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.78세 여성. 고혈압, 심방세동, 우울증, 무릎 골관절염, 경도 만성 신질환(기저 eGFR 45). 독립적 생활. 2주 전 정원 가꾸기 후 무릎 통증 발생.
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, 실내 공기 SpO2 97 percent. 급성 고통 없음.
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 (목표 2.0~3.0); Hgb 11.2; K 5.4 mEq/L (참고 3.5-5.0); Na 138; 크레아티닌 1.4 mg/dL (기저치 1.0~1.1); eGFR 45 mL/min/1.73 m2; AST와 ALT 정상.
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.Warfarin 5 mg PO 매일; lisinopril 20 mg PO 매일; spironolactone 25 mg PO 매일; metoprolol succinate 25 mg PO 매일; sertraline 50 mg PO 매일.
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.환자가 지난 2주간 무릎 통증으로 OTC ibuprofen 400 mg을 6시간마다 복용했다고 보고함. 처방의에게 알리지 않음. 흑색변이나 새로운 출혈은 부인함.