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사망진단서 작성법

사망진단서, 시체검안서, death certificate
by

Jinwoo Jeong

on 16 October 2014

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Transcript of 사망진단서 작성법

사망진단서 작성의 실제
사망 진단
사망했다는 사실을 확인
매장, 화장
사망 신고
상속, 보험
개인 식별이 중요
이름, 주민등록번호, 등록기준지, 주소
사망의 종류
사망의 원인 (사인)
사망원인 통계 (통계청)
보험 관련 문제
수사
사망진단서
진료 중에 사망
진료 후 48시간 이내에 사망
시체검안서
이미 사망한 상태에서 검안 후 발급
사인 네 칸을 다 채울 필요는 없다
사망의 증세 (sign of death)는 적지 않는다
호흡마비, 심장정지, 심폐기능상실, 심정지 등
'한국표준질병사인분류' 기준
병사가 아니면 '변사'
변사체를 발견한 의사는 경찰에 신고 의무
Shortly after dinner on the day prior to admission to the hospital, this 48-year-old male developed a cramping, epigastric pain, which radiated to his back, followed by nausea and vomiting. The pain was not relieved by positional changes or antacids.

The pain persisted, and 24 hours after its onset, the patient sought medical attention. He had a 10-year history of excessive alcohol consumption and a 2-year history of frequent episodes of similar epigastric pain. The patient denied diarrhea, constipation, hematemesis, or melena.

The patient was admitted to the hospital with a diagnosis of an acute exacerbation of chronic pancreatitis. Radiological findings included a duodenal ileus and pancreatic calcification. Serum amylase was 4,032 units per liter.

The day after admission, the patient seemed to improve. However, that evening he became disoriented, restless, and hypotensive. Despite intravenous fluids and vasopressors, the patient remained hypotensive and died. Autopsy findings revealed many areas of fibrosis in the pancreas with the remaining areas showing multiple foci of acute inflammation and necrosis.
만성 췌장염의 급성 악화
3일
만성 췌장염
2년
알콜 의존증
10년
V
This 75-year-old male was admitted to the hospital complaining of severe chest pain.
He had a 10-year history of arteriosclerotic heart disease with EKG findings of myocardial ischemia and several episodes of congestive heart failure controlled by digitalis preparations and diuretics.

Five months before this admission, the patient was found to be anemic, with an hematocrit of 17,and to have occult blood in the stool.A barium enema revealed a large polypoid mass in the cecum diagnosed as carcinoma by biopsy.
Because of the patient’s cardiac status, he was not considered to be a surgical candidate. Instead, he was treated with a 5-week course of radiation therapy and periodic packed red cell transfusions.

He completed this course 3 months before this hospital admission. On this admission the EKG was diagnostic of an acute anterior wall myocardial infarction. He expired2 days later.
심근 경색
2일
협심증
10년
대장암, 울혈심부전
A 75-year-old female had a 15-year history of noninsulin-dependent diabetes mellitus, a 13-year history of mild hypertension treated with thiazide diuretics, and an uncomplicated myocardial infarction 6 years prior to the present illness.

She was found disoriented in her apartment and brought to the hospital. On admission she was noted to be unresponsive, without focal neurologic signs, and severely dehydrated with a blood pressure of 90/60. Initial laboratory tests disclosed severe hyperglycemia, hyperosmolarity, azotemia, and mild ketosis without acidosis.
A diagnosis of hyperosmolar nonketotic coma was made.

The patient was vigorously treated with fluids, electrolytes, insulin, and broad-spectrum antibiotics, although no source for infection was documented.
Within 72 hours, the patient’s hyperosmolar, hyperglycemic state was resolved.

However, she remained anuric with progressive azotemia. Attempts at renal dialysis were unsuccessful, and the patient died on the 8th hospital day in severe renal failure.
급성 신부전
On January 2, 2003, a 21-year-old female was critically injured in an automobile accident and died from a fractured skull causing cerebral contusion soon after being brought to the hospital.
Police records indicated she was the driver in a two-car collision that occurred at 2:15 a.m. at the corner of 21st Street and Ash Street. The decedent crossed the center line and struck an oncoming car head on.
뇌 좌상
머리뼈 골절
운전자 교통사고
30분
30분
30분
V
V
V
V
V
2003
1
2
02
15
V
고삼투압성 뇌증
제2형 당뇨
5일
8일
15년
On May 5, 2003, a 54-year-old male was found dead from carbon monoxide poisoning in an automobile in a closed garage.

A hose, running into the passenger compartment of the car, was attached to the exhaust pipe.

The deceased had been despondent for some time as a result of a malignancy, and letters found in the car indicated intent to take his own life.
일산화탄소 중독
자동차 배기 가스 흡입
V
미상
미상
V
V
2003
5
5
미상
-
-
-
On September 4, 2003, a 50-year-old alcoholic male was found unconscious in an abandoned house at 4 a.m. by police.

He was admitted to the hospital where he died at 10 a.m. on the same day.

Examination on admission to the hospital revealed a large subdural hematoma causing intracerebral hemorrhage. There was a large subgaleal hemorrhage over the area of the subdural hematoma.
경막밑 혈종
머리의 둔상
미상
미상
V
V
미상
V
2003
9
4
미상
V
On October1, 2003,at 2:30 p.m.,a 22-year-old male was found hanging by the neck in the garage at the rear of his residence.
He had a history of despondency and drug abuse and was last seen by his mother 30 minutes earlier.
목맴
수분 이내
질식
목맴
V
V
목맴
V
2003
10
1
14
30
V
On August 18, 2003, a 32-year-old female was found dead at home. Initial investigation did not reveal cause of death;
미상
V
미상
V
V
Don't
Do This

불확실한 병명
선행사인 미기재
사인의 순서 바뀜
사망의 증상을 기록
손상 상황 미기재
한 칸에 두 개 이상의 사인
심장병
노환
출혈성 쇼크
위장관 출혈
교통 사고
흉부 둔상
긴장 기흉
심폐정지
심장기능부전
저산소증
호흡마비
경질막바깥출혈
머리뼈 골절
V
V
V
혈흉, 간열상, 경막외출혈
갈비뼈 골절, 머리뼈 골절
보행자 교통 사고
Full transcript