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.78세 여성. 9개월 전 진단된 4기 췌장 선암, 추가 항암 거부. 배우자와 거주; 딸이 의료대리인. Five Wishes / 사전의료의향서 등록: comfort measures, DNR/DNI, 인공 영양·수액 없음.
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 SpO2 91%, T 37.1 C, 상복부 통증 6/10, 안정 시 호흡곤란.
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, 알부민 2.4 g/dL, 총 빌리루빈 4.8 mg/dL, BUN 38 mg/dL — 질병 경과에 일치하는 검사; 팀이 재확인하지 않기로 합의함.
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.Morphine 2-4 mg SC q2h PRN 통증 또는 호흡곤란. Senna 2정 PO BID. Polyethylene glycol 17 g PO 매일 PRN. 안위를 위해 q2h 체위 변경. q2h 구강 간호. 가족 침상 동반 허용.
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.호스피스 자문 완료; 가족 회의 기록됨. 케어 목표: 안위. 환자가 통증 조절과 호흡곤란 감소를 주된 목표로 표현함. 가족 회의 노트에 따라 추가 영상 또는 적극 검사 계획 없음.