History
Vitals
Labs
Orders
Notes
65-year-old male, admitted yesterday for COPD exacerbation. Long-standing severe COPD, 40 pack-year smoking history (quit 5 years ago), former coal miner. DNR/DNI status confirmed on admission. Family present and supportive.65 歲男性，因 COPD 急性惡化昨日入院。長期重度 COPD，40 pack-year 吸菸史(5 年前戒菸)，前煤礦工。入院時確認 DNR/DNI 狀態。家屬在旁支持.
BP 138/82, HR 92, RR 22, T 37.1 C, SpO2 91 percent on 2 L nasal cannula. Time of measurement not documented in the handoff note.BP 138/82、HR 92、RR 22、T 37.1 C、2 L 鼻導管下 SpO2 91 percent。測量時間在交班紀錄上未記載.
WBC 14.2 (high), Hgb 13.4, BMP within normal limits, ABG pH 7.35, PaCO2 52, PaO2 64, HCO3 28. Time of ABG draw not documented in the handoff note.WBC 14.2 (升高)、Hgb 13.4、BMP 在正常範圍、ABG pH 7.35、PaCO2 52、PaO2 64、HCO3 28。ABG 採血時間在交班紀錄上未記載.
Prednisone 40 mg PO daily; azithromycin 500 mg PO daily; ipratropium-albuterol nebulizer every 4 hours; oxygen 2 L NC titrated to SpO2 88-92 percent; full diet; out of bed as tolerated; pulmonary rehab consult.Prednisone 40 mg PO 每日; azithromycin 500 mg PO 每日; ipratropium-albuterol 噴霧每 4 小時; 氧氣 2 L NC 調整至 SpO2 88-92 percent; 全餐; 可耐受時下床; 肺部復健會診.
Off-going RN handoff note: "Client is DNR/DNI, family at bedside, on standard COPD bundle. Will continue current orders. Please call respiratory therapy if breathing changes."下班 RN 交班紀錄：「病人為 DNR/DNI，家屬在床邊，採標準 COPD 組合。維持現行醫囑。呼吸變化時通知呼吸治療師。」