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成長門診病歷系統 EMR　BY 許鈺敏醫師

極速勾選 · 病歷分區 · 套組展開 · 智慧衛教 V14

雲端看診碼:

1. 生長數據 (自動計算)

性別

年齡(歲/月)

Ht(cm)

Wt(kg)

HC(cm)

2. 過去病史 & 家族史 ▼

GA (wk+d)

Delivery

Twin

BBW (g)

BBL (cm)

IUGR

___

hypoglycemia

___

Father Ht

Mother Ht

M. Menarche (y)

F. CDGP

___

F. rapid growth at y/o

anemia

___

Thyroid

___

Chronic Hx

3. 臨床紀錄 (CC, PE, DDx, Plan)

主訴 (CC) (選填區輸入自動打勾)

short stature since y/o poor growth poor weight gain for breast dev. for menarche suspected since delayed puberty rapid Ht/Wt gain for consultation referred by LMD/school

Other:

理學檢查 (PE)

G PH TV ml

axillary hair

___

arm spancm

limbs discrepancy

___

鑑別診斷 (DDx)

診斷標籤

CPP EFP FSS FTT CDGP ISS Obesity Metabolic syndrome Turner CAH SGA Hypothyroidism PCOS Graves DSD

臨床印象快速句

Early puberty, be ware of EFP FTT, to r/o nutritional or endocrinological cause Obesity, be ware of metabolic syndrome

Other:

處置與計畫 (Plan)

套組快選點選後展開全項目，再取消不需要的

LAB ITEMS（勾選後輸出）

CBC/DC ESR/CRP Ferritin CMP Ca/P/ALP Albumin AST/ALT Lipid profile Uric acid Cr/eGFR Electrolytes CK AC sugar HbA1c Insulin C-peptide Ketones TSH/FT4 T3/FT3 TSI/TRAb Anti-TPO/Tg Ab LH/FSH E2 Testosterone DHEA-S 17-OHP Androstenedione SHBG Prolactin β-hCG AFP IGF-1 IGFBP-3 Cortisol ACTH Aldosterone Renin AMH Inhibin B 25-OH Vit D PTH FGF23 Karyotype Islet Ab (GAD65/IA-2/ZnT8) UACR UA VBG Stool/urine routine Urine Osm/SpGr Pregnancy test

Other Lab:

Image: BA brain MRI abdomen echo pelvic echo thyroid US renal US Echo ECG wrist X-ray

Tx: Leu 1M Leu 3M Dip 1M Dip 3M Eligard 6M

Refer: Dietician Uro OPD GYN OPD Cardiology Hearing referral

Edu:

SGA: metabolic risks EFP: advanced BA, monitor GV CPP: check BA & suppression @ 6M ISS: monitor GV; GH test if <4cm/yr Obesity: lifetime cardiometabolic risk Normal puberty: sleep early, exercise; f/u 3-6M Hashimoto: be aware of thyroid storm signs

F/U: RTC on

病歷預覽 (系統已自動分區)

🗣️ 主訴 (CC)

📝 病史 (History)

🔍 理學檢查 + DDx (PE / Objective)

💊 處置與計畫 (Plan)

🤒 急性病快速病歷

病名快選

URI

Pharyngitis

AGE

Bronchitis

UTI

病程

症狀持續天

Subjective 症狀

Objective PE

S — Subjective

O — Objective

P — Plan

成長門診病歷系統 EMR BY 許鈺敏醫師

1. 生長數據 (自動計算)

2. 過去病史 & 家族史 ▼

3. 臨床紀錄 (CC, PE, DDx, Plan)

🤒 急性病快速病歷

成長門診病歷系統 EMR　BY 許鈺敏醫師