3. 舉例說明 problem list 的臨床運作 # 5 CRI (Cr 2.5 mg/dl) # 4 Hyperuricemia Problem List # 1 Pneumonia, RLL 11/26 # 2 Type 2 DM, out of control # 3 HTN (SBP 180 mmHg) Inactive Active Date 12/5 well controlled 12/11 # 6 Gouty arthritis attack 12/9 improved 12/10 well controlled 12/12 # 7 Hyperglycemia (410 mg/dl) 12/13 improved 12/15 well controlled
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11. 舉例說明 problem list 與 progress note 的寫法 # 4 Proteinuria # 3 Hypertension # 2 Type 2 DM, out of control # 1 Sepsis, R/O pneumonia 12/1 Inactive Active Date Progress Notes Finger stick (AC) 160 mg/dl RML crackle decreased in intensity then yesterday Skin turgor good, urine 1300ml, no edema O: T38 0 C P86 R12 BP120/68mmHg S: Feel better this morning 12/6 12/5 12/7
12. P: 增加 actropid 劑量 14 unit tid ，同時給予糖尿病衛教 可能是 insulin 劑量不夠，也可能是病人沒有忌口 A: insulin actropid 10 unit tid ， but F/S around 150-200 ， Recorded by XXX Progress Notes P: Keep the same regime and F/U CXR, CBC tomorrow A: cefuroxime 1.5 gm, q8h (6th day). Clearly improving ( 續 ) in general condition A / P: Diovan (80mg) 1# qd. SBP around 115-135 mmHg #3 #2 #1 12/6
13. Rule 3 Weekly Summary, Transfer / Acceptance Note, On / Off Service Note Help your colleagues to manage your patient when you are absent 當你不在時，同事看過病情 摘要，就可以幫你處理患者
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15. Problem list, Progress note, Weekly summary 應用 12/19 之前，依 #1, #2, #3 分別寫三個 A/P 12/20 以後，只要寫 #4 的 A 、 P 即可 Problem list 中，可寫 symptom 、 sign 、 lab. data 、 Image finding 不一定只寫診斷；若有需要也可以簡化合併成一個新的 problem Problem List # 4 Colon cancer with near total 12/20 obstruction and lung metastasis # 3 Pulmonary nodules # 1 Fever and leukocytosis 12/19 # 2 ileus, r/o obstructive Inactive Active Date Abdominal CT ［ 12/19 小夜班完成］
16. check CBC, PT, APTT and do pre-OP evaluation Progress Notes #4 bowel sounds: hypoactive, diffuse tenderness PE of abdomen: more distended then yesterday A: ERCT last night. 大小腸皆脹， obstruction level NG tube free drainage: 550 ml, turbid, mucoid ( 六 ) O: T 37.9 C P102 / min R18 / min BP122/60mmHg Recorded by XXX / P: 會診今天值班的 GS doctor for surgical intervension 似乎在 sigmoid colon 附近，需要手術做腸造口 S: progressively abdominal fullness 12-20
17. 患者術後狀況良好，預計一兩天後開始由口進食 Nako No 5. 60 ml/hr Progress Notes 在 sigmoid colon ，因此會診 GS 開刀減壓 sign ，昨天 abdominal CT 證實 obstruction level Current Problem and plan: Brief Hx: 患者因 obstructive ileus 來急診，入院時有 toxic Diagnosis: colon cancer with obstruction ileus s/p OP ( 日 ) Recorded by XXX / Parental Nutrition support: D50W 20 ml/hr 、 Current Rx: Antibiotics －－ Augmentin 1.2 g q8h IV drip 《 Weekly summary 》 12-21
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