89812068
Physician 3 name
Title
M.D.
Test Clinic 1
JPN999999900009
________________, Miyazaki-gun
Postal code
JPN
Area code
Tel. No. A
Tel. No. B
81
doctor
0002261411
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Medical group to which the person who kept the medical record belongs
Progress Notes
JPN999999900009AC1F1B6944A3A2200202080926070003
JPN999999900009AC1F1B6944A3A2200202080926070002
2002-02-08
41603232
Physician 4 name
Physician
Test Clinic 1
JPN999999900009
Internal Medicine No. 1
001
doctor
No particular complaints.
No cold symptoms.
No finger joint symptoms.
Urinalysis: Sugar (-) Protein (2) Occult blood (3)
152/78Attach 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 +
+---------------------+-----------------+-----------------+-----------------+
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.
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)
2
T
Dosage: 2 times/day after morning and evening meals
28
days
Medication: Acinon capsules (150)
1
C
Dosage: 1 time/day after evening meal
28
days
Medication: Mevalotin tablets (10)
1
T
Dosage: 1 time/day after evening meal
28
days
Continue prescriptions.
Add HbA1c to next month's lab work.
Reserved order for reexamination
(March 8, 2002)
Order details
Physician 4 name
Urinalysis, hemanalysis