Nurses' Notes
0910: The client began allopurinol 100 mg daily 8 days ago for recurrent gout. The client reports that a red rash began on the trunk and is spreading to both arms. The affected knee is less tender than it was at the previous visit. Yesterday's uric acid level was lower than the pretreatment value. At 0830, the client measured a temperature of 38.6 °C. The nurse observes new facial edema with fever and malaise. The client reports drinking water regularly unless otherwise instructed. During the interview, the client states that urine remains clear yellow without dysuria. The oral examination shows painful mouth erosions with burning eyes. The client had mild nausea for 10 minutes after breakfast yesterday. Medication reconciliation confirms the prescribed dose was taken once each morning. The client denies shortness of breath at rest. The right great toe has no warmth or new swelling today. The client asks whether the next refill can be synchronized with other medications. The nurse notes that the pharmacy label and daily instructions match the active prescription. No new injury was reported.
護理紀錄
0910：個案於8天前因反覆痛風開始每日服用allopurinol 100 mg。個案主訴軀幹出現紅色皮疹，並擴散至雙臂。受影響的膝關節壓痛較前次門診減輕。昨日尿酸值低於治療前數值。0830時，個案測得體溫38.6 °C。護理師觀察到新發生臉部水腫，伴隨發燒及倦怠。個案表示除非另有指示，否則會規律飲水。會談中，個案表示尿液仍為清澈黃色，無排尿疼痛。口腔檢查顯示疼痛的口腔糜爛，伴隨眼睛灼熱感。個案昨日早餐後有10分鐘輕微噁心。用藥整合確認處方劑量於每日早晨服用一次。個案否認休息時呼吸急促。右腳大拇趾今日無發熱或新腫脹。個案詢問下次續藥能否與其他藥物同步。護理師注意到藥袋標示及每日用藥指導與現行處方相符。無新通報的傷害。