會診範本

Dear Dr:

This patient with mental disorder was admitted to TTPC for treatment. The patient also accepted regular follow-up under your professional service. The medical hstory was reviewed.


Problems:
--HTN
--DM==>check DM-KIT every 3 months
       可視情形調整項目
--Hyperglycemia
--Hyperlipidemia
--Gout or hyperuricemia
--Hyperthyroidism
--Hypothyroidism
--Auto-immune thyroid disease
--Goiter
--Constipation
--BPH
--Anemia, microcytic-->f/u TIBC + Ferrtin next time
--Anemia, macrocytic-->f/u VIT-B12 + Folate next time
--Hepatitis B. C.
  ==>本院3-6個月檢驗一次肝功能，外院6-12個月一次超音波

HbA1c, AC/PC, Cr, GPT, CHOL, LDL, TG, HDL, Na, K, Ca

建議追蹤頻率：  個月
如病人同意，外診藥物可於院內整合。
若外診院所有故定替病人安排檢查，可回診以利安排。

Suggestion:
--Control underline disease as your experience
--Follw-up as your order
--Check HbA1c/AC, GOT/GPT, Cr, CHOL/TG/LDL/TG, Uric acid
  every 3-6 months(可視病人臨床情況調整頻率及項目)
--Check thyroid function every 3-6 months
--Diet control(may consult dietitian for suggestion)
--Activity control