History
Vitals
Labs
Orders
Notes
78-year-old female. Stage IV pancreatic adenocarcinoma diagnosed 9 months ago, declining further chemotherapy. Lives with spouse; daughter is healthcare proxy. Five Wishes / advance directive on file: comfort measures, DNR/DNI, no artificial nutrition or hydration.78歳女性。9か月前に診断されたステージIV膵腺癌、追加化学療法を辞退。配偶者と同居; 娘がヘルスケアプロキシ。Five Wishes / 事前指示登録：comfort measures、DNR/DNI、人工栄養・輸液なし.
BP 102/64, HR 96, RR 22, SpO2 91% on 2 L NC, T 37.1 C, Pain 6/10 in epigastrium, dyspnea at rest.BP 102/64、HR 96、RR 22、2 L NCでSpO2 91%、T 37.1 C、心窩部痛6/10、安静時呼吸困難.
Hgb 8.6 g/dL, albumin 2.4 g/dL, total bilirubin 4.8 mg/dL, BUN 38 mg/dL — labs consistent with disease trajectory; team has agreed not to retrend.Hgb 8.6 g/dL、アルブミン2.4 g/dL、総ビリルビン4.8 mg/dL、BUN 38 mg/dL — 病勢に一致する検査; チームは再評価しない方針で合意.
Morphine 2-4 mg SC q2h PRN pain or dyspnea. Senna 2 tabs PO BID. Polyethylene glycol 17 g PO daily PRN. Reposition q2h for comfort. Mouth care q2h. Family permitted at bedside.モルヒネ2-4 mg SC q2h PRN疼痛または呼吸困難。センナ2錠PO BID。ポリエチレングリコール17 g PO毎日PRN。快適性のためq2h体位変換。q2h口腔ケア。家族のベッドサイド付き添い許可.
Hospice consult completed; family meeting documented. Goal-of-care: comfort. Patient verbalizes pain control and feeling less short of breath as primary goals. No further imaging or aggressive workup planned per family meeting note.ホスピスコンサルト完了; 家族会議記録あり。ケアゴール：快適性。患者は疼痛コントロールと呼吸困難軽減を主な目標として表明。家族会議ノートに従い追加画像や積極的精査は予定なし.