Patient data
Patient ID 99990000999 Name Patient 4 name Sex Female DOB Nov. 19, 1932

<MML Version = 2.3>
Progress Notes
Recorded by Physician 4 name 　 Facility Test Clinic 1 [JPN999999900099]
Date recorded 02-08-2002 　 Department Internal Medicine No. 1 [001]
Subjective

No particular complaints.
No cold symptoms.
No finger joint symptoms.
Objective

Urinalysis: Sugar (-) Protein (2) Occult blood (3)
152/78

Attach lab record (February 8, 2002).

Sample date 2001.12.14 2002.01.11 2002.02.08
Time 11:28:00 09:54:00 09:45:00
Invoice name 　 　 　
TP 7.12 6.86 7.07
ALB 4.00 3.73 3.57
BUN 12.9 17.7 22.4
CRE 1.2 1.3 1.2
GLU 117 130 127
T-CHO 256 244 238
CRP 1.4 2.4 2.3


Assesment

Crescentic nephritis: 1 year since start of symptoms. There is protein in urine, however blood serum protein is sufficient. Continuing with oral Mevalotin; cholesterol is normalizing.
Creatinine may be somewhat high? CRP positive. Insufficient steroids? Or other cause?
Blood pressure rather high. Blood pressure was similarly high when hospitalized one year before.
Blood sugar rather high. Results negative for glucose in urine.
Plan

General lab work (March 3, 2002)

Order details
Substance: Blood
Analysis: Total protein
Analysis: Albumin
Analysis: Urea nitrogen
Analysis: Creatinine
Analysis: Uric acid
Analysis: Glucose
Analysis: Total cholesterol
Analysis: LDL-cholesterol
Analysis: Neutral fat
Analysis: Sodium
Analysis: Potassium
Analysis: Chloride
Analysis: AST
Analysis: ALT
Analysis: LD
Analysis: Cholinesterase
Analysis: CRP
Analysis: Rapid
Substance: Blood
Analysis: HbA1c
Analysis: Rapid
Substance: Urine
Analysis: Urine protein
Analysis: Urine glucose
Analysis: Urine creatinine
Substance: Blood
Analysis: Blood set
Analysis: Rapid

Outpatient prescription (February 8, 2002)

Order details
Medication: Prednisolone tablets (5) 2T
Dosage: 2 times/day after morning and evening meals for 28 days
Medication: Acinon capsules (150) 1C
Dosage: 1 time/day after evening meal for 28 days
Medication: Mevalotin tablets (10) 1T
Dosage: 1 time/day after evening meal for 28 days

Continue prescriptions.
Add HbA1c to next month's lab work.
Reserved order for reexamination (March 8, 2002)

Order details
Physician 4
Urinalysis, hemanalysis