在院病人 (4)

P003

7B08

82M / HD#7

COPD AE, type II RF

💊 Augmentin D7 📅 預定 MBD 5/3

P001

7B12

76M / HD#4

eGFR↓

CAP, AKI stage 1

⚠️ 抽血待回 💊 Cefepime D1 🔔 2

P002

7B15

65F / HD#2

DNR

CHF exacerbation

🔥 持續發燒 ⚠️ I/O imbalance

P004

7C04

58F / HD#1

AGE, hypokalemia

新入院,待整理

📂 已出院 (1)

P000 7C08 MBD 4/29

UTI, treated

Demo: 點任一張卡片進 detail page。其他 3 床載相同 mock data。

📌 今日 (5/1) 提醒

• Daily panel 結果待回 (CBC/DC, BUN, Cr, Na, K, CRP)
• Cefepime D1 — 觀察 response
• Renal consult 24h 未回 → 可考慮再 push

P001 7B12

76M / 入院 2026-04-28 / HD#4

Diet: DM diet

⚠️ eGFR 48 (CKD 3a) — 抗生素 / NSAID / contrast agent 需評估 renal adjustment

🔔 我的提醒

5/3 追 CT chest report (4/30 排的)
5/4 若 afebrile 3d → 跟 attending 討論 MBD

Assessment

CAP, started levofloxacin 4/28, switched to cefepime 5/1 due to incomplete response
AKI stage 1, likely pre-renal, improving (Cr 1.8 → 1.5)
T2DM, holding metformin during AKI, on sliding scale insulin
HTN, controlled on amlodipine

HTN x 20 years
T2DM x 15 years, on metformin
CKD stage 2 (baseline Cr 1.4)
No prior MI / CVA

Allergies: NKDA

Social: Ex-smoker (quit 10y, 30 pack-years), no alcohol

76M with HTN x 20y, DM2 x 15y on metformin, CKD stage 2 (baseline Cr 1.4). Presented with fever 38.5°C, productive yellowish sputum x 5d, mild dyspnea on exertion. ER CXR: RLL infiltration. Admitted for IV antibiotics. AKI on admission (Cr 1.8) attributed to dehydration, improving with hydration.

每日進度

咳嗽改善,痰量減少,無胸痛 / 呼吸困難。胃口稍差,睡眠尚可。

F/S: AC 145, HS 180 → SS 4U

I/O: 1500 / 1200 (24h)

📈 Vitals

項目	4/28	4/29	4/30	5/1
Tmax	38.9	38.1	37.8	37.6
BP	145/90	138/85	135/82	130/80
HR range	95-110	88-100	85-95	80-92
SpO2 lowest	92	93	94	95

每天記 Tmax + range 即可,不需每筆 timestamp

📊 Lab

項目	4/28 HD#1	4/29 HD#2	4/30 HD#3	5/1 HD#4
WBC (K)	15.2	14.1	12.8	11.0
Hb	11.8	12.0	12.0	12.1
Plt (K)	220	235	240	240
Cr	1.8	1.7	1.6	1.5
BUN	35	31	29	28
Na	135	137	138	138
K	4.5	4.3	4.2	4.2
CRP	8.1	7.5	6.0	4.2

🖼 Imaging

日期	類型	Impression
4/28	CXR PA	RLL infiltration, c/w pneumonia
4/30	CT chest w/o	Pneumonia RLL, no abscess/effusion

現狀用藥

點 ⋮ → DC / 改設定 / 暫停

•Cefepime 1g IV q12h D1, 起 5/1
•Insulin glargine 10U SC QHS
•Insulin sliding scale per AC/HS
•Acetaminophen 500mg PO q6h prn (fever)
•Amlodipine 5mg PO QD

📋 曾用過 (1)

• Levofloxacin 750mg IV QD (DC 5/1, D1-D4)

Orders

📋 Active orders

●⚡ Daily panel (CBC/DC, BUN, Cr, Na, K, CRP)today
●CXR follow-uptoday
●N/S 60 mL/h IVdrip
●I/O monitoring qdrecurring
●DM dietstanding

⏳ Pre-orders

📅 5/3Sputum culture follow
📅 5/4若 afebrile 3d → 考慮 MBD

🔔 Follow-up

●Blood culture (day 2 of 5)
●CT chest report (taken 4/30)
●Renal consult (sent 4/30, awaiting reply)

📋 過往 orders (4)

4/30✓ Echo已歸檔
4/29✓ ECG已歸檔
4/28✓ Sputum culture (sent)已歸檔
4/28✓ Admission orders已歸檔

🗑 最近刪除 (0)

沒有已刪除項目

📝 今日 Order list (我今天開的，5/1)

勾 = 已在 HIS 下

Start Cefepime 1g q12h IV執 5/1
⚡ Daily panel執 5/1 ✓
CXR follow-up執 5/1
Sputum culture (排 5/3)執 5/3

⚠️ 隔天自動清空

在院病人 (4)

🔔 我的提醒

Assessment

每日進度

📈 Vitals

📊 Lab

🖼 Imaging

Orders

📋 Active orders

⏳ Pre-orders

🔔 Follow-up

📝 今日 Order list (我今天開的，5/1)

📝 備註

+ 新增病人

🏥 確認 MBD

Cefepime 1g IV q12h

新增 Order

📦 已選 (0)

⭐ 常用