Nurses' Notes
0830: The rheumatology nurse returns a call from a client who began oral methotrexate after the last clinic visit. Medication reconciliation shows that the client has taken 1 prescribed tablet every morning for six days. The original instruction in the electronic record is a weekly regimen for rheumatoid arthritis. The client reports that a phone reminder is set for the scheduled weekly dose. At 0840, the client describes several painful mouth ulcers that make eating difficult. The food record shows that soft foods and cool liquids remain tolerated throughout the day. The client also reports that a fever and sore throat began during the night. No household contact has a similar illness. The client states that unexplained bruises appeared on both forearms. The nurse confirms that folic acid is taken according to the prescription. The client says that morning joint stiffness has improved slightly. At 0850, the client reports that water intake has remained near the usual amount despite the schedule change. The client denies a new cough or shortness of breath. The nurse asks the client not to take another dose while urgent evaluation is arranged.
護理紀錄
0830：風濕科護理師回覆一位在上次門診後開始口服 methotrexate 的個案來電。用藥整合顯示個案已連續六天每天早上服用 1 顆處方藥錠。電子病歷中的原始指示為針對類風濕性關節炎的每週療程。個案表示手機已設定每週劑量的提醒。0840 時，個案描述數個疼痛的口腔潰瘍導致進食困難。飲食紀錄顯示整天仍可耐受軟質食物和冷飲。個案也提到夜間開始發燒和喉嚨痛。家中無人有類似症狀。個案表示雙側前臂出現無法解釋的瘀傷。護理師確認葉酸依處方服用。個案說早晨關節僵硬已輕微改善。0850 時，個案表示儘管時程改變，水分攝取量仍接近平常量。個案否認有新發生的咳嗽或呼吸急促。護理師請個案在緊急評估安排期間勿再服用下一劑。