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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