<?xml version="1.0" encoding="UTF-8"?> <mmlPc:ProgressCourseModule xmlns:mmlPc="http://www.medxml.net/MML/v4/ContentModule/ProgressCourse/1.0" xmlns:mmlCm="http://www.medxml.net/MML/v4/SharedComponent/Common/1.0" xmlns:mmlPs="http://www.medxml.net/MML/v4/ContentModule/Prescription/1.0" xmlns:xhtml="http://www.w3.org/1999/xhtml" xmlns:xsi="http://www.w3.org/2001/XMLSchema-instance"> <mmlPc:structuredExpression> <mmlPc:problemItem> <mmlPc:subjective> <mmlPc:subjectiveItem> <mmlPc:timeExpression> 25-Aug-1999. AM. </mmlPc:timeExpression> <mmlPc:eventExpression> Palpitation was felt early in the morning. </mmlPc:eventExpression> </mmlPc:subjectiveItem> <mmlPc:subjectiveItem> <mmlPc:timeExpression> 25-Aug-1999. PM. </mmlPc:timeExpression> <mmlPc:eventExpression> No palpitations. </mmlPc:eventExpression> </mmlPc:subjectiveItem> </mmlPc:subjective> <mmlPc:objective> <mmlPc:objectiveNotes> 検尿 糖(-)蛋白(1)潜血(2)<xhtml:br/> 心音呼吸音正常(usually piping rales)<xhtml:br/> 118/86<xhtml:br/> </mmlPc:objectiveNotes> </mmlPc:objective> <mmlPc:assessment> <mmlPc:assessmentItem> 貧血はHb10程度らしい。鉄剤終了後に再検されるだろう。<xhtml:br/> 全身的には安定。関節症状も無し。<xhtml:br/> </mmlPc:assessmentItem> </mmlPc:assessment> <mmlPc:plan> <mmlPc:rxOrder> <mmlPs:PrescriptionModule> <mmlPs:issuedTo>external</mmlPs:issuedTo> <mmlPs:medication> <mmlPs:medicine> <mmlPs:name>プレドニゾロン錠 5mg</mmlPs:name> <mmlPs:code mmlPs:system="YJ">61222033</mmlPs:code> </mmlPs:medicine> <mmlPs:dose>4</mmlPs:dose> <mmlPs:doseUnit>錠</mmlPs:doseUnit> <mmlPs:frequencyPerDay>1</mmlPs:frequencyPerDay> <mmlPs:startDate>2015-05-13</mmlPs:startDate> <mmlPs:duration>P14D</mmlPs:duration> <mmlPs:instruction>内服 1回 朝食前</mmlPs:instruction> <mmlPs:batchNo>1</mmlPs:batchNo> <mmlPs:brandSubstitutionPermitted>true</mmlPs:brandSubstitutionPermitted> </mmlPs:medication> <mmlPs:medication> <mmlPs:medicine> <mmlPs:name>プレドニゾロン錠 5mg</mmlPs:name> <mmlPs:code mmlPs:system="YJ">61222033</mmlPs:code> </mmlPs:medicine> <mmlPs:dose>2</mmlPs:dose> <mmlPs:doseUnit>錠</mmlPs:doseUnit> <mmlPs:frequencyPerDay>1</mmlPs:frequencyPerDay> <mmlPs:startDate>2015-05-13</mmlPs:startDate> <mmlPs:duration>P14D</mmlPs:duration> <mmlPs:instruction>内服 1回 昼食後</mmlPs:instruction> <mmlPs:batchNo>1</mmlPs:batchNo> <mmlPs:brandSubstitutionPermitted>true</mmlPs:brandSubstitutionPermitted> </mmlPs:medication> <mmlPs:medication> <mmlPs:medicine> <mmlPs:name>メトリジン錠2mg</mmlPs:name> <mmlPs:code mmlPs:system="YJ">612160027</mmlPs:code> </mmlPs:medicine> <mmlPs:dose>1</mmlPs:dose> <mmlPs:doseUnit>錠</mmlPs:doseUnit> <mmlPs:frequencyPerDay>2</mmlPs:frequencyPerDay> <mmlPs:startDate>2015-05-13</mmlPs:startDate> <mmlPs:duration>P14D</mmlPs:duration> <mmlPs:instruction>内服 2回 朝夕食後</mmlPs:instruction> <mmlPs:batchNo>2</mmlPs:batchNo> <mmlPs:brandSubstitutionPermitted>true</mmlPs:brandSubstitutionPermitted> </mmlPs:medication> <mmlPs:medication> <mmlPs:medicine> <mmlPs:name>マーズレンS顆粒</mmlPs:name> <mmlPs:code mmlPs:system="YJ">612160027</mmlPs:code> </mmlPs:medicine> <mmlPs:dose>0.5</mmlPs:dose> <mmlPs:doseUnit>g</mmlPs:doseUnit> <mmlPs:frequencyPerDay>2</mmlPs:frequencyPerDay> <mmlPs:startDate>2015-05-13</mmlPs:startDate> <mmlPs:duration>P14D</mmlPs:duration> <mmlPs:instruction>内服 2回 朝夕食後</mmlPs:instruction> <mmlPs:batchNo>2</mmlPs:batchNo> <mmlPs:brandSubstitutionPermitted>true</mmlPs:brandSubstitutionPermitted> </mmlPs:medication> <mmlPs:medication> <mmlPs:medicine> <mmlPs:name>ジクロフェナクnaゲル</mmlPs:name> <mmlPs:code mmlPs:system="YJ">612320261"</mmlPs:code> </mmlPs:medicine> <mmlPs:dose>50</mmlPs:dose> <mmlPs:doseUnit>g</mmlPs:doseUnit> <mmlPs:startDate>2015-05-13</mmlPs:startDate> <mmlPs:instruction>一日3回左膝に塗布</mmlPs:instruction> <mmlPs:batchNo>3</mmlPs:batchNo> <mmlPs:brandSubstitutionPermitted>true</mmlPs:brandSubstitutionPermitted> </mmlPs:medication> </mmlPs:PrescriptionModule> </mmlPc:rxOrder> <mmlPc:planNotes> ステロイド減量<xhtml:br/> 15/10mgに挑戦。<xhtml:br/> 難病外来指導料(250);服薬および生活指導<xhtml:br/> <xhtml:u><xhtml:b>再診予約オーダ</xhtml:b> (2002年03月06日 )</xhtml:u> <xhtml:br/> <xhtml:br/> <xhtml:font color="#0000ff"><xhtml:b>オーダ内容</xhtml:b></xhtml:font> <xhtml:br/> <xhtml:font color="#000000">医師氏名4</xhtml:font> <xhtml:font color="#000000"> </xhtml:font> <xhtml:font color="#000000"> </xhtml:font> <xhtml:br/> <xhtml:font color="#000000">尿検査が終わったら連絡をしてください</xhtml:font> <xhtml:font color="#000000"> </xhtml:font> <xhtml:font color="#000000"> </xhtml:font> <xhtml:br/> <xhtml:br/> </mmlPc:planNotes> </mmlPc:plan> </mmlPc:problemItem> </mmlPc:structuredExpression> </mmlPc:ProgressCourseModule>