History
Vitals
Labs
Orders
Notes
65-year-old male, admitted yesterday for COPD exacerbation. Long-standing severe COPD, 40 pack-year smoking history (quit 5 years ago), former coal miner. DNR/DNI status confirmed on admission. Family present and supportive.65歳男性、COPD増悪で昨日入院。長期重症COPD、40 pack-yearの喫煙歴(5年前に禁煙)、元炭鉱夫。入院時にDNR/DNI状態確認。家族が付き添い支援的.
BP 138/82, HR 92, RR 22, T 37.1 C, SpO2 91 percent on 2 L nasal cannula. Time of measurement not documented in the handoff note.BP 138/82、HR 92、RR 22、T 37.1 C、2 L経鼻カニューラでSpO2 91 percent。測定時間が引き継ぎノートに未記載.
WBC 14.2 (high), Hgb 13.4, BMP within normal limits, ABG pH 7.35, PaCO2 52, PaO2 64, HCO3 28. Time of ABG draw not documented in the handoff note.WBC 14.2 (高値)、Hgb 13.4、BMP正常範囲内、ABG pH 7.35、PaCO2 52、PaO2 64、HCO3 28。ABG採取時間が引き継ぎノートに未記載.
Prednisone 40 mg PO daily; azithromycin 500 mg PO daily; ipratropium-albuterol nebulizer every 4 hours; oxygen 2 L NC titrated to SpO2 88-92 percent; full diet; out of bed as tolerated; pulmonary rehab consult.プレドニゾン40 mg PO毎日; アジスロマイシン500 mg PO毎日; イプラトロピウム-アルブテロールネブライザー4時間ごと; 酸素2 L NCをSpO2 88-92 percentに調整; 全粥食; 可能なら離床; 呼吸リハビリコンサルト.
Off-going RN handoff note: "Client is DNR/DNI, family at bedside, on standard COPD bundle. Will continue current orders. Please call respiratory therapy if breathing changes."退勤RN引き継ぎノート：「患者はDNR/DNI、家族がベッドサイド、標準COPDバンドル中。現行指示を継続。呼吸変化時は呼吸療法士に連絡。」