History
Vitals
Labs
Orders
Notes
82-year-old female. HTN, type 2 diabetes, hyperlipidemia, mild osteoarthritis. Lives independently. Two falls in past 3 months without serious injury. Daughter reports daytime drowsiness and increased forgetfulness over past 2 months.82歳女性。高血圧、2型糖尿病、脂質異常症、軽度OA。独居自立。過去3か月で重傷なしの転倒2回。娘が過去2か月の日中傾眠と物忘れ増加を報告.
BP 138/82, HR 72, RR 16, T 36.8 C, SpO2 97% on room air, MMSE 24/30 (down from 28 last year).BP 138/82、HR 72、RR 16、T 36.8 C、室内空気SpO2 97%、MMSE 24/30 (前年28から低下).
A1c 7.2%, eGFR 64 mL/min/1.73 m2, LDL 92 mg/dL, sodium 138, potassium 4.1, normal LFTs.A1c 7.2%、eGFR 64 mL/min/1.73 m2、LDL 92 mg/dL、ナトリウム138、カリウム4.1、LFT正常.
Lisinopril 10 mg daily. Metformin 500 mg BID. Atorvastatin 20 mg at bedtime. Diphenhydramine 50 mg at bedtime PRN for sleep (taking nightly per patient). Calcium carbonate / vitamin D supplement daily.Lisinopril 10 mg毎日。Metformin 500 mg BID。Atorvastatin 20 mg就寝時。Diphenhydramine 50 mg就寝時PRN睡眠 (患者によれば毎晩服用)。炭酸カルシウム/ビタミンD補充剤毎日.
Daughter requests medication review due to falls and cognitive decline. Patient denies symptoms but acknowledges occasional dry mouth and drowsiness during the day.娘が転倒と認知機能低下のため薬剤レビューを依頼。患者は症状を否定するが時折の口渇と日中の眠気は認める.