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.78 歲女性。9 個月前診斷之 IV 期胰腺腺癌，拒絕進一步化療。與配偶同住；女兒為健康代理人。Five Wishes / 事前指示在案：comfort measures、DNR/DNI、不予人工營養或水分.
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、上腹部疼痛 6/10、休息時呼吸困難.
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、白蛋白 2.4 g/dL、總膽紅素 4.8 mg/dL、BUN 38 mg/dL — 與疾病進程一致；團隊已同意不再追蹤趨勢.
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 疼痛或呼吸困難。Senna 2 錠 PO BID。Polyethylene glycol 17 g PO 每日 PRN。為舒適 q2h 翻身。q2h 口腔護理。允許家屬在床邊.
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.已完成安寧會診；家屬會議已紀錄。照護目標：舒適。病人表達疼痛控制與緩解呼吸困難為主要目標。依家屬會議紀錄不再安排進一步影像或積極檢查.