: 2. : SL is a 50 year old male. He was 180 lbs in June, : he currently weights 121 lbs. He is 5'9". : His diagnosis obtained from the medical chart are as follows: : NIDDM, CHF, COPD, CVA L-hemi. His medications are as follows: Zetia, : Novolin N, Cardura, Diovan, Dilantin, Glucotrol XL, Colace. : He receives sliding scale. 好吧! 没人先开始,那我就来抛砖引玉一下 ^_^ 先丢个SOA上来,P的部分看看高手有没有兴趣了... Subjective: He is unable to feed himself after the episode of CVA L-hemi. Two days ago, he was send to the hospital due to unconscious condition. It has been confirmed by the lab exam is due to the increasing of the PaCO2 in arterial blood. He have been on the medical ventilator with endotracheal tube-oral and NG tube (nasogastric tube). Objective: Gender: Male Age: 50 y.o. Height: 5’9” (69 inches; 175.26 cm) Weight: 121 lbs (55 Kg) Medications: Zetia, Novolin N, Cardura, Diovan, Dilantin, Glucotrol XL, Colace Hx: Non-Insulin Dependent Diabetes Mellitus, Congestive Heart Failure, Chronic Obstructive Pulmonary Disease, Cerebrovascular accident L-hemi (Stroke) According to the lab values of HbA1c and glucose, his blood glucose status is well controlled by diet and medication. The examination of arterial blood gas sampling showed that his PaO2 is 80 and his PaCO2 is 60. Assessment: His BMI = (121×705) / (69)2 = 17.9 (Underweight) His IBW = 110 + 5×9 = 155 lbs ± 10% = 139.5~170.5 lbs SL has significant body weight loss. It could be determined by followed formula. 10% weight loss in one year, 7.5% weight loss in 3 months, or 5% weight loss in 30 days. Date ML’s Body Weight Weight Loss Jun 2007 180 lbs Nov 2007 121 lbs 33.7% 基本上,我是把SOA合理的乱编 XD 最近Midterm和报告多,所以写的不好大家别笑, 以上就是我的砖头,希望能引出好玉 ^_^ --

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