※ 引述《vicliu (泊忆)》之铭言： : : 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 ^_^ 其实还蛮有趣的抛砖引玉 不过 感觉跟自己在临床上的SOAP也有些许的不同 因为不知道他其他的clinical condition EX:blood sugar or poor appetite.... 再者 consult 的原因是因为要增胖 还是其他 suggestion 很难给... (也许是我才疏学浅啦....) --

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