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: 130/82mmHg

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.

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.

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 thereconstructive ladder.

*To obtain an informed consent.

*To keep current antibiotic treatment and DM control.

  1. 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.

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.

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 replantmotion or contusion.

*Keep the replant warm withthe heating lamp.

  1. 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.

六、【POMR 範本】Left zygoma tripod fracture

2011/01/11 10:30 AM

S:Tolerable wound pain.

O:

T/P/R:36.3℃/71beats per minute/14times 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. Apply medication for symptom relief.
  2. Keep ice packing.
  3. Keep wound care.
  4. Prepare for recent discharge, if uneventfully

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. Keep wound care.
  2. Employ empirical antibiotic.
  3. Medications for symptoms relief
  4. Maintain left hand splinting.

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.

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.

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.

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