【Past History】
1. Systemic disease: hypertension
2. Hospitalization history: denied
Surgical history: denied
3. Allergy history:
- Medication Allergy: No 病人自述 2018/04/13
- Medication ADR: unknown
- Allergy to Medical Device and Materials: No 病人自述 2018/04/13
4. Current medication:
- NTUH:
Mycostatin Susp 0.1 MU/1 mL 24 mL/btl 4 mL Q6H PO 5 days
PARAMOL 500 mg/tab 1 tab QID PO 5 days
Ativan 0.5 mg/tab 1 tab HS PO 5 days
- LMD:
Candesartan 8 mg/tab 1 tab QD PO
Singulair 25 mg/tab 1 tab QD PO
Carvedilol 25 mg/tab 0.5 tab QD PO
Bokey 100 cap/tab 1 cap QD PO for 10+ years, discontinued in 2018/02
- 中草藥: denied
- 保健食品: 葡萄糖胺
5. Lifestyle
- Cigarette smoking: denied
- Alcohol consumption: denied
- Betelnut chewing: denied
6. TOCC
- Travel history: visited 張家界 in 2017/12
- Occupation history: 幼兒園教師
- Contact history: denied
- Cluster of illness: denied, works in the garden at home
7. Family history:
- the patient's mother had hypertension
小兒科專用
Birth History:
G2P2, ,GA:41weeks, BBW:3358g, DOIC(-), PROM(-)
Feeding:
On full diet
Vaccination:
As schedule, Pneumococcus vaccine(-), Rotavirus vaccine(-)
Growth and Development:
BW: Kg( th%), BL: cm( - th%), HC: cm( - th%)
Developmental milestones: WNL
連結
婦產科專用
GYN & OBS Hx: Marital status: married Sexual experience:(+) Contraception: (-)
G P A LMP: PMP:
menarche: y/o
Mensturation cycle: regular Duration: days Interval: days
Amount: Blood clot: (-)
Dysmenorrhea: (-) Diarrhea: (-) Dizziness:(-)
Dyspareunia: (-) Post-coital bleeding: (-)
Last PAP smear: abnormal
Previous PAP smear: within normal limit
Menopause: (-) Age: y/o HRT(-)
palpitation(-), hot flash(-), insomnia(-), anxiety(-)
Review of systems
General: No body weight change, No fatigue, No fever, No chills, No anorexia, No
night sweating, No weakness, No insomnia, No irritability
Skin: No rashes, No itching, No bruising, No petechiae, No spider angiomata, No hair loss, No nail change
Head: No head trauma history, No headache
Eyes: No blurred vision, No photophobia, No diplopia, No red eye, No discharge, No eye pain
Ears: No hearing impairment, No tinnitus, No otalgia, No discharge
Nose: No epistaxis, No nasal obstruction, No rhinorrhea
Throat and oral cavity: No gum bleeding, no hoarsening, no sore throat
Neck: No neck pain, No neck stiffness
Breast: No gynecomastia, No nipple discharge, No pain, no lump
Respiratory: No cough, No sputum, No hemoptysis, No wheezing, No stridor, No shortness of breath
Cardiovascular: No exertional chest pain, No DOE, No PND, No palpitation, No hypertension
Gastrointestinal: No dysphagia, No heart burn, No bloating, No belching, No flatulence, No nausea, No vomiting, No hematemesis, No tarry stool, No matochezia,No constipation, No diarrhea, No abdominal pain, No jaundice, No tea-color urine, No change of bowel habit, No dyspepsia, No borborygmus, No food intolerance.
Genitourinary: No polyuria, No nocturnal micturation, No urinary urgency, No post-micturation dripping, No urinary incontinence.
Endocrine: No cold intolerance, No heat intolerance, No tremor, No polyuria, No polydipsia, No polyphagia, Musculoskeletal.No joint pain, No myalgia, No stiffness of joint, No deformity of joint, No back pain,
Hematology: No anemia, No easy bruising, No ecchymosis, No night sweating,
Neuropsychiatric: No syncope, No seizure, No fainting, No paralysis, No paresthesia, No tremor, No involuntary movement, No anxiety No emotional distress, No memory impairment, No auditary or visual halluciation, no consciousness.
PE
Consciousness: Clear, E4V5M6
Appearance: fair-looking Appetite: fair
T/P/R= 37.6/ 110/ 23 BP= 130/70 mmHg
HEENT
Head: trauma (-), scar(-)
Eye& Ear: pale conjunctiva (-), icteric sclera (-), Frank's sign(-)
Nose: rhinorrhea (-), epistaxis (-), obstruction (-)
Mouth: Thrush(-), ulcers(-), sore throat (-)
Neck: supple, lymph adenopathy (-), jugular vein engorgement(-)
Chest
Inspection: symmetric expansion, Accessory muscle exertion(-)
Auscultation: bilateral clear, crackles(-), wheezing(-)
Heart
Auscultation: Regular heart beat, no audible murmur
Abdomen
Inspection: soft, flat, operation scar(-), caput medusa(-)
Auscultation: bowel sound(normo-active)
Palpation: peritoneal sign(-), tenderness(-), hepatomegaly(-), splenomegaly(-), mass(-)
Percussion: normo-tympanic, No shifting dullness
Limbs: Warm, edema(-), decreased arterial pulsation (-)
Skin: Skin turgor fine, petechiae(-), ecchymosis(-)
Back: Knocking pain (-)
NE
[Higher Cortical Function]
[Cranial Nerve]
[Motor system]
註: DTR的分級
[Sensory system]
[Coordination]
Assessment
Type 2 diabetes mellitus
The patient had diabetes mellitus for several years, and under OAD control now. The complication of diabetes mellitus include DM neuropahy, retinopahy, nephropathy.
Lateset HbA1c:
Hypertension
The patient had hypertension for several years.
OPD medications:
Baseline BP
Benign prostate hyperplasia
The patient had benign prostate hyperplasia for several years.
Urinary symptoms include dysuria, frequency, urinary retention.
End-stage-renal-disease on hemodialysis, qW1,3,5 qW2,4,6
The patient had endstage stage renal disease and had regular hemodialysis 3 times a week for several years. The baseline BUN/Creatinine= /
Heart failure
The patient had heart failure for several year. NYHA functional class I II III VI.
Symptoms: PND(+), orthopnea(+), edema(+)
OPD medications:
Plan
Daignostic plan
Pre-OP assessment as CBC/DC, BUN/Cre, Na, K, PT, aPTT, EKG, CxR
Check F/S 四段
Check HbA1c
Monitor BP during admission
Follow up BUN/Creatinine, uremic symptoms, bleeding events.
Therapeutic plan
Keep OPD medication
Arrange surgery tomorrow
On regular hemodialysis
Educational plan
Inform the therapeutic plain to the family
Sign permit
衛教拍痰
營養師衛教、衛教監測血糖、足部護理、定期檢查視網膜的重要性
建議規則量測血壓
Limit salt & water intake
Avoid high K/P fruits or drugs
Avoid nephrotoxicity drugs