Timeline (→ ⇒ ↑ ↓)
[Baseline]
ADL/iADL dependent, ___照顧, cons clear, ECOG
ADL/iADL dependent, ___照顧, cons clear, ECOG
[Active problems]
[Underlying]
[Underlying]
[OPD]
[Key person]
[HD]
[Code]
[HD]
[Code]
================== NTUH ER ====================================
CC:
CC:
/ [VS]
[PE]
[ECG]
[Lab]
[PE]
[ECG]
[Lab]
[CXR]
[Mx, Tx]
===============================================================
[Event]
[Abx]
------------------------------------
[Microbiology]
[Ventilation]
PCV //
[Inotropes/Vasopressors]
[PADIS]
F
[Nutrition]
[Image/Examination]
[CKRT]
[Code]
Full resuscitation
Full resuscitation
================ CCU ==================
[Event]
[Event]
[Abx]
------------------------------------
[Microbiology]
[Ventilation]
PCV //
[Inotropes/Vasopressors]
mcg/kg/min
mcg/kg/min
[Mechanical circulatory support]
[PADIS]
F
[Nutrition]
[Image/Examination]
[CKRT]
[Code]
=== Ward ===========
[Event]
[Abx]
--------------------------------------
[Microbiology]
[Image/examination]
[Inotr./vasopr.]
Nil
[Ventilation/O2]
Nil
[Nutrition]
Normal diet
[Code]
Full resuscitation
Full resuscitation
===================================================
[Physical Examination]E4V5M6
HEENT: Pink conjunctiva, anicteric sclera
Heart: Regular heart beat without murmur
Chest: clear breath sounds
Abdomen: Soft and flat, normoactive bowel sounds
Extremities: No pitting edema
Skin: no ecchymoses. no rash
===================================================
■ CAD Risk:
DM(), Hypertension(), Dyslipidemia(), Smoking(), Sex(), Age>45(men)(), Age>55(woman or postmenopause)(), Family history(male<55, female<65), Lack of exercise(), obesity (BMI)
-----------------------------------------------------------------
【History of Obstetrics and Gynecology】
1. G P AA SA E (NSD* , C/S* ), sexual experience: , marital status:
2. Menarche: years old, menopause: , hormone therapy: ,
Menstrual cycle: interval/duration: / days,
Amount: moderate, dysmenorrhea:( ),
last menstrual period: 2019/
3. Last Pap smear and result: (2021/ / )
【Brief History】
1. Birth history:
GP, GA wks, BBW: gm, NSD/ C/S due to _____
PROM(-), Perinatal asphyxia(-), Neonatal jaundice(-)
2. Feeding: on full diet
3. Vaccination: As scheduled
4. Growth and development:
- BW: kg ( th percentile);
- BH: cm ( th percentile);
- Developmental milestones: within normal limits
5. Allergies: Denied drug and food allergy
6. Past history:
- Systemic disease:
- Admission history:
- Surgical history:
7. Current medication:
- NTUH:
- Other: nil
8. Maternal history: denied any systemic disease, DM(-), HTN(-)
Denied radiation or drug exposure during pregnancy
9. Family history: no relevant disease, HTN(-), DM(-), Allergy(-)
10.TOCC:
T:travel history: denied
O:occupation :
C:contact : denied
C:cluster : denied
【Oncology Summary】 revised on
■1. Initial Presentations
■2. Definite Diagnosis
■3. Disease Extent
■4. Treatment Course
■5. Effects and Side effects
■6. Plan
