Part A - 修改文法
Part 1 - 要修改文法的病歷
This 59 y/o male he last time admitted on 2019/04/10 admitted due to Productive
cough and intermtittent fever ,BW loss>10 Kg in 6 month ,CXR bilateral upper
lobe infiltration ,suspect pulmoanry TB ,After admission ,On air isolation ,F/U
Sputum AFB 1++++2++++ 3++++,On anti TB medication with Rina (300 )2#po qd ,EMB
2#po QD PZA 3# PO QD since 4/12. He asked discharged on 2019/04/15. He never
OPD follow up until 2022/07/04. Shopping hospital in recent 2 years due to
productive cough and shorthness of breath.
Part 2 - 要修改文法的病歷 - 學習版
請修改此份醫療病歷的文法
輸出:
(1) 用刪除線來標註修改前內容
(2) 用粗體字來標註修改後內容
---
This 59 y/o male he last time admitted on 2019/04/10 admitted due to Productive
cough and intermtittent fever ,BW loss>10 Kg in 6 month ,CXR bilateral upper
lobe infiltration ,suspect pulmoanry TB ,After admission ,On air isolation ,F/U
Sputum AFB 1++++2++++ 3++++,On anti TB medication with Rina (300 )2#po qd ,EMB
2#po QD PZA 3# PO QD since 4/12. He asked discharged on 2019/04/15. He never
OPD follow up until 2022/07/04. Shopping hospital in recent 2 years due to
productive cough and shorthness of breath. ---
Part 3 - 要修改文法的病歷 - 學習版/不能有縮寫版
請修改文法，並改為醫學美式英文用語。
輸出:
(1) 用刪除線來標註修改前內容
(2) 用粗體字來標註修改後內容
(3) 醫學專有名詞，不能用縮寫，請寫全名。
---
This 59 y/o male he last time admitted on 2019/04/10 admitted due to Productive
cough and intermtittent fever ,BW loss>10 Kg in 6 month ,CXR bilateral upper
lobe infiltration ,suspect pulmoanry TB ,After admission ,On air isolation ,F/U
Sputum AFB 1++++2++++ 3++++,On anti TB medication with Rina (300 )2#po qd ,EMB
2#po QD PZA 3# PO QD since 4/12. He asked discharged on 2019/04/15. He never
OPD follow up until 2022/07/04. Shopping hospital in recent 2 years due to
productive cough and shorthness of breath. ---
Part 4 - 要修改文法的病歷 - 學習版/不能有縮寫版 + 好複製版本
請修改文法，並改為醫學美式英文用語。
第一部份輸出:
(1) 用刪除線來標註修改前內容
(2) 用粗體字來標註修改後內容
(3) 醫學專有名詞，不能用縮寫，請寫全名。
第二部份輸出: 把修改後無標記的文字，輸出 in code block
---
This 59 y/o male he last time admitted on 2019/04/10 admitted due to Productive
cough and intermtittent fever ,BW loss>10 Kg in 6 month ,CXR bilateral upper
lobe infiltration ,suspect pulmoanry TB ,After admission ,On air isolation ,F/U
Sputum AFB 1++++2++++ 3++++,On anti TB medication with Rina (300 )2#po qd ,EMB
2#po QD PZA 3# PO QD since 4/12. He asked discharged on 2019/04/15. He never
OPD follow up until 2022/07/04. Shopping hospital in recent 2 years due to
productive cough and shorthness of breath. ---
Part 5 - GPTs - 修改醫療病歷小幫手
此 GPTs 的指令如下:
---
---請修改使用者給你的醫療病歷的文法及用字，並改為醫學美式英文用語。
第一部份輸出:
(1) 用刪除線來標註修改前內容
(2) 用粗體字來標註修改後內容
(3) 醫學專有名詞，不能用縮寫，請寫全名。
(4) 僅根據原始病歷進行修改，確保內容限於病歷中已有的描述。
第二部份輸出: 把修改後無標記的文字，輸出 in code block
This 59 y/o male he last time admitted on 2019/04/10 admitted due to Productive
cough and intermtittent fever ,BW loss>10 Kg in 6 month ,CXR bilateral upper
lobe infiltration ,suspect pulmoanry TB ,After admission ,On air isolation ,F/U
Sputum AFB 1++++2++++ 3++++,On anti TB medication with Rina (300 )2#po qd ,EMB
2#po QD PZA 3# PO QD since 4/12. He asked discharged on 2019/04/15. He never
OPD follow up until 2022/07/04. Shopping hospital in recent 2 years due to
productive cough and shorthness of breath.
Part B - Weekly Summary
11/24~11/29 病歷
2024/11/24 15:11
<>
Brief history:
This 89-year-old male patient was admitted through the Emergency Room (ER) due to tremors, vomiting, and drowsiness that began earlier this afternoon. His medical history includes:1.Right head injury with a prior craniotomy (Burr hole) on September 3, 2024.2.Type 2 diabetes mellitus.3.He was recently discharged from the Neurosurgery Department on October 29, 2024, following treatment for a right frontal-temporal-parietal (F-T-P) subdural effusion with mass effect and midline shift. He had been bedridden and on nasogastric (NG) feeding since discharge.
According to his caregiver, the patient developed a fever with chills this afternoon, along with shortness of breath and vomiting. There were no reports of cough, seizures, local joint pain, or dysuria. Due to these symptoms, he was brought to our ER for further evaluation.Upon arrival in the ER, the patient's Glasgow Coma Scale (GCS) score was E4 V1 M3. His vital signs were as follows:Temperature: 38.8°C,Pulse: 112 /bpm.Respiratory rate: 26/min,BP: 107/68 mmHg.Physical examination revealed coarse breath sounds, a soft abdomen, and no pitting edema.Laboratory results showed the following WBC: 13.69 x10^3/uL,RBC: 4.78 x 10?/?L,Hb: 13.9 g/dL,Hct: 40.5%,Segs: 82.7%, Lymphocytes: 3.8%, Bands: 11.5%. Urinalysis revealed:Leukocyte esterase: 3+,Color: Yellow,Turbidity: Cloudy,Protein: 50 mg/dL,WBC: ?100/HPF.Chest X-ray showed no active lesions. A Head CT revealed an old subdural hematoma (SDH) but no new active lesions.Under the tentative diagnosis of :1.Fever, likely secondary to urinary tract infection (UTI),2.Old subdural hematoma (SDH) in a bedridden,3.Type 2 diabetes mellitus. He was admitted to ward for further evaluation and management.
Course and treatment:
At ward, GCS E3-4V21M4 , BT：37.8度 PULSE：106次/分 RESP：20次/分 BP：140/84mmHg SpO2：98% , kept Flomoxef 1g q8h ivf use. On nasal cannula O2 2-3
L/min, on NG tube with NG feeding 1600kcal/day. Closely follow up clinical symptom.
Active problem:
1. Urinary tract infection
2. Type 2 Diabetes Mellitus
Plan:
藥名 劑量 用法 數量
____________________________________________________________________
N/S 袋裝【５００】ml/bag(run 40ml/hr病房常備藥) 1000ML QD 7天
Acetaminophen 500mg/tab(Acetal)(PRN, Q4H, For Feve 1PC PRN 7天
r ＞ 38℃(發燒 ＞ 38℃時))
Flomoxef***1gm/vial(Flumarin)(in NS 100ml run 0.5 1PC Q8H 7天
hr *照會感控醫師審核用藥之適當性)
N/S 袋裝【５００】ml/bag(in NS 100ml run 0.5hr fo 100ML Q8H 7天
r Flomoxef use病房常備藥)
Midodrine 2.5mg/tab(Midorine) 2PC Q6H 9天
Atorvastatin 10mg/tab(Atorva) 1PC BID 9天
Sennoside A+B 12.5mg/tab(Sennapur) 2PC HS 9天
GALVUS Met(Vildagliptin 50mg/metformin 500mg)/tab 1PC QD PC PO 9天
2024/11/25 16:41
Ｓ:
Had fever
Ｏ:
T:36.8/℃ P:89/min R:18/min
BP:122/72mmHg
非語言疼痛評估量表(NVPS):0分 記錄日期: 2024/11/25 17:46
Conscious E3-4V3M4
Ear: no discharge, hearing impairment
Breath pattern:shallow, no distress. on O2 N-C 2-3L/min,SpO2: 97-100%
Neck: no bruits; no JVD
Heart: regular heart beat, no S3, no murmur
Abdomen: soft, no tenderness
Extremities: no pitting edema, bed rest.
NG tube (+)
11/25 08:30 299
11/25 13:15 225
復健科今日已做吞嚥評估，狀況比上次住院好
醫師同意營養師陳怡琪對此病患營養建議:2024/11/25 15:07:48
焦點問題:NG feeding assessment
S:1.present feeding:益力壯14 150c.c.(1.0kcal/c.c.)/q4h for 6meals.
2.主護：gastric empty well
O:1.Diagnosis:1.Urinary tract infection
2.Type 2 Diabetes Mellitus
2.BH:167cm BW:(11/23)62.6kg IBW:61kg
3.Present dietary order:(11/23)NG feeding
4.(11/23)Glu:212 BUN:17 Cre:0.74 Ccr:99.6 GPT:27 Na:133.9 K:4.1
(11/24)SBS:8:30 328
A:1.BMI:22.45→body weight in normal range
2.TEE:1708kcal/day(28kcal/kg-IBW)
Protein:61-73.2g/day(1.2g/kg-IBW)
P:與團隊溝通suggestion:(調整管灌配方＜2500)
益力壯17 280c.c.(1.0kcal/c.c)/q4h for 6meals
1.total calories:1680kcal/day
2.total protein:71.4g/day
Ａ:
1. Urinary tract infection
2. Type 2 Diabetes Mellitus
Ｐ:
1. Flomoxef 1gm/vial(Flumarin) q8h ivf use
2. DC GALVUS Met, Regular human insulin by scale treatment
主治醫師迴診意見:
-----------------
Check blood sugar
2024/11/26 15:43
Ｓ:
No fever
Ｏ:
T:37.1/℃ P:88/min R:18/min
BP:133/77mmHg
非語言疼痛評估量表(NVPS):0分 記錄日期: 2024/11/26 15:40
Conscious E3-4V3M4
Ear: no discharge, hearing impairment
Breath pattern:shallow, no distress. on O2 N-C 2-3L/min,SpO2: 98-100%
Neck: no bruits; no JVD
Heart: regular heart beat, no S3, no murmur
Abdomen: soft, no tenderness
Extremities: no pitting edema, bed rest.
NG tube (+)
2024/11/26 08:44
F/S：229mg/dL
測量病患血糖:229mg/dl，告知病人或家屬同意後胰島素注射，藥名、劑量：▲Regular human insulin 1000u/10ml/vial 6UN，部位：左前臂D1
2024/11/26 13:13
F/S：231mg/dL
測量病患血糖:231告知病人或家屬同意後胰島素注射，藥名、劑量：▲Regular human insulin 1000u/10ml/vial 6UN，部位：左前臂E1
Ａ:
1. Urinary tract infection
2. Type 2 Diabetes Mellitus
Ｐ:
Consult rehabilitation department for swallowing rehabilitation
2024/11/27 11:47
Ｓ:
No chilness, no fever
Ｏ:
T:36.8(2024/11/27 11:27)/℃ P:82(2024/11/27 11:27)/min R:18(2024/11/27 11:27)/min
BP:130(2024/11/27 11:27)/74(2024/11/27 11:27)mmHg
非語言疼痛評估量表(NVPS):0分 記錄日期: 2024/11/27 11:46
Glasgow coma scale E3-4V3M4
Ear: no discharge, hearing impairment
Breath pattern:shallow, no distress. on O2 N-C 2L/min,SpO2: 97-100%
Neck: no bruits; no JVD
Heart: regular heart beat, no S3, no murmur
Abdomen: soft, no tenderness
Extremities: no pitting edema, bed rest.
NG tube (+)
11/27 08:30 F/S：243mg/dL
09:25 Regular human insulin 6UN SC USE
Ａ:
1. Urinary tract infection and bacteremia ( urine culture and blood culture: Escherichia coli on 2024/11/23 )
2. Type 2 Diabetes Mellitus
Ｐ:
1. Flomoxef 1gm/vial(Flumarin) q8h ivf use
2. GALVUS Met(Vildagliptin 50mg/metformin 500mg) 1pc po once and qd use
3. Discontinue 0.9% N/S 1000ML IVF QD, change 0.9% N/S for drug
主治醫師迴診意見:
-----------------
Discontinue 0.9% N/S 1000ML IVF QD, change 0.9% N/S for drug
2024/11/28 14:14
Ｓ:
No fever
Ｏ:
T:36.7(2024/11/28 11:30)/℃ P:91(2024/11/28 11:30)/min R:18(2024/11/28 11:30)/min
BP:130(2024/11/28 11:30)/77(2024/11/28 11:30)mmHg
非語言疼痛評估量表(NVPS):0分 記錄日期: 2024/11/28 10:00
Conscious E3-4V3M4
Ear: no discharge, hearing impairment
Breath pattern:shallow, no distress. on O2 N-C 2-3L/min,SpO2: 98-100%
Neck: no bruits; no JVD
Heart: regular heart beat, no S3, no murmur
Abdomen: soft, no tenderness
Extremities: no pitting edema, bed rest.
NG tube (+)
11/28 08:25 BS:270
Ａ:
1. Urinary tract infection and bacteremia ( urine culture and blood culture: Escherichia coli on 2024/11/23 )
2. Type 2 Diabetes Mellitus
Ｐ:
1. Flomoxef 1gm/vial(Flumarin) q8h ivf use
2. GALVUS Met(Vildagliptin 50mg/metformin 500mg) 1pc po qd change bid use
2024/11/29 10:31
Ｓ:
No cough, no fever
Ｏ:
T:36.8(2024/11/29 07:33)/℃ P:88(2024/11/29 07:33)/min R:20(2024/11/29 07:33)/min
BP:128(2024/11/29 07:33)/85(2024/11/29 07:33)mmHg
非語言疼痛評估量表(NVPS):0分 記錄日期: 2024/11/29 10:00
Conscious E3-4V3M4
Ear: no discharge, hearing impairment
Breath pattern:shallow, no distress. room air, SpO2:99%
Neck: no bruits; no JVD
Heart: regular heart beat, no S3, no murmur
Abdomen: soft, no tenderness
Extremities: no pitting edema, bed rest.
NG tube (+)
11/29 08:30 Blood Sugar:204
Ａ:
1. Urinary tract infection and bacteremia ( urine culture and blood culture: Escherichia coli on 2024/11/23 )
2. Type 2 Diabetes Mellitus
Ｐ:
1. Discontinue Flomoxef 1gm(Flumarin) IVF Q8H, change Cefixime 200mg(Cexime) po bid treatment
2. Discharge today (2024/11/29)
主治醫師迴診意見:
-----------------
Discharge today
2024/11/23 20:24
類別 醫囑名稱 用法/方向 檢體/部位
Admit to the service of Dr
Diagnosis(1):(Urinary tract infection)
Diagnosis(2):(Right chronic subdural hematoma (SDH), (MCA) infarct, left hemiparesis)
Diagnosis(3):(Type 2 DM)
Vital Sign:(qid + prn)
Diet as tolerated
O2 Nasal Cannula(2-3L/min use)
Pulse oximeter(天)(BID)
Record I/O(QD)
FINGER SUGAR血糖試驗 (成人)(BID/AC)
病人嚴重度分級:C級
(心內)E.K.G RESTING(EKG心電圖)
(腎內)KIDNEYS ECHO (檢查室執行)
類別 藥品名稱 劑量 用法 飯前後 途徑 數量 流速 首日量
NEW N/S 袋裝【５００】ml/bag 1000ML QD IVF 7天 0PC
(run 40ml/hr病房常備藥)
NEW Acetaminophen 500mg/tab(Acetal) 1PC PRN PC PO 7天 0PC
(PRN, Q4H, For Fever > 38℃(發燒 > 38℃時))
NEW Flomoxef***1gm/vial(Flumarin) 1PC Q8H IVF 7天 5PC
(in NS 100ml run 0.5hr *照會感控醫師審核用藥之適當性)
NEW N/S 袋裝【５００】ml/bag 100ML Q8H IVF 7天 0PC
(in NS 100ml run 0.5hr for Flomoxef use病房常備藥)
NEW Midodrine 2.5mg/tab(Midorine) 2PC Q6H PC PO 9天 14PC
NEW Atorvastatin 10mg/tab(Atorva) 1PC BID PC PO 9天 3PC
NEW Sennoside A+B 12.5mg/tab(Sennapur) 2PC HS PC PO 9天 4PC
NEW GALVUS Met(Vildagliptin 50mg/metformin 500mg)/tab
1PC QD PC PO 9天 2PC
2024/11/23 22:17
類別 醫囑名稱 用法/方向 檢體/部位
DC Diet as tolerated
.CONSULT DISCHARGE PLANNING
On NG tube
NASAL FEEDING鼻胃管灌食 (成人)
Consult 營養治療科
2024/11/24 08:26
類別 醫囑名稱 用法/方向 檢體/部位
PHYSICAL RESTRAINT(DAY) 約束 (成人) (次,>8小時)(for 行為紊亂、協助治療、有自拔管路動機; 約束部位: 雙手 約束用具:棒球手套+ 棉質腕踝帶)
2024/11/25 08:53
類別 醫囑名稱 用法/方向 檢體/部位
(腎內)KIDNEYS ECHO (檢查室執行)
2024/11/25 09:42
類別 醫囑名稱 用法/方向 檢體/部位
PHYSICAL RESTRAINT(DAY) 約束 (成人) (次,>8小時)
DC (腎內)KIDNEYS ECHO (檢查室執行)
2024/11/25 10:39
類別 醫囑名稱 用法/方向 檢體/部位
(耳鼻)SWALLOWING EVALUATION
2024/11/25 10:49
類別 醫囑名稱 用法/方向 檢體/部位
FINGER SUGAR血糖試驗 (成人)(QID and by HR scale) CONT
SUBCU,IM INJECT 胰島素注射(成人) CONT
類別 藥品名稱 劑量 用法 飯前後 途徑 數量 流速 首日量
DC-D GALVUS Met(Vildagliptin 50mg/metformin 500mg)/tab
1PC QD PC PO 9天
NEW ▲Regular human insulin 1000u/10ml/vial 1UN QID AC SC 7天 1UN
(If SBS 141-180 2U;181-220 4U;221-260 6U;261-300 8U;301-340 10U;341-380 12U;381-420 14U; >421 16U)
2024/11/26 09:49
類別 醫囑名稱 用法/方向 檢體/部位
PHYSICAL RESTRAINT(DAY) 約束 (成人) (次,>8小時)
Consult(復健科醫師)
2024/11/26 13:13
類別 醫囑名稱 用法/方向 檢體/部位
(復健) 複雜治療
肌力訓練
耐力訓練
姿態訓練
平衡訓練
(復健) 物理治療評估
(復健) 語言治療:複雜
VERBAL PRODUCTIPN
HIGH LEVEL COGNITIVE FUNCTION TRAINING
TACTILE STIMULATION
ORAL TX.
ST OTHERS
(復健) 吞嚥治療 Simple swallowing therapy
(復健) 語言治療評估
2024/11/27 11:05
類別 藥品名稱 劑量 用法 飯前後 途徑 數量 流速 首日量
DC-D N/S 袋裝【５００】ml/bag 1000ML QD IVF 7天
(run 40ml/hr病房常備藥)
NEW GALVUS Met(Vildagliptin 50mg/metformin 500mg)/tab
1PC QD PC PO 9天 0PC
NEW GALVUS Met(Vildagliptin 50mg/metformin 500mg)/tab
1PC ONCE PC PO 1PC 1PC
(2小時內給藥)
2024/11/28 11:07
類別 醫囑名稱 用法/方向 檢體/部位
PHYSICAL RESTRAINT(DAY) 約束 (成人) (次,>8小時)
類別 藥品名稱 劑量 用法 飯前後 途徑 數量 流速 首日量
DC-C GALVUS Met(Vildagliptin 50mg/metformin 500mg)/tab
1PC QD PC PO 9天
CHG GALVUS Met(Vildagliptin 50mg/metformin 500mg)/tab
1PC BID PC PO 9天 0PC
NEW 栓劑Bisacodyl 10 mg/supp. 1PC ONCE RECT 0PC 0PC
(2小時內給藥)
2024/11/29 09:01
類別 醫囑名稱 用法/方向 檢體/部位
Discharge order(11/29)
Discharge Today(11/29)
出院狀況:改本院門診治療 RTC/Fu of 開立診斷書(1份)
.門診藥物自備繼續使用
類別 藥品名稱 劑量 用法 飯前後 途徑 數量 流速 首日量
NEWD GALVUS Met(Vildagliptin 50mg/metformin 500mg)/tab
1PC BID PC PO 6天 12PC
NEWD Cefixime**100mg/cap(Cexime) 2PC BID PC PO 6天 24PC
2024/11/29 09:06
類別 藥品名稱 劑量 用法 飯前後 途徑 數量 流速 首日量
DC-V GALVUS Met(Vildagliptin 50mg/metformin 500mg)/tab
1PC BID PC PO 6天
NEWD GALVUS Met(Vildagliptin 50mg/metformin 500mg)/tab
1PC HS PC PO 6天 6PC
Part C - 同場加映 - Pocket Medicine
