Progress 範本

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[Baseline]
ADL/iADL dependent, ___照顧, cons clear, ECOG

[Active problems]
[Underlying]

[OPD]

[Key person]
[HD]
[Code]

[Course]

================== NTUH ER ====================================
CC:

/  [VS]
   [PE]
   [ECG]        
   [Lab]

   [CXR]    

   [Mx, Tx]

===============================================================

[Event]

[Abx]
------------------------------------

[Microbiology]

[Ventilation]
PCV //

[Inotropes/Vasopressors]

[PADIS]
F

[Nutrition]

[Image/Examination]

[CKRT]

[Code]
Full resuscitation

================ CCU ==================
[Event]

[Abx]
------------------------------------

[Microbiology]

[Ventilation]
PCV //

[Inotropes/Vasopressors] 
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

===================================================

[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