指導：蒲秀瑾醫師 報告：PGY 江泓賢 報告日期：2012/8/29 General Information Gender: male Age: 79 y/o Marriage: widower Race: Taiwanese Occupation: grocery store, retired Education: junior high school 資料來源: children and care-giver Date of admission:
Download ReportTranscript 指導：蒲秀瑾醫師 報告：PGY 江泓賢 報告日期：2012/8/29 General Information Gender: male Age: 79 y/o Marriage: widower Race: Taiwanese Occupation: grocery store, retired Education: junior high school 資料來源: children and care-giver Date of admission:
Slide 1
指導：蒲秀瑾醫師
報告：PGY 江泓賢
報告日期：2012/8/29
Slide 2
General Information
Gender: male
Age: 79 y/o
Marriage: widower
Race: Taiwanese
Occupation: grocery store, retired
Education: junior high school
資料來源: children and care-giver
Date of admission: 2012/8/8
Slide 3
Chief complaint
Gross hematuria for 2 days
Slide 4
Present Illness (1)
Hematuria was noted for 2 days.
With nocturia
No dysuria, no urgency, no frequency, no
intermittency
No fever or chills. No headache/dizziness. No
chest pain/tightness. No abdominal pain. No
flank pain. No trauma history. No contact or
traveling history.
Fighting behavior and irritable
Slide 5
Present Illness (2)
He was sent to ER on 8/6. Urinary tract
infection was impressed. Urologist was
consulted and patient was inserted Foley cath..
Then he was admitted on 8/8 for further
management.
Trace back to his history…
BPH, s/p TURP in 2010/10
Bladder tumor found for 2 years about 1.7cm over
lateral wall, Operation on 20101028: stone(+), left
hemitrigone area swelling and erythematous
change, no typical TCC looking
Slide 6
Patient’s other underlying problems
Hypertension
Type
2 diabetes mellitus, diet control
Bipolar disorder in 2003 (出現攻擊行為,躁動不
安,自言自語,有時則情緒低落) and follow-up at 桃
療 regularly since 2008 (因攻擊鄰居並毀壞門窗
強制接受治療)
Dementia
with behavioral and
psychological symptoms
Slide 7
Patient’s other underlying problems
HCV
related hepatitis with cirrhosis
Thrombocytopenia, favor cirrhosis
related
Multiple small sized colon polyps and
gastric ulcer history reported by the
health exam in 2003
Slide 8
Personal History
Allergy: no known allergy to food or drug
Cigarette smoking: 1-2 PPD for more
than 40 years
Alcohol drinking: denied
Betelnut chewing: denied
Slide 9
Family history
No hypertension
No DM
No psychosis
Slide 10
Review of system (1)
1.General: weakness: (yes), fever: (no)
2.Skin: wound: ( no)
3.HEENT: Head: headache: (no ),Ear:
hearing impairment: (yes)
4. Respiratory: cough: (no), dyspnea:
(no)
5. CV: chest pain : (no)
Slide 11
Review of system (2)
6. GI: vomiting: (no), abdominal pain: (no)
7. GU: **On Foley hematuria: (gross
hematuria)
8. Metabolic and endocrine: Polyphagia (no)
9. Hematological: anemia: ( no )
10. Neuropsychiatry : dizziness ( no)
11. musculoskeletal: muscular
weakness( yes)
Slide 12
Physical Examination (1)
BT:36.3C, PR:66/min, RR:18/min, BP:143/65
mmHg, BH:170 cm, BW:60 Kg, BMI:21
E4V3M6
Consciousness: clear
Not anemic, not icteric
Neck: supple, no LAP, no carotid bruit
Chest: clear BS
Heart: RHB, no murmur
Slide 13
Physical Examination (2)
Abdomen: soft, no palpable mass, no
tenderness/rebound pain. Bowel sound
normoactive
Back: no tenderness, no flank knocking
pain
Extremities: symmetric pulsation, no
edema, ROM full
Neurological examination: no focal deficit
Slide 14
CBC on 8/6
(ER)
檢驗項目
血液組(CBC)
WBC
RBC
Hemoglobin
Hematocrit
MCV
MCH
MCHC
RDW
Platelets
Segment
Lymphocyte
Monocyte
Eosinophil
Basophil
Band
血液組(B)
P.T
Control P.T
INR
APTT
Control aPTT
單位
1010806
1000/uL
million/uL
g/dL
%
fL
pg/Cell
gHb/dL
%
1000/uL
%
%
%
%
%
%
6.4
4.46
12.2
37.8
84.8
27.4
32.3
13.8
108
72.1
21.7
3.9
2
0.3
sec
sec
13.1
10.7
1.2
27.1
27.4
sec
sec
Slide 15
Urinalysis on 8/6 (ER)
檢驗項目
鏡檢組(U)
Color
Turbidity
SP.Gravity
pH
Leukocyte
Nitrite
Protein
Glucose
Ketone
Urobilinogen
Bilirubin
Blood
Bacteria
RBC
WBC
Epith-Cell
單位
1010806
Red
Turbid
1.018
6
mg/dL
mg/dL
mg/dL
mg/dL
EU/dL
mg/dL
/uL
/uL
/uL
1+
Negative
1+ (30)
Negative
1+ (15)
1
Negative
3+
POSITIVE
> 500
30
0
Slide 16
Biochemistry on 8/6 (ER)
檢驗項目單位
生化組(B)
BUN
mg/dL
Creatinine mg/dL
Sugar
mg/dL
1010806
14.9
0.89
120
Slide 17
Impression on admission at 8/8
Hematuria, cause? suspect bladder tumor
related
Urinary tract infection
Prostate benign hyperplasia , s/p TURP in
2010/10
Hypertension
Diabetes mellitus
Bipolar disorder
Dementia
Hepatitis C with liver cirrhosis and
thrombocytopenia
Slide 18
Treatment plan on admission
Diagnostic:
Follow U/A, U/C, Hemogram and Biochem. Data
Arrange non invasive exam first such as kidney
echo and TRUS
Consult urologist for possible cystoscope
Arrange CXR, KUB to rule out other possible
infection focus
Theraputic:
Transamine use
Empiric antibiotics
Consult psychiatrist for adjustment the
medication prescribed by 桃療
Slide 19
Hospital course…
After admission, psychiatrist was
consulted and keep antipsychotic
medication from 桃療 was suggested.
Medication:
Trihexyphenidyl 2mg 1PC QD
Piracetam 1200mg 1PC BID
Estalozam 2mg 1PC HS
Trazodone 50mg 1PC HS
Lithium carbonate 300mg 1PC HS
Olanzapine 10mg 1PC HS
Valporate 200mg/ml 1ML Q8H
Slide 20
Slide 21
Chest X ray
(8/9)
Old fracture of
left clavicle and
left ribs
The heart size
and shape within
normal limits
Mild infiltration
on BLL
Slide 22
KUB (8/9)
Degenerative
change with bony
spur formation of L
spine
Scoliosis of the L
spine
Increased bowel
gas
Clear bilateral
psoas muscle
shadow
Slide 23
EKG on 8/9
Normal
sinus
rhythm
Left axis
deviation
Slide 24
Slide 25
檢驗項目 單位
血液組(CBC)
WBC
1000/uL
million/u
RBC
L
Hemoglob
g/dL
in
Hematocri
%
t
MCV
fL
MCH
pg/Cell
MCHC gHb/dL
RDW
%
Platelets 1000/uL
Segment %
Lymphoc
%
yte
Monocyte %
Eosinophi
%
l
Basophil %
Band
%
1010806 1010810 1010813
6.4
5.1
5.8
4.46
4.67
4.55
12.2
12.8
12.6
37.8
39.3
37.7
84.8
27.4
32.3
13.8
108
72.1
84.2
27.4
32.6
14.2
92
62.3
82.9
27.7
33.4
13.7
89
66.8
21.7
29.7
25.1
3.9
4.3
5
2
3.5
2.9
0.3
0.2
0.2
檢驗項
單位 101080610108101010813
目
生化組(B)
BUN mg/dL
14.9
9.7
7.8
Cre
mg/dL
0.89
0.6
0.6
Na
mEq/L
144
K
mEq/L
3.4
Slide 26
AFP
CA15-3
CEA
PSA
Vit B12
Folate
Li(Lithium)
Valproic acid
Sugar
Hb-A1c
T-Cholesterol
Albumin
Total Protein
HBsAg
Anti-HCV
AST/GOT
ALT/GPT
ALK-P
Total Bilirubin
TSH
Cortisol
ng/mL
U/mL
ng/mL
ng/mL
pg/mL
ng/mL
mEq/L
ug/mL
mg/dL
%
mg/dL
g/dL
g/dL
4.1
8.9
1.09
11.96
327.6
3.43
<0.2
5.71
120
6.6
125
3.34
6.2
0.41Nonreactive
666.9Reactive
U/L
U/L
U/L
mg/dL
uIU/mL
ug/dL
16
8
66
0.4
4.067
10.71
Slide 27
Renal echo 8/13
Slide 28
TRUS 8/13
bladder: incompletely
distended without abnormal
seen
seminal vesicle: symmetric
with clear content
On Foley catheter.
Prostate: Marked enlarged,
4.98 x 4.23 x 5.34 cm, size
about: 58.49 gm ,T zone:
42.46 gm
Slide 29
Rehabilitation Consultation on 8/14
因病人躁動不安且無法配合,應先
控制急性期症狀,目前實行復健並
不合適
Slide 30
Colonscope and PES on 8/16
Colonfibroscope:
Incomplete study due to much of stool
Panendoscope:
Tiny gastric ulcers
Slide 31
Cystoscope on 8/16
Incomplete sutdy due to turbid urine,
blood clot and patient’s poor compliance
Urologist suggest further survey under
general anesthesia, but patient’s famiy
refused due to the high risk
Slide 32
Slide 33
Fever episode on 8/16 night
Turbid urine and gross hematuria with
blood clot, progressing
Change antibiotics to levofloxacin (Urine
culture revealed Pseudomonas)
BT with PLT 12U due to progress
thrombocytopenia
Slide 34
檢驗項目 單位
血液組(CBC)
WBC
1000/uL
RBC
million/uL
Hemoglobi
g/dL
n
Hematocrit %
MCV
fL
MCH
pg/Cell
MCHC
gHb/dL
RDW
%
Platelets 1000/uL
Segment %
Lymphocyt
%
e
Monocyte %
Eosinophil %
Basophil %
1010806
1010810
1010813
1010816
1010818
6.4
4.46
5.1
4.67
5.8
4.55
10.6
4.12
9.1
3.52
12.2
12.8
12.6
11.3
9.7
37.8
84.8
27.4
32.3
13.8
108
72.1
39.3
84.2
27.4
32.6
14.2
92
62.3
37.7
82.9
27.7
33.4
13.7
89
66.8
33.6
81.6
27.4
33.6
13.8
86
86
29.3
83.2
27.6
33.1
13.7
99
78.2
21.7
29.7
25.1
6
16.2
3.9
2
0.3
4.3
3.5
0.2
5
2.9
0.2
4
0
0
4.3
1.2
0.1
Slide 35
檢驗項
單位
目
BUN mg/dL
Creatini
mg/dL
ne
Na
mEq/L
K
mEq/L
1010806 1010810 1010813 1010816 1010818
14.9
9.7
7.8
10.2
13.7
0.89
0.6
0.6
0.76
0.62
144
138
143
3.4
3.1
3.5
檢驗項目
鏡檢組(U)
單位
1010806
1010809
1010817
Color
Red
Yellow
Dark Yellow
Turbidity
SP.Gravity
pH
Leukocyte
Nitrite
Protein
Glucose
Ketone
Turbid
Clear
Cloudy
mg/dL
mg/dL
mg/dL
mg/dL
Urobilinogen
EU/dL
Bilirubin
Blood
Bacteria
RBC
WBC
Epith-Cell
mg/dL
1.018
6
/uL
/uL
/uL
1+
Negative
1+ (30)
Negative
1+ (15)
1.013
6.5
1+
Negative
1+ (30)
Negative
Negative
1
Negative
3+
POSITIVE
> 500
3+
+ (>0.08)
1+ (30)
Negative
Negative
1
Negative
3+
POSITIVE
> 500
30
0
1.013
6.5
0.1
Negative
3+
POSITIVE
12
0
121
154
0
Slide 36
Chest X ray and KUB (8/17)
Slide 37
Problem lists
Medical
Psychological
Physical
Nutrition
Social-economic
Slide 38
Medical problems
Hematuria, cause?
DDx: bladder tumor, UTI, urolithiasis, prostatitis,
GNs, thrombocytopenia……
Urinary tract infection
Prostate benign hyperplasia , s/p TURP in
2010/10
Hypertension
Diabetes mellitus
Bipolar disorder
Dementia
Hepatitis C with liver cirrhosis
Slide 39
Cognition
Education: 初中
MMSE:無法評估
Slide 40
Geriatric depression scale
GDS:無法評估
Slide 41
Sensory deprivation
Hearing impairment (yes, bilateral)
Visual impairment (no)
Body sensation (preserved)
Slide 42
ADL
Barthel index : 0/100
Total dependent
Foreign caregiver
Slide 43
Iatrogenesis
Polypharmacy
( yes)
Tubes (Foley catheter)
Foley catheter (yes)
NG tube ( no)
Tracheostomy( no)
Pressure
ulcer (no)
Slide 44
Psychological problem
Delirium (?)
Depression (yes)
Dementia (yes)
Slide 45
Physical
ADL: total dependent
Swallowing: normal
Slide 46
Nutrition
BH：170 cm, BW：60 kg, BMI: 21
Albumin: 3.34 gm/dL
Hemoglobin:12.2 gm/dL
Lymphocytes: 1280/mm3
Recent body weight loss (no)
Mininutritional assessment, short
form:6/14 , 11/30, malnutriton
Slide 47
Social economic status
Main caregiver: foreign aid and sons
(病人輪流住在大兒子和二兒子家)
Slide 48
安全的醫療
SAFE
1
a病人照護 (是/否)
PATIENT
CARE
yes
及時的服務
TIMELY
2
yes
有用的處置
EFFECTIVE
3
yes
yes
照顧評估
b醫療知識技能
MEDICAL
KNOWLEDGE and
SKILLS
(應該熟知的)
c人際溝通技巧
INTERPERSONAL
and
COMMUNICATION
SKILLS
(應該表達的)
d專業素養倫理
PROFESSIONALIS
M
(應該做為的)
e醫療體系行醫
SYSTEMS-BASED
PRACTICE
(應該支援的)
f行醫導向之
學習改進
PRACTICE-BASED
LEARNING and
IMPROVEMENT
效率的工作
EFFICIENT
4
平等的就醫
EQUITABLE
5
yes
病人為中心
PATIENTCENTERED
6
yes
Slide 49
Ethic discussion
Family support: good, but…
家屬對病患的處置有兩派看法
(積極控制vs消極處理)
Economic condition: no problem
Slide 50
Geriatric combined conference
Physician
Nurse
Physical therapist
Occupation therapist
Nutritionist
Pharmacist
Social worker
Slide 51
Thanks for your attention
指導：蒲秀瑾醫師
報告：PGY 江泓賢
報告日期：2012/8/29
Slide 2
General Information
Gender: male
Age: 79 y/o
Marriage: widower
Race: Taiwanese
Occupation: grocery store, retired
Education: junior high school
資料來源: children and care-giver
Date of admission: 2012/8/8
Slide 3
Chief complaint
Gross hematuria for 2 days
Slide 4
Present Illness (1)
Hematuria was noted for 2 days.
With nocturia
No dysuria, no urgency, no frequency, no
intermittency
No fever or chills. No headache/dizziness. No
chest pain/tightness. No abdominal pain. No
flank pain. No trauma history. No contact or
traveling history.
Fighting behavior and irritable
Slide 5
Present Illness (2)
He was sent to ER on 8/6. Urinary tract
infection was impressed. Urologist was
consulted and patient was inserted Foley cath..
Then he was admitted on 8/8 for further
management.
Trace back to his history…
BPH, s/p TURP in 2010/10
Bladder tumor found for 2 years about 1.7cm over
lateral wall, Operation on 20101028: stone(+), left
hemitrigone area swelling and erythematous
change, no typical TCC looking
Slide 6
Patient’s other underlying problems
Hypertension
Type
2 diabetes mellitus, diet control
Bipolar disorder in 2003 (出現攻擊行為,躁動不
安,自言自語,有時則情緒低落) and follow-up at 桃
療 regularly since 2008 (因攻擊鄰居並毀壞門窗
強制接受治療)
Dementia
with behavioral and
psychological symptoms
Slide 7
Patient’s other underlying problems
HCV
related hepatitis with cirrhosis
Thrombocytopenia, favor cirrhosis
related
Multiple small sized colon polyps and
gastric ulcer history reported by the
health exam in 2003
Slide 8
Personal History
Allergy: no known allergy to food or drug
Cigarette smoking: 1-2 PPD for more
than 40 years
Alcohol drinking: denied
Betelnut chewing: denied
Slide 9
Family history
No hypertension
No DM
No psychosis
Slide 10
Review of system (1)
1.General: weakness: (yes), fever: (no)
2.Skin: wound: ( no)
3.HEENT: Head: headache: (no ),Ear:
hearing impairment: (yes)
4. Respiratory: cough: (no), dyspnea:
(no)
5. CV: chest pain : (no)
Slide 11
Review of system (2)
6. GI: vomiting: (no), abdominal pain: (no)
7. GU: **On Foley hematuria: (gross
hematuria)
8. Metabolic and endocrine: Polyphagia (no)
9. Hematological: anemia: ( no )
10. Neuropsychiatry : dizziness ( no)
11. musculoskeletal: muscular
weakness( yes)
Slide 12
Physical Examination (1)
BT:36.3C, PR:66/min, RR:18/min, BP:143/65
mmHg, BH:170 cm, BW:60 Kg, BMI:21
E4V3M6
Consciousness: clear
Not anemic, not icteric
Neck: supple, no LAP, no carotid bruit
Chest: clear BS
Heart: RHB, no murmur
Slide 13
Physical Examination (2)
Abdomen: soft, no palpable mass, no
tenderness/rebound pain. Bowel sound
normoactive
Back: no tenderness, no flank knocking
pain
Extremities: symmetric pulsation, no
edema, ROM full
Neurological examination: no focal deficit
Slide 14
CBC on 8/6
(ER)
檢驗項目
血液組(CBC)
WBC
RBC
Hemoglobin
Hematocrit
MCV
MCH
MCHC
RDW
Platelets
Segment
Lymphocyte
Monocyte
Eosinophil
Basophil
Band
血液組(B)
P.T
Control P.T
INR
APTT
Control aPTT
單位
1010806
1000/uL
million/uL
g/dL
%
fL
pg/Cell
gHb/dL
%
1000/uL
%
%
%
%
%
%
6.4
4.46
12.2
37.8
84.8
27.4
32.3
13.8
108
72.1
21.7
3.9
2
0.3
sec
sec
13.1
10.7
1.2
27.1
27.4
sec
sec
Slide 15
Urinalysis on 8/6 (ER)
檢驗項目
鏡檢組(U)
Color
Turbidity
SP.Gravity
pH
Leukocyte
Nitrite
Protein
Glucose
Ketone
Urobilinogen
Bilirubin
Blood
Bacteria
RBC
WBC
Epith-Cell
單位
1010806
Red
Turbid
1.018
6
mg/dL
mg/dL
mg/dL
mg/dL
EU/dL
mg/dL
/uL
/uL
/uL
1+
Negative
1+ (30)
Negative
1+ (15)
1
Negative
3+
POSITIVE
> 500
30
0
Slide 16
Biochemistry on 8/6 (ER)
檢驗項目單位
生化組(B)
BUN
mg/dL
Creatinine mg/dL
Sugar
mg/dL
1010806
14.9
0.89
120
Slide 17
Impression on admission at 8/8
Hematuria, cause? suspect bladder tumor
related
Urinary tract infection
Prostate benign hyperplasia , s/p TURP in
2010/10
Hypertension
Diabetes mellitus
Bipolar disorder
Dementia
Hepatitis C with liver cirrhosis and
thrombocytopenia
Slide 18
Treatment plan on admission
Diagnostic:
Follow U/A, U/C, Hemogram and Biochem. Data
Arrange non invasive exam first such as kidney
echo and TRUS
Consult urologist for possible cystoscope
Arrange CXR, KUB to rule out other possible
infection focus
Theraputic:
Transamine use
Empiric antibiotics
Consult psychiatrist for adjustment the
medication prescribed by 桃療
Slide 19
Hospital course…
After admission, psychiatrist was
consulted and keep antipsychotic
medication from 桃療 was suggested.
Medication:
Trihexyphenidyl 2mg 1PC QD
Piracetam 1200mg 1PC BID
Estalozam 2mg 1PC HS
Trazodone 50mg 1PC HS
Lithium carbonate 300mg 1PC HS
Olanzapine 10mg 1PC HS
Valporate 200mg/ml 1ML Q8H
Slide 20
Slide 21
Chest X ray
(8/9)
Old fracture of
left clavicle and
left ribs
The heart size
and shape within
normal limits
Mild infiltration
on BLL
Slide 22
KUB (8/9)
Degenerative
change with bony
spur formation of L
spine
Scoliosis of the L
spine
Increased bowel
gas
Clear bilateral
psoas muscle
shadow
Slide 23
EKG on 8/9
Normal
sinus
rhythm
Left axis
deviation
Slide 24
Slide 25
檢驗項目 單位
血液組(CBC)
WBC
1000/uL
million/u
RBC
L
Hemoglob
g/dL
in
Hematocri
%
t
MCV
fL
MCH
pg/Cell
MCHC gHb/dL
RDW
%
Platelets 1000/uL
Segment %
Lymphoc
%
yte
Monocyte %
Eosinophi
%
l
Basophil %
Band
%
1010806 1010810 1010813
6.4
5.1
5.8
4.46
4.67
4.55
12.2
12.8
12.6
37.8
39.3
37.7
84.8
27.4
32.3
13.8
108
72.1
84.2
27.4
32.6
14.2
92
62.3
82.9
27.7
33.4
13.7
89
66.8
21.7
29.7
25.1
3.9
4.3
5
2
3.5
2.9
0.3
0.2
0.2
檢驗項
單位 101080610108101010813
目
生化組(B)
BUN mg/dL
14.9
9.7
7.8
Cre
mg/dL
0.89
0.6
0.6
Na
mEq/L
144
K
mEq/L
3.4
Slide 26
AFP
CA15-3
CEA
PSA
Vit B12
Folate
Li(Lithium)
Valproic acid
Sugar
Hb-A1c
T-Cholesterol
Albumin
Total Protein
HBsAg
Anti-HCV
AST/GOT
ALT/GPT
ALK-P
Total Bilirubin
TSH
Cortisol
ng/mL
U/mL
ng/mL
ng/mL
pg/mL
ng/mL
mEq/L
ug/mL
mg/dL
%
mg/dL
g/dL
g/dL
4.1
8.9
1.09
11.96
327.6
3.43
<0.2
5.71
120
6.6
125
3.34
6.2
0.41Nonreactive
666.9Reactive
U/L
U/L
U/L
mg/dL
uIU/mL
ug/dL
16
8
66
0.4
4.067
10.71
Slide 27
Renal echo 8/13
Slide 28
TRUS 8/13
bladder: incompletely
distended without abnormal
seen
seminal vesicle: symmetric
with clear content
On Foley catheter.
Prostate: Marked enlarged,
4.98 x 4.23 x 5.34 cm, size
about: 58.49 gm ,T zone:
42.46 gm
Slide 29
Rehabilitation Consultation on 8/14
因病人躁動不安且無法配合,應先
控制急性期症狀,目前實行復健並
不合適
Slide 30
Colonscope and PES on 8/16
Colonfibroscope:
Incomplete study due to much of stool
Panendoscope:
Tiny gastric ulcers
Slide 31
Cystoscope on 8/16
Incomplete sutdy due to turbid urine,
blood clot and patient’s poor compliance
Urologist suggest further survey under
general anesthesia, but patient’s famiy
refused due to the high risk
Slide 32
Slide 33
Fever episode on 8/16 night
Turbid urine and gross hematuria with
blood clot, progressing
Change antibiotics to levofloxacin (Urine
culture revealed Pseudomonas)
BT with PLT 12U due to progress
thrombocytopenia
Slide 34
檢驗項目 單位
血液組(CBC)
WBC
1000/uL
RBC
million/uL
Hemoglobi
g/dL
n
Hematocrit %
MCV
fL
MCH
pg/Cell
MCHC
gHb/dL
RDW
%
Platelets 1000/uL
Segment %
Lymphocyt
%
e
Monocyte %
Eosinophil %
Basophil %
1010806
1010810
1010813
1010816
1010818
6.4
4.46
5.1
4.67
5.8
4.55
10.6
4.12
9.1
3.52
12.2
12.8
12.6
11.3
9.7
37.8
84.8
27.4
32.3
13.8
108
72.1
39.3
84.2
27.4
32.6
14.2
92
62.3
37.7
82.9
27.7
33.4
13.7
89
66.8
33.6
81.6
27.4
33.6
13.8
86
86
29.3
83.2
27.6
33.1
13.7
99
78.2
21.7
29.7
25.1
6
16.2
3.9
2
0.3
4.3
3.5
0.2
5
2.9
0.2
4
0
0
4.3
1.2
0.1
Slide 35
檢驗項
單位
目
BUN mg/dL
Creatini
mg/dL
ne
Na
mEq/L
K
mEq/L
1010806 1010810 1010813 1010816 1010818
14.9
9.7
7.8
10.2
13.7
0.89
0.6
0.6
0.76
0.62
144
138
143
3.4
3.1
3.5
檢驗項目
鏡檢組(U)
單位
1010806
1010809
1010817
Color
Red
Yellow
Dark Yellow
Turbidity
SP.Gravity
pH
Leukocyte
Nitrite
Protein
Glucose
Ketone
Turbid
Clear
Cloudy
mg/dL
mg/dL
mg/dL
mg/dL
Urobilinogen
EU/dL
Bilirubin
Blood
Bacteria
RBC
WBC
Epith-Cell
mg/dL
1.018
6
/uL
/uL
/uL
1+
Negative
1+ (30)
Negative
1+ (15)
1.013
6.5
1+
Negative
1+ (30)
Negative
Negative
1
Negative
3+
POSITIVE
> 500
3+
+ (>0.08)
1+ (30)
Negative
Negative
1
Negative
3+
POSITIVE
> 500
30
0
1.013
6.5
0.1
Negative
3+
POSITIVE
12
0
121
154
0
Slide 36
Chest X ray and KUB (8/17)
Slide 37
Problem lists
Medical
Psychological
Physical
Nutrition
Social-economic
Slide 38
Medical problems
Hematuria, cause?
DDx: bladder tumor, UTI, urolithiasis, prostatitis,
GNs, thrombocytopenia……
Urinary tract infection
Prostate benign hyperplasia , s/p TURP in
2010/10
Hypertension
Diabetes mellitus
Bipolar disorder
Dementia
Hepatitis C with liver cirrhosis
Slide 39
Cognition
Education: 初中
MMSE:無法評估
Slide 40
Geriatric depression scale
GDS:無法評估
Slide 41
Sensory deprivation
Hearing impairment (yes, bilateral)
Visual impairment (no)
Body sensation (preserved)
Slide 42
ADL
Barthel index : 0/100
Total dependent
Foreign caregiver
Slide 43
Iatrogenesis
Polypharmacy
( yes)
Tubes (Foley catheter)
Foley catheter (yes)
NG tube ( no)
Tracheostomy( no)
Pressure
ulcer (no)
Slide 44
Psychological problem
Delirium (?)
Depression (yes)
Dementia (yes)
Slide 45
Physical
ADL: total dependent
Swallowing: normal
Slide 46
Nutrition
BH：170 cm, BW：60 kg, BMI: 21
Albumin: 3.34 gm/dL
Hemoglobin:12.2 gm/dL
Lymphocytes: 1280/mm3
Recent body weight loss (no)
Mininutritional assessment, short
form:6/14 , 11/30, malnutriton
Slide 47
Social economic status
Main caregiver: foreign aid and sons
(病人輪流住在大兒子和二兒子家)
Slide 48
安全的醫療
SAFE
1
a病人照護 (是/否)
PATIENT
CARE
yes
及時的服務
TIMELY
2
yes
有用的處置
EFFECTIVE
3
yes
yes
照顧評估
b醫療知識技能
MEDICAL
KNOWLEDGE and
SKILLS
(應該熟知的)
c人際溝通技巧
INTERPERSONAL
and
COMMUNICATION
SKILLS
(應該表達的)
d專業素養倫理
PROFESSIONALIS
M
(應該做為的)
e醫療體系行醫
SYSTEMS-BASED
PRACTICE
(應該支援的)
f行醫導向之
學習改進
PRACTICE-BASED
LEARNING and
IMPROVEMENT
效率的工作
EFFICIENT
4
平等的就醫
EQUITABLE
5
yes
病人為中心
PATIENTCENTERED
6
yes
Slide 49
Ethic discussion
Family support: good, but…
家屬對病患的處置有兩派看法
(積極控制vs消極處理)
Economic condition: no problem
Slide 50
Geriatric combined conference
Physician
Nurse
Physical therapist
Occupation therapist
Nutritionist
Pharmacist
Social worker
Slide 51
Thanks for your attention