Download 皮膚科標準病歷範本-POMR

皮膚科標準病歷範本-POMR
一、【POMR 範本】Herpes zoster
2011/01/11 10:30 AM
S: Pain over inguinal area
Difficulty of urination, and decreased urine output
O: T/P/R: 36.2/80/18, BP: 130/85
Cutaneous findings: Multiple grouped, pin-head to bean-sized vesicles over left major labia
and buttock. No new vesicles were noted.
Problem #1: Herpes zoster, left S2 area with urinary retention
A: Herpes zoster, left S2 area with urinary retention under control
P: 1.Keep acyclovir ivd treatment for at least 5 days.
2.Pain control.
3.Keep immunosuppressant medication.
Problem #2: End stage renal disease status post renal transplantation
A: End stage renal disease status post renal transplantationstationary
P: 1.Record I/O QD.
2.Keep H/D on maintenance
二、【POMR 範本】Cellulitis
2011/01/11 10:30 AM
S: Painful nodules over cheeks and nape. No fever.
O: T/P/R: 36.0/80/18, BP: 115/65
Cutaneous findings: Two painful erythematous nodules (about 5*5cm in sized) on bilateral
neck and several erythematous pinhead-sized papules over face. No new lesion was noted.
Problem #1: Dissecting cellulitis, bilateral cheeks and nape
A: Dissecting cellulitis, bilateral cheeks and nape,  under control with Minocycline iv Day 2,
improving
P: 1.Keep current antibiotics use.
2.Apply for the use of Roaccutane 1# BID for six months.
三、【POMR 範本】Cellulitis with bacteremia
2011/01/11 10:30 AM
S: No fever for 2 days.
Itching over the whole body persisted.
A painful nodule over right palm.
Swelling of bilateral lower legs, especially left leg
O: T/P/R: 36.6/80/18, BP: 145/75
Cutaneous findings: Multiple erythematous itchy plaques with excoriation over bilateral
extremities and back. Swelling over left lower leg and sole with fissures, local heat, and
erythema. An erythematous nodule on the right palm.
Fever work-up: leukocytosis (WBC 14000), CRP 60
CXR: clear, no pneumonia patch
U/A: clear. B/C*2: CONS*2
Wound culture over left leg and pus on right palm nodule: pending
Problem #1: Bacteremia, left leg cellulitis and right hand abscess related
A: Bacteremia, left leg cellulitis and right hand abscess related
Under antibiotics control, no progression
P: 1.Keep current antibiotics
2.Pending for the results of wound and pus culture
Problem #2: Generalized eczema
A: Generalized eczema  under control
P: 1.Solu-cortef 100mg QD was discontinued due to infection.
2.Keep Zyrtec 1# HS and Incidal 1# TID use
3.Topsym cream BID topical use, except left lower leg.
4.Gentamicin BID topical use on sole fissures.
5.Watch out possible new infection
四、【POMR 範本】Hailey-Hailey disease
2011/01/11 10:30 AM
S: Still painful over axillary and inguinal area. No fever.
O: T/P/R: 36.2/80/18, BP: 130/85
Cutaneous findings: Large areas of erythematous hypertrophic and ulcerative patches
with pus discharge and rhagades over bilateral axillary and inguinal area. Mild
improvement was noted compared to the condition at admission.
Problem #1: Hailey-Hailey disease with secondary infection and chronic ulcers
A: Hailey-Hailey disease with secondary infection and chronic ulcers Mild improvement
P: 1.Low energy laser (660nm) QD prior to wound care.
2.Uburn topical use for the wound.
3.Keep Cefa for secondary infection.
五、【POMR 範本】Bullous drug eruption
2011/01/11 10:30 AM
S: No new bulla or vesicle was noted. Mild itchy over bilateral legs.
O: T/P/R: 36.2/80/18, BP: 130/85
Cutaneous findings: Multiple bullae over four limbs and left anterior chest wall. The bullae
became smaller and dry after admission. NO new skin lesion was noted.
Problem #1: Bullous drug eruption, r/o bullous pemphigoid
A: Bullous drug eruption, r/o bullous pemphigoid, active
P: 1.Keep Solu-cortef 100mg Q12H.
2.PP solution soaking for 15 mins, and then use Uburn on the large bullae BID.
3.Add antihistamine for skin itch.
4.Pending for the pathology report
5.Watch out possible new infection