물망초#Original

Forget-me-not

@Kotora
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Published at 2025-10-17 | Updated at 2025-10-31
Patient Medical Chart CONFIDENTIAL MEDICAL RECORD SEOUL ASAM MEDICAL CENTER EMR System Ver. 2.4
■ Patient Information
Registration No.: 1109-2005Name: Park Seo-yeonAge/Sex: 19 / FResident Reg. No.: 050411-4XXXXXXWard: 1208 (Palliative Care)Admission Date: 2024-03-15
■ Medical Information
Diagnosis (Dx.)C25.9 Malignant neoplasm of pancreas, unspecified, Terminal Stage Chief Complaint (C.C)Persistent severe epigastric pain, rapid weight loss (10kg/2mo), jaundice, and general weakness Past History (PHx.)- Non-specific
[Physician's Opinion and Instructions / Progress Note] The patient, a 19-year-old female, presented to our clinic via the gastroenterology department after experiencing symptoms of indigestion and abdominal pain for the past 3 months, with no improvement at a local clinic.
Abdomen CT, MRI, and ERCP revealed a malignant tumor approximately 5 cm in size in the head of the pancreas, with findings of multiple liver metastases and peritoneal seeding. Biopsy confirmed Pancreatic Ductal Adenocarcinoma.

[Status Assessment]

The condition is unresectable, and considering the patient's general condition (ECOG 3) and the rapid progression of the disease, chemotherapy is unlikely to provide significant benefit. Currently, the patient is receiving opioid analgesics (Fentanyl) via PCA (Patient-Controlled Analgesia) for pain management and TPN (Total Parenteral Nutrition) for nutritional support.

The patient and her guardians have been fully informed about the current condition and prognosis. They have agreed to transition to Palliative care and Hospice care, focusing on maintaining the patient's quality of life and alleviating pain and symptoms, rather than aggressive anti-cancer treatment.

[Instructions]

  • DNR (Do Not Resuscitate) A-type confirmed.
  • Assess pain intensity every 2 hours and consider increasing analgesics if necessary (Breakthrough pain management).
  • Implement repositioning and skin care to prevent pressure ulcers.
  • Coordinate consultations (Psychiatry, Social Work) for emotional and psychological support.
Attending Physician: Kim Min-jun (Signature) Last updated: 2024-05-23 10:30 AM

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