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Emergency Note
Emergency Note
Emergency Note
急診病歷
建置時間: 2023-04-30 07:23 掛號時間: 2023-04-30 07:04
就診科別: 急內 3
病 人: 病歷號:22701322 姓名:黃素青 生日:1943-04-28 性別:女
主訴(CHIEF COMPLAINT):
非
tarry stool, epigastric pain, nausea for one day
VAS:7
現在疾病(PRESENT ILLNESS):
直腸肛診(RECTAL EXAM):
not done
四肢(EXTREMITIES):
Pitting edema(-), freely movable
神經學檢查(NEUROLOGICAL EXAM):
No focal neurological deficit
- 1 -
初步診斷(TENTATIVE DIAGNOSIS):
ICD10:
[ K92.2 ]Gastrointestinal hemorrhage, unspecified
[ N18.6 ]End stage renal disease
- 2 -
急診檢傷
檢傷時間:1120430 0705
大類:A03腸胃系統
主訴:A0301腹痛
判斷依據:急性中樞中度疼痛(4-7)
體溫:36.3℃ 脈搏:95/M 呼吸:18/M
血壓:140/94mmHg 意識狀態: E:4 V:5 M:6 血氧濃度:
急診檢傷分級:3
非
到院方式:步入
護送人員:自入
來源:住處
過敏史:不詳
過去病史:腎臟病 惡性腫瘤 其它
跌倒危險因子:協助代步或攙扶
正
TOCC:null
特殊個案:無
呼吸道:通暢
呼 吸:正常
循 環:正常
疼痛評估:7 分
式
腸胃系統:胃痛 嘔吐
檢傷人員:NUR3829 林玲吟
病
歷
- 3 -
急診紀錄
# 主旨 內容 建立人員及時間
1 GM consult GM 6389 詹承翰 DOC5756F
recent discharge (4/24-28 for UTI) 2023-04-30
OA due to very recent discharge. 14:23:47
2 GI consult for EGD GI 6260 葉勇呈 agreed on EGD for survey. DOC5756F
2023-04-30
14:23:15
3 CRS consult CRS 2356 白雪翠: will see patient. DOC5756F
suggest sump NG first. suggest discuss 2023-04-30
非
with GM (4/28 recent discharge) for 10:44:19
survey.
正
式
病
歷
- 4 -
會診記錄
行政院國軍退除役官兵輔導委員會臺北榮民總醫院
會診記錄 ( CONSULTATION NOTE )
病房床號:ER01 - 姓名:黃素青 病歷號:22701322
病危否: 性別:F 出生日:19430428
病人科別: 會診科部:CRS - SURD 會診等級:URGENT30
申請日期:20230430 1024 會診期限:20230430
病史:
非
tarry stool, epigastric pain, nausea for one day
CT: obstruction
VAS:7
DX:K92.2
會診內容:
Dear doctor in charge,
This 80-year-old woman had a history of colon cancer s/p operations. Tracing back
the patient's chart, she suffered from ileus last year which resolved after
正
conservative treatment. She was just discharged on 4/28 from our hospital due to
UTI. This time, she visited ER due to abdominal pain, nausea, and vomiting for a
day. Upon ER, the vital signs were stable. The WBC 10020, seg 80.2%, CRP 0.73. The
abdominal CT revealed a dilated small bowel without evidence of a transitional
zone.
PE: abdomen: soft, tender at the low abdomen, distended abdomen, no muscle
guarding, no rebounding pain, no peritoneal signs.
式
After NG decompression, some coffee grounds were noted, also complaints tarry
stool for 3 days.
A:
1. Ileus?
2. R/O upper GI bleeding.
P:
病
1. There was no evidence of a transitional zone in this image.
2. Due to no bed available at the current, we will closely follow up this patient.
If there had progressive abdominal pain, we will arrange an operation for this
patient (Patient understood).
- 5 -
累積報告
CBC
日期 WBC RBC HGB HCT MCV MCH MCH RDW PLT INR PT APT BAN SEG LYM MON EOS BAS
C (PT T D O O
)
2023- 1002 3.5 11. 33. 94. 31. 32. 13. 28200 0.0 80. 14. 5.3 0.2 0.2
04-30 0 4 0 5 6 1 8 2 0 2 1
07:43
2023- 1.0 10. 25.
非
04-30 0 6 4
07:46
2023- 8260 3.7 11. 36. 96. 30. 32. 13. 23100 0.0 82. 11. 5.2 0.4 0.2
05-01 9 7 4 0 9 1 5 0 8 4
08:03
SMAC
正
日期 TP AL CA BU UA CR BI AL LD AL AS NA K CL GL IP CK GG DB CK CK TR TR CR CR PC eG eG Am Li
B N EA LI KP H T T U T IL MB MB OP OP P P( T( FR FR yl pa
T I (P (P PO PO (M (C as se
OC OC CT CT ) - e
T) T) ) ) G)
2023- 18 1. 0. 14 13 3. 12 55 24 - <0 - 0. - - 34 - 18
04-30 46 41 7 5 7 .1 73
07:48 0
式
2023- 1. 18 - - - - 34 -
05-01 49 5
08:14
2023- 22 - - - - -
05-01 8
08:14
一般生化
病
日期 IG G IG A IG M C3 C4 RF CER. APO APO B CRP H.S.C TRAN
A1 RP
2023-04-30 0.73
07:48
歷
- 6 -
檢查驗
項目名稱 檢體名稱 報告日期
Blood culture-2nd set Blood 2023-04-30
Blood culture Blood 2023-04-30
SMALL SURGICAL SPECIMEN-LEVEL 4 Tissue 2023-05-01
ENDOSCOPIC BIOPSY, EACH EXAM. Patient 2023-05-01
ENDOSCOPIC TX. IN UGI BLEEDING Patient 2023-05-01
非
A1C (HbA1C) Blood 2023-05-01
Glu,Crea, Blood 2023-05-01
LDH, Blood 2023-05-01
CBC,DC, Blood 2023-05-01
KUB- PLAIN Patient 2023-04-30
正
CHEST PA VIEW Patient 2023-04-30
CT SCAN- UPPER ABDOMEN UPPER ABDOMEN 2023-04-30
NON-IONIC CONTRAST MEDIUM(NHI) 2023-04-30
SYRINGE DIS.KIT SINGLE#SDS-CTP-Q 2023-04-30
CRP,Crea,NA,K,CK,Troponin I,Glu,ALT,GGT,Bil- Blood 2023-04-30
式
T,Lipase,BUN,Lactate
PT,APTT, Blood 2023-04-30
CBC,DC, Blood 2023-04-30
病
歷
- 7 -
藥囑
藥品學名 劑量 單位 途徑 頻次 開始日 結束日 狀態 總 自 說明
量 購
Tramal #^ inj 1 AMP IM ONCE 20230430 2023-05- 已取消 1 -
100 mg/2 ml :0713 01:1339
Brosym for * inj 2000 MG IVA ONCE 20230430 2023-05- 已取消 1 -
2 g :0821 01:1339
Normal saline 500 CC IVD ONCE 20230430 2023-05- 已取消 1 -
"YF" *inj 500 ml :0821 01:1339
非
Pantoloc iv inj 80 MG IVA ONCE 20230430 2023-05- 已取消 2 -
40 mg :1420 01:1339
Dextrose 5%0.45% 500 CC IVD ONCE 20230430 2023-05- 已取消 1 -
NS inj 500ml YF :1420 01:1339
Medicon-A * 1 CAP PO TIDP 20230430 2023-05- 已取消 3 - for cough
cap/PTP :1427 01:1339 with sputum
Through FC tab 1 TAB PO HSPR 20230430 2023-05- 已取消 1 - If
正
20 mg :1427 01:1339 constipation
Trajenta FC # 1 TAB PO QD 20230430 2023-05- 已取消 1 -
tab 5 mg :1427 01:1339
Famo FC * tab 20 1 TAB PO QOD 20230430 2023-05- 已取消 0 -
mg/PTP :1427 01:1339
Brosym for * inj 4000 MG IVA Q12H 20230430 2023-05- 已取消 4 -
2 g :1427 01:1339
式
Normal saline 500 CC IVD QD 20230430 2023-05- 已取消 1 -
"YF" *inj 500 ml :1427 01:1339
Dextrose 5%0.45% 1000 CC IVD QD 20230430 2023-05- 已取消 2 -
NS inj 500ml YF :1427 01:1339
Pantoloc iv inj 40 MG IVA QD 20230430 2023-05- 已取消 1 -
40 mg :1427 01:1339
Humulin-R ## inj 8 IU SC QIDP 20230430 2023-05- 已取消 32 - 200-250, 2U
100iu/ml 1iu(UD :1638 01:1339
病
歷
- 8 -