Progress-Weekly-Discharge模組

Problem list

<Active problem>

    1. Community acquired pneumonia

<Inactive problem>

    1. Diabetes mellitus
    2. Hypertension
    3. Chronic kideny disease, stage III

Brief history

<Treatment course at 5E3>

...

<Treatment course at 3C2>

..

Assessment

<Antibiotics>

Mepem 12/02-12/09

Vancomycin 12/04-12/09

Tygacil 12/09-12/22

Mepem 12/16-12/29

<Respiration>

MV: PCV, FiO2 50%, IP 20, PEEP 10

-> TV 350, RR 20, MV 7.6

<RRT>

Type: iHD, QW2,4,6

Vascular access: DL

DW: 62kg

Dialysate: Ca 3.0, K 2.0

Heparin: free

EPO: nil

Residual renal function: UO < 100ml/day

<PE>

GCS E1VtM4 (sedated)

Head: pink conjunctiva, anicteric sclera

Chest: bilateral clear brething sound

Heart: regular heart beat, no obvious murmur

Abdomen: soft, normoactive bowel sound, no tenderness

Limbs: edema(-)

<Important Study Findings>

<Important Intervention and Newly Added medication>

<Important consultation>

<Important family's decision>

Nil

Plan

    1. ...
    2. ...

住院治療經過

TACE

After admission, the evaluations for transarterial chemoembolization(TACE) were unremarkable. TACE was done smoothly on 2015/02/10. After the procedure, transient nausea and mild epigastralgia were noted. The epigastric pain reliefed a lot 1 day after the TACE. On 2015/02/12, both clinical evaluation and liver function test showed stable condition. The patient was discharged on 2/12 with clinic follow up.