History
Vitals
Labs
Orders
Notes
78-year-old female. Hypertension, atrial fibrillation, depression, knee osteoarthritis, mild chronic kidney disease (baseline eGFR 45). Lives independently. Recent knee pain after gardening 2 weeks ago.78歳女性。高血圧、心房細動、うつ病、膝OA、軽度CKD(基線eGFR 45)。独居自立。2週前のガーデニング後の膝痛.
BP 134/78, HR 72, RR 14, T 36.7 C, SpO2 97 percent on room air. No acute distress.BP 134/78、HR 72、RR 14、T 36.7 C、室内空気SpO2 97 percent。急性苦痛なし.
INR 4.6 (target 2.0 to 3.0); Hgb 11.2; K 5.4 mEq/L (ref 3.5-5.0); Na 138; Creatinine 1.4 mg/dL (baseline 1.0 to 1.1); eGFR 45 mL/min/1.73 m2; AST and ALT normal.INR 4.6 (目標2.0〜3.0); Hgb 11.2; K 5.4 mEq/L (基準3.5-5.0); Na 138; クレアチニン1.4 mg/dL (ベースライン1.0〜1.1); eGFR 45 mL/min/1.73 m2; ASTとALT正常.
Warfarin 5 mg PO daily; lisinopril 20 mg PO daily; spironolactone 25 mg PO daily; metoprolol succinate 25 mg PO daily; sertraline 50 mg PO daily.ワルファリン5 mg PO毎日; リシノプリル20 mg PO毎日; スピロノラクトン25 mg PO毎日; メトプロロールコハク酸塩25 mg PO毎日; セルトラリン50 mg PO毎日.
Client reports she has been taking ibuprofen 400 mg every 6 hours over the counter for the past 2 weeks for knee pain. She did not tell her prescriber. She denies black stools or new bleeding.患者は過去2週間、膝の痛みのためOTCのイブプロフェン400 mgを6時間ごとに服用していたと報告。処方医には伝えていない。タール便や新規出血は否定.