Please enable JavaScript.
Coggle requires JavaScript to display documents.
Peter Hu - Coggle Diagram
Peter Hu
ED會診胸內for去ICU
P.E.:
1.BT: 38.5C, HR: 118 beats/min,
RR: 22breaths/min,BP:86/55mmHg,
Sp02:92%(O2 cannula 5L/min)
2.General Appearance: Acutely ill-looking.
3.Consciousness: Alert and orientated.
4.Chest: Crackles over bilateral lower lungs.
-
Lab.:
1.WBC 15,600/mm3 with Seg 93.1%.
2.Finger stick blood sugar a.c / p.c. >>> 122/168mg/dL.
3.Sputum culture (2011/3/26) K.P sensitive to Ceftriaxone.
-
-
-
-
-
-
-
PE
-
第二次:BT: 38.5 °C , HR: 118beats/min, RR: 22breaths/min,
BP: 86/55mmHg, SpO2: 92%.
入院後
.Chest: Crackles over bilateral lower lungs, increased in intensity compared to yesterday.
.Chest: Crackles over bilateral lower lungs, increased in intensity compared to yesterday.
-
-
入院時
Abdomen: Soft and flat, normoactive bowel sounds,no tenderness, no hepatosplenomegaly.
-
.Extremities: Freely movable, no leg pitting edema.
Chest: Symmetrical expansion, bilateral basal crackles, mild wheezing.
-
Neck: Supple, no lymphadenopathy, no JVE
Sclera: anicteric, throat: Not erythematous
-
HEENT: Pupils: +3/+3, pink conjunctiva.
-
-
Heart: Regular rate and rhythm, no murmur.
-
急診病歷
-
現在病史.
-
-
-
-
No orthopnea, no PND, no palpitation. No sorethroat, no headache, no ear pain.
No dysuria, no urinary frequency, no urinary urgency, no flank pain.
No abdominal pain, no nausea, no vomiting, no constipation, no diarrhea.
-
-
-