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.78 歲女性。高血壓、心房顫動、憂鬱、膝部退化性關節炎、輕度慢性腎病(基線 eGFR 45)。獨立生活。2 週前園藝後出現膝痛.
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、室內空氣 SpO2 97 percent。無急性不適.
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 (目標 2.0 至 3.0); Hgb 11.2; K 5.4 mEq/L (參考 3.5-5.0); Na 138; 肌酸酐 1.4 mg/dL (基線 1.0 至 1.1); eGFR 45 mL/min/1.73 m2; AST 與 ALT 正常.
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 每日; lisinopril 20 mg PO 每日; spironolactone 25 mg PO 每日; metoprolol succinate 25 mg PO 每日; sertraline 50 mg PO 每日.
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.病人報告過去 2 週因膝部疼痛自行服用 OTC ibuprofen 400 mg 每 6 小時。未告知處方者。否認黑便或新發出血.