Download POMR範本(1)

整形外科標準病歷範本-POMR
一、【POMR 範本】Burn injury
2011/01/11 10:30 AM
S: Wound pain.
O: T/P/R: 36.8/110/22; BP: 130/82 mmHg
Consciousness: Clear
Wound condition: Mild clean serous discharge.
Granulation tissue formation.
:
No surrounding erythema, local heat, or pus discharge.
Wound culture: Nil.
Lab data: WBC: 9200/μL; Hb: 13.8 g/dL; PLT: 228000/μL.
Problem #1: Second to third degree scald burns on the right forearm, left thigh and
abdomen, 4% total body surface area (TBSA) with eschar formation on the right
forearm
A: post debridement on postoperative day (POD) 6. No infection sign; improved
wound condition.
P: 1. To treat wound with Flamazine ointment.
2. To control pain.
3. To arrange STSG for wound reconstruction.
1
二、【POMR 範本】Trauma s/p repair
2011/01/11 10:30 AM
S: Wound pain.
O: T/P/R: 36.7/62/20; BP: 128/76 mmHg.
Consciousness: Clear.
Wound condition: No active bleeding.
No discharge.
No dehiscence.
Silicone tube: Well secured with 6-0 nylon.
Problem #1: Left medial canthus laceration with lacrimal canaliculi rupture
A: Post surgical repair on POD 2. Stable postoperative wound.
P:
1. To treat wound with Garamycin ointment.
2. To control pain.
3. To arrange discharge and outpatient department (OPD) follow-up.
2
三、【POMR 範本】PAOD with infection s/p debridement
2011/01/11 10:30 AM
S: Mild wound pain when wound dressing changed.
O: Cons.: Clear; Temperature: 37℃; Pulse rate: 72/min; Respiratory rate: 18/min.
Wound condition: Well vascularized wound bed with granulation tissue covered;
no bad smell, no discharge
Note that to present wound pictures for reference (建議放傷口照片輔助說明)
Finger stick glucose: at 90/110/98/120 mg/dL.
Lab data: WBC: 5800/μL; CRP: 16.7 mg/L.
Wound culture: S. aureus.
Problem #1: Peripheral arterial occlusive disease in the diabetic foot and with
osteomyelitis in the right foot
A: Post sequestrectomy and debridement on POD 7. Improved wound condition,
ready for wound reconstruction.
P:
1. Diagnostic plan: Nil.
2. Therapeutic plan:
*To arrange wound reconstruction as indicated by the reconstructive ladder.
*To obtain an informed consent.
*To keep current antibiotic treatment and DM control.
3. Educational plan:
*To inform the patient and family of probable post-operative complications
such as bleeding, hematoma, infection or tissue necrosis.
*To do absolute foot hygiene.
Problem #2: Type 2 Diabetes mellitus (DM) with poor control
A: DM with poor control, improved
P:
1. Diagnostic plan: To regularly follow-up finger stick test.
2. Therapeutic plan: Adjust OHA regimen for better DM control
3. Educational plan:
*To remind the patient and family of the necessity of health care and diet
control compliance.
*To regularly follow-up in the endocrinology OPD.
3
四、【POMR 範本】Finger cutting wound s/p repair
2011/01/11 10:30 AM
S: Tolerable cut pain.
O: TPR: 36.8/82/18; BP: 126/78 mmHg.
Consciousness: Clear.
Cut: Clean.
Problem #1: Right index cut with extensor tendon rupture
A: Post tendon repair on POD 2. Wound condition: Good.
P:
1. To keep cut care and symptom relief medication.
2. To shift antibiotic treatment to the oral form.
3. To offer cut care education.
4. To arrange discharge and OPD follow-up.
4
五、【POMR 範本】Finger amputation s/p operation
2011/01/11 10:30 AM
S: Mild wound pain.
O: Consciousness: Clear.
Temperature: 37℃, Pulse rate: 72/min, Respiratory rate: 18/min.
Replant condition:
1) Color: Pink; 2) Turgor: Fine; 3) Capillary refilling time: About 1.5 seconds.
Note that to present wound pictures for reference (建議放傷口照片輔助說明)
Problem #1: Right middle finger total amputation at the distal interphalangeal joint
level
A: Post replantation on POD 2. Stable condition of the replant.
P:
1. Diagnostic plan: Nil.
2. Therapeutic plan:
*Keep current medication for better replant circulation and symptom relief
*Keep the replant stable for avoiding replant motion or contusion.
*Keep the replant warm with the heating lamp.
3. Educational plan:
*Explain to the patient and family probable complications such as bleeding,
delayed replantation failure, infection and replant motion limitation.
*Absolutely avoid drinking and smoking.
5
六、【POMR 範本】Left zygoma tripod fracture
2011/01/11 10:30 AM
S: Tolerable wound pain.
O:
T/P/R:36.3℃/71 beats per minute/14 times per minute; Blood pressure: 133/88
mmHg.
Consciousness: Clear.
Visual function: Normal, no diplopia, blurred vision or limited eyeball range of
motion.
Wound: Clean.
Problem #1: Left zygoma tripod fracture post open reduction internal fixation
A: POD 2. Stable postoperative condition and adequate projection of malar eminence.
P:
1.
2.
3.
4.
Apply medication for symptom relief.
Keep ice packing.
Keep wound care.
Prepare for recent discharge, if uneventfully
6
七、【POMR 範本】Finger fracture s/p fixation
2011/01/11 10:30 AM
S: Wound pain.
O:
T/P/R: 36.2 ℃/71 beats per minute/15 times per minute; Blood pressure: 122/88
mmHg.
Consciousness: Clear.
Wound: Mild blood clot coated; no hematoma or infection sign.
Radiographically left hand: Adequately reduced and fixated.
Problem#1: Left first metacarpal fracture post open reduction internal fixation
A: POD 1. Satisfactory surgical correction; stable postoperative condition.
Plan:
1.
2.
3.
4.
Keep wound care.
Employ empirical antibiotic.
Medications for symptoms relief
Maintain left hand splinting.
7
八、【POMR 範本】Finger cutting wound s/p repair
2011/01/11 10:30 AM
S: Tolerable cut pain.
O: TPR: 36.8/82/18, BP: 126/78 mmHg.
Consciousness: Clear.
Cut: Clean.
Right index radial half numbness: existing.
Problem #1: Right index cut with radial digital nerve injury post nerve repair
A: POD 2. Cut condition: Good.
P:
1. Keep wound care and symptom relief medication.
2. Shift antibiotic treatment to the oral form.
3. Exercise wound care education.
4. Arrange discharge and OPD follow-up.
8
九、【POMR 範本】Lipoma s/p excision
2011/01/11 10:30 AM
S : Tolerable wound pain.
O: TPR: 36.8/ 82/18; BP: 126/78 mmHg.
Consciousness: Clear.
Wound: Clean.
CWV drain: 10 ml; serosanguinous.
Problem #1: Right thigh lipoma post excision
A: POD 3. Stable wound condition.
P:
1. Remove CWV drain.
2. Shift antibiotic treatment to the oral form.
3. Arrange discharge and OPD follow-up.
4. Hold wound care education programs.
9
十、【POMR 範本】Lipoma s/p excision
2011/01/11 10:30 AM
S: Wound pain.
O: T/P/R: 37.3/90/18; BP: 120/75 mmHg.
Consciousness: Clear.
Wound condition:
1. Some necrotic debris with minimal serous discharge.
2. Granulation tissue growth from the wound bed without tendon or bone
exposure.
3. No foul smell.
Wound culture: Vibrio vulnificus.
Lad data: WBC: 9000/μL; Hb: 10.1 g/dL; PLT: 150000/μL; CRP: 10.1 mg/L.
Finger stick glucose levels (whose units were mg/dL): 200 (AC) through 298 (PC)
and158 (at 4 PM) to 265 (at 9 PM)  fluctuated
Problem #1: Necrotizing fasciitis with sepsis post fasciotomy and debridement
A: POD 7. Stable postoperative condition and improved wound condition.
P: 1. Keep using Fortum and Minocin.
2. Keep wound wet dressing q8h and follow-up.
3. Medications for symptoms relief
4. Arrange STSG for wound reconstruction.
Problem #2: DM with blood sugar fluctuated.
A: Unstable blood sugar status
P: 1. Consult endocrinologists for adjusting current insulin dosage.
2. Inform the patient and family of medical compliance importance.
10