둥록번호: 432-62-78-3 초진기록

성명: YOO, JENNIFER F

주민번호: 730130-******* SAMSUNG MEDICAL CENTER

14 January 2020 신장내과분과

■ 주호소
* 주증상 Foamy urine: F/U for LN (병동 퇴원)
Onset (2MA)
■ 현병력
06 December 2019 ~ 13 December IM9 입원 중 협진
#. Lupus nephritis, class V+III (A)
-- (December 2019) initial uP/Cr 4.84, uA/Cr 4282.15
-- (December 2019) 24 HU protein 1215.8mg, albumin 1032.6mg, CCr 122.7, CKD-EPI eGFR 106.8
-- (09 December 2019 Kidney biopsy) Membranous and focal lupus nephritis, class V+III (A)
(by 2004 ISN/RPS)
-- (December 2019 Renal doppler US) RK 11.5cm/ LK 9.7cm, RAS (-/-), normal parenchymal echo.
#. SLE -- IM9
-- (October 2019) FANA 1: 640, 4+, Speckled, Anti-SSA (+, >200)
-- (December 2019) Anti-ds-DNA 11.3, C3 63.8 / C4 18.3
-- Pd + MMF (~ December 2019)
#. R/O Pericardial cyst: 4.9cm (December 2019. CT) / LAE (December 2019. LVEF: 61%) -- IM2
#. Thyroid nodule -- s/p hemi-thyroidectomy (2007)
Hypothyroidism on T4 (since November 2019.)
퇴원 후 general condition -- ok
NSAIDs / COX2 inhibitor or herbal mx. history -- 이전에 홍삼 & celecoxib / naproxen 드
시다가 중단
외부 병원 처방전 -- 외부에서 복용하시는 약 없음.
■ 과거력
* 질환력
당뇨병 ( - )
고혈압 ( - )
Tb / CLD - denied
Allergic disease - denied
Drug or food allergy - denied
* 수술 및 치료력
s/p hemi-thyroidectomy (2007)
■ 가족력
Kidney disease FHx.- denied
■ 개인력 및 사회력
흡연력: Non-smoker
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원본대조필 +541331050
 둥록번호: 432-62-78-3 초진기록
성명: YOO, JENNIFER F
주민번호: 730130-******* SAMSUNG MEDICAL CENTER

■ 계통문진
Weight change ( - )
Edema ( + )
Urinary symptom ( + )
Foamy urine - 호전 경과

■ 신체검진
* 기본신체사항 및 활력징후
신장 159.9 cm 체중 55.5 kg BMI 21.7 kg/m2

혈압 105/56 mmHg 맥박 86 회
LE pitting edema ( - ): 2+/2+

■ 통증평가
통증: 무

■ 검사소견
* 본원 [검사명] [단위] [시행일] [결과]
WBC Count, Blood x103 / µL 03 January 2020 10:27 12.22
Hemoglobin, Blood g/dL 03 January 2020 10:27 11.3
Platelet Count, Blood x103 / µL 03 January 2020 10:27 353
Protein, Total g/dℓ 03 January 2020 10:27 5.1
Albumin g/dℓ 03 January 2020 10:27 1.8
Cholesterol mg/dℓ 03 January 2020 10:27 266
BUN mg/dℓ 03 January 2020 10:27 21.3
Creatinine mg/dℓ 03 January 2020 10:27 0.63

삼성서울병원 2/4 15 January 2020 오전 08: 09: PP5701

원본대조필 +541331050
 둥록번호: 432-62-78-3 초진기록
성명: YOO, JENNIFER F
주민번호: 730130-******* SAMSUNG MEDICAL CENTER

Estimated GFR mL/min/1.73m203 January 2020 10:27 107.9

Ca mg/dℓ 03 January 2020 10:27 8.0
P mg/dℓ 03 January 2020 10:27 3.3
Na mmol/ℓ 03 January 2020 10:27 140
Potassium (K) mmol/ℓ 03 January 2020 10:27 4.1
Cl mmol/ℓ 03 January 2020 10:27 104
TCO2 (Carbon Dioxide, Total) mmol/ℓ 03 January 2020 10:27 29.2
CRP, Quantitative (High Sens.. mg/dℓ 03 January 2020 10:27 0.03
Triglyceride mg/dℓ 03 January 2020 10:27 159
LDL-C mg/dℓ 03 January 2020 10:27 154
Protein/Creatinine Ratio, Uri.. mg/mgCr 03 January 2020 11:04 2.11

■ 진단명
Lupus nephritis, class V
Lupus nephritis, class III

■ 진료계획
(IM2 -- )
(IM4 -- )
(IM9 -- Cavid chewabIe / Prednisolone / hydroxychloroQUINE / Mycophenolate /
Rosuvastatin / Levothyroxine / Furosemide / Losartan / Rabeprazole)
Lifestyle modification / low salt & low fat diet / oral hydration / weight control
NSAIDs / COX2 inhibitor & Herbal mx. 금지 교육
Home BP & PR

삼성서울병원 3/4 15 January 2020 오전 08: 09: PP5701

원본대조필 +541331050
 둥록번호: 432-62-78-3 초진기록
성명: YOO, JENNIFER F
주민번호: 730130-******* SAMSUNG MEDICAL CENTER

1mo.
[검사]
CBC, with Differential (Blood)
Chemistry Profile 2-1 (Cholesterol 제외)
Electrolyte Profile (3131-33)
TCO2 (Carbon Dioxide, Total)
Routine Urinalysis
Urine Microscopy (Flow cytometry 법)
Dysmorphic RBC
Protein/Creatinine Ratio, Urine
Cystatin-C, Profile
Lipid Profile (3113, 41-42)
CK
Ca, Ionized
Mg
CRP, Quantitative (High Sensitivity)
CHEST PA

작성의사: 장혜련
---------------------------------------------------- < 이하여백 >-----------------------------------------------------

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원본대조필 +541331050
 ORDER LIST (14 January 2020 ~ 15 January 2020) [전체]
출력일시: 15 January 2020 08:09 ► YOO, JENNIFER (43262783) F/46 세
처방일자 종류 구분 처방명 內 세부사항(병력 및 임상소견) 처방의 처방결과 과 실시일자 시간/실시자 시간/실시자 시간/실시자
14 January 검사 CBC, with Differential [L01][차기진료전][18 February 2020] 장혜련 IM5
2020 (Blood)
중복처방 확인했음 ©
Chemestry Profile 2-1 [L01] [차기진료전][18 February 2020] © 장혜련 IM5
원본대조펄

(Cholesterol 제외)
Electrolyte Profile [L01][차기진료전][18 February 2020] 장혜련 IM5
(3131-33)
중복처방 확인했음 ©
TCO2 (Carbon Dioxide, [L01] [차기진료전][18 February 2020] © 장혜련 IM5
Total)
Routine Urinalysis [L03][차기진료전][18 February 2020] 장혜련 IM5

중복처방 확인했음 ©
Urine Microscopy (Flow [L03][차기진료전][18 February 2020] © 장혜련 IM5
Cytometry 법)
Dysmorphic RBC [L03][차기진료전][18 February 2020] © 장혜련 IM5
Protein/Creatine Ratio, [L03][차기진료전][18 February 2020] 장혜련 IM5
Urine
중복처방 확인했음 ©
Cystatin-C, Profile [L01][차기진료전][18 February 2020] © 장혜련 IM5
Lipid Profile (3113, 41-42) [L01][차기진료전][18 February 2020] 장혜련 IM5

중복처방 확인했음 ©
CK [L01][차기진료전][18 February 2020] © 장혜련 IM5
Ca,Ionized [L01][차기진료전][18 February 2020] © 장혜련 IM5
+ 5 4 1 3 3 1 0 50

Mg [L01][차기진료전][18 February 2020] © 장혜련 IM5

CRP, Quantitative (High [L01][차기진료전][18 February 2020] 장혜련 IM5
Sensivity)
중복처방 확인했음 ©

[원내한] 15 January 2020 08:09:24 PP5701 119.4.215.143 MDI602F1 20200115080924913_PP5701

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삼성서울병원
 ORDER LIST (14 January 2020 ~ 15 January 2020) [전체]
출력일시: 15 January 2020 08:09 ► YOO, JENNIFER (43262783) F/46 세
처방일자 종류 구분 처방명 內 세부사항(병력 및 임상소견) 처방의 처방결과 과 실시일자 시간/실시자 시간/실시자 시간/실시자
TFT profile (T3, Free T4, [L01][차기진료전][31 January 2020] © 박성운 IM4
TSH)
Microsomal Ab [N01][차기진료전][31 January 2020] © 박성운 IM4
원본대조펄

CHEST PA [차기진료전][18 February 2020] Lupus 장혜련 IM5

nephritis for routine check & malignancy
screening
+ 5 4 1 3 3 1 0 50

[원내한] 15 January 2020 08:09:24 PP5701 119.4.215.143 MDI602F1 20200115080924913_PP5701

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삼성서울병원