28. Basic Data
陳○生 , male, 90y/o
Past medical history
HTN, DM, carotid stenosis bilaterally s/p
stent 5 years ago
PFT on 2014-7-15, COPD?
FVC= 59.8% of predicted value
FEV1= 43.7% of predicted value
FEV1/FVC= 72.4% of predicted value
Severe mixed ventilatory defect, inadequate
tracing and inspiratory limb
29. OP Date and Method
Hepatocellular
carcinoma
Left hepatectomy
and
cholecystectomy
on 2014-7-16
30. Progress Note(1)
Date SpO2, O2
demand
Event Lab CXR Remarks
7/16
(OP
day)
99%, N/C
3L/min
Extubation,
transferred
to ICU
─ ─ Conscious-
ness:clear,
mild wound
pain
7/17 99%, N/C
3L/min
Transferred
to general
ward
RBC:3.96
HB:11.9
HCT:35. 9
T-BIL:1.24
AST:467
ALT:343
Bilater
ally
opaciti
y
Conscious-
ness:aware
but drowsy
7/16
7/17
31. Progress Note(2)
Date SpO2,O2
demand
Event Lab Remarks
7/18 (W5)
8:07
3L->6L N/C Sputum(+)under
Actein
Actein→Mesna(IH)
CXR arranged,
Consulted PT for chest
care education(13:52)
WBC:10.06
HB:12.9
HCT:38.1
D-BIL:0.61
T-BIL:2.70
AST:191
ALT:317
Upright on bed
看護到達 ,chest care
Flatulence, try water and
liquid diet
Difficulty coughing
sputum
7/18
17:00
88~92%,
N/C 6L/min
PT: Postural drainage
and percussion 10mins
bilaterally
Sit at bed edge for
coughing
Consciousness:
aware but drowsy
No suction equipment at
bedside
7/18
18:28
91%, 40%
10L Mask
Transferred to ICU
Chest care, sputum
suction prn
Normal ABG
38. Basic Data
陳○險 , female, 78y/o
Past medical history
Bilateral inguinal hernia s/p herniorrhaphy on
2009/06/15
Hiatal hernia s/p laparoscopic reduction and
mesh repair on 2010/03/02
HTN, iron deficiency anemia
Parkinsonism
Brain CT on 2014-6-16
Brain atrophy and leukoaraiosis
39. OP Date and Method
Date Method
6/3 Ventral hernia s/p laoparotomy herniorrhaphy with suture and
mesh
(One 3x2cm lower abdomen fascia defect beneath previous
laparoscopy port scar)
6/11 Sigmoid colon necrosis s/p anterior resection of sigmoid colon
and loop ileosotmy
40. Progress Note(1)
Date SpO2,O2 demand Event CXR PT program
6/18 PiMax: -20 cmH2O
PeMax: +30 cmH2O
RR: 34 lpm
VT: 279 ml
VE: 9.4 L/Min
RSI: 122
Suspected
respiratory
muscle weakness
Consult PT for
rehabilitation
Bilateral lung
infiltrate
Small volume
lungs
Degenerative
spondylosis
Scoliosis
─
6/19
(W4)
100%,CPAP+PS
PS/PEEP:10/6
T-Piece tranining 40mins
:passed
Parkinsonism
under Rotigotine
started
PT started
─ AAROM and
breathing
exerxise
Upright 30∘
42. Progress Note(3)
6/22
6/23
Date SpO2,O2
demand
Event CXR,breath
sound
PT
program
6/22 Pimax : - 30
Pemax : + 28
RR : 23 bpm
VT : 255.7 ml
VE : 5.88 lpm
RSI : 89.97
100%,40% 10L
mask
Extubated
at 13:30
Chest care
Right hemi-
diaphragm
elevation
Bilateral lung
infiltration
scoliosis
Clear breath
sound
─
6/23 SpO2:98%,N/C
3L/min
Chest care Right hemi-
diaphragm
elevation
Bilateral lung
infiltration
scoliosis
─
6/24
(W2)
SpO2:98%,roo
m air
Chest care ─ Sit at bed
edge,Mod.
A.,10mins
43. Progress Note(4)
Date SpO2,O2
demand
Event CXR,breath
sound
PT program
6/25 SpO2:97%,
room air
Transferre
d to
general
ward
Chest care
Activity
Bilateral lung
infiltrate
Elevated right
hemidiaphrag
m
scoliosis
─
6/26
(W4)
Smooth
respirator
y pattern
under
room air
Chest care
Activity
─ AAROM and
breathing
exerxise
Chest care
Sit at bed
edge,Mod.A.,
10mins
6/28 ─ Chest care
Activity
Bilateral lung
infiltrate
─
6/25
6/28
44. Progress Note(5)
Date PT program
6/30 AAROM and breathing
exerxise
Chest care
Sit on W/C,20mins
7/2 AAROM and breathing
exerxise
Chest care
Sit on W/C,30mins
7/4 AAROM and breathing
exerxise
Chest care
Sit on W/C,40mins 7/1
