6 18 )
H4
01 2 3 4 5 6 7 8 ()____________ 9
H5 H6
/
H7
A5 /
0 1 2 () 3 4 () 5 6.1 () 6.2 () 7 /() 8 ()
F5
0() 1() 2()
H8 0 123 45 6 7 8 9
1 0 1 2 3 4
2
0 1 2 3 4
3
01(: /) 23 4 5 6 :
4
0 1 2: () 3() 4 5 6 7:
5
1 0 ?
0 ()
1 ()
2 ()
3 ()
9 ()
1
1.
0 1 2 3 9
2. 0 1 2 3 9
3. 0 1 2 3 9
4. 0 1 2 3 9
5.
0 1 2 3 9
6.
0 1 2 3 9
-
29
0 ()
1 ()
2 ()
3 ()
9 ()
1
1.
0 1 2 3 9 2. 0 1 2 3 9 3. 0 1 2 3 9 4. 0 1 2 3 9 5.
0 1 2 3 9
6.
0 1 2 3 9
0 ()
1 ()
2 ()
3 ()
9 ()
2
7.
0 1 2 3 9 8. 0 1 2 3 9
9.
0 1 2 3 9
10.
0 1 2 3 9
0 ()
1 ()
2 ()
3 ()
9 ()
2
7.
0 1 2 3 9 8. 0 1 2 3 9 9.
0 1 2 3 9
10.
0 1 2 3 9
/(3) 3 4
0 ()
1 ()
2 ()
3 ()
9 ()
3
11.
0 1 2 3 9
12.
0 1 2 3 9
13.
0 1 2 3 9
14. 0 1 2 3 9 15.
0 1 2 3 9
-
30
0 ()
1 ()
2 ()
3 ()
9 ()
3
11.
0 1 2 3 9
12.
0 1 2 3 9
13.
0 1 2 3 9
14. 0 1 2 3 9 15.
0 1 2 3 9
0 ()
1 ()
2 ()
3 ()
9 ()
4
16.
0 1 2 3 9 17./
0 1 2 3 9
18.
0 1 2 3 9
19.
0 1 2 3 9
/(0)(1)(2) 20 19
20.
0 1 2 3 9
0 ()
1 ()
2 ()
3 ()
9 ()
4
16.
0 1 2 3 9 17./
0 1 2 3 9
18.
0 1 2 3 9
19.
0 1 2 3 9
/(0)(1)(2) 20
20.
0 1 2 3 9
0() 1() 2()
1 0 1 2
2 0 1 2
3 0 1 2
4 0 1 2
5
0 1 2
-
31
0() 1() 2()
6 0 1 2
7 0 1 2
8 0 1 2
9 0 1 2
10 0 1 2
11 0 1 2
12 0 1 2
13 0 1 2
14 0 1 2
15
0 1 2
0() 1() 2() 9()
1
0 1 2 9
2
0 1 2 9
3
0 1 2 9
4
0 1 2 9
5
0 1 2 9
6
0 1 2 9
7 0 1 2 9
8
0 1 2 9
9 0 1 2 9
10 0 1 2 9
11
0 1 2 9
12 0 1 2 9
13
0 1 2 9
-
32
/ (0)(1)(2)(3)13
141719
0() 1() 2() 9()
14
0 1 2 9
15
0 1 2 9
16
0 1 2 9
17
0 1 2 9
/ (3) 17 18 19
18
0 1 2 9
19
??
() ()
()