「Johns Hopkins 大学病院臨床実習体験記」 医学部4年生(M4)の体験記
「大学間交流協定プログラム」 他の体験記もあり
Pt Ms. L. T. 81y/o F
CC chest pain, SOB
CC: chief complaint, SOB: shortness of breathing
HPI substernal, diffuse, 2 days, constant, sharp, tight, 10/10, onset while eating, worse with movement and deep breath, no radiation, no N/V/D HPI: history of present illness, N/V/D: nausea, vomiting, diarrhea
PMH Chronic Leukemia, chronic cough (3years), back and knee pain, night sweat, constipation, HTN 2-3 years
PMH: past medical history, HTN: hypertension
腹部の痛みを治療するために使用される植物の根
FH Mother: LK
FH: family hisotory, LK: lung cancer
SH Meds: omeprazole, felodipine, nortriptyline, levothyroxine Allergy: 2 meds Tobacco, EtOH, Drug -
SH: social history, Meds: medications, EtOH: ethanol
SxH NAD
SxH: sex history?, NAD: no abnormality detected
VS P112, BP141/64, RR 18, T 100.3
VS: vital signs, P: pulse, T: body temperature
O/E
Heart RRR, no M/R/S, no loss of pulse on radial and posterior tibial artery, edema 2+
Lung: bilateral diffuse crackle, respiratory distress
O/E: on examination, RRR: regular rate & rhythm, M/R/S: murmur, regurgitation, stenosis?
うつ病の治療にどのように?
DD
Pneumonia
Pleuritis
exacerbation of asthma
pericarditis
COPD
DD: diferential diagnosis
Rule out MI, dissection, tamponade, pneumothorax, acute esophageal perforation
O2, EKG, CXR, Chem-7 with CK-MB and troponin, CBC with diff
CXR: chest X ray, CBC: complete blood count, diff: differential
Result: positive only for WBC high and CXR (infiltration and congestion especially in left lower lobe, hilar hernia), CK-MB and troponin (-)
Dx: Pneumonia (lober)
Dx: diagnosis
Tx: IV fluid, antibiotics (ceftriaxone and azythromycin), Admission to Pneumo
Tx: treatment
うつ病のプレドニゾン治療
【参考】
THE FREE DICTIONAR BY FARLEX (Acronyms) オンライン略語辞典
THE FREE DICTIONAR BY FARLEX (Medical dictionary) オンライン医学用語辞典
(単語の頭や語尾でもひくことができ、曖昧な綴りを確認できる。薬物名もあり)
JD-MD 医療過誤コンサルタント (カルテの略語を読むためのページ)
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