胸腔內科標準病歷範本-POMR
一、【POMR 範本】COPD withacuteexacerbation
2011/01/11 10:30 AM
S:Breathlessness, chest tightness
O: T/P/R: 36.5C/132/36, BP:165/88mmHg
Consciousness: clear, GCS:E4V5M6
Breath sound: bilateral expiratory wheezing
Heart sound: tachycardia, no murmur
Abdomen: active of bowel sound, soft, no tenderness
Lower leg: mild pitting edema, bilateral
ABG: PH: 7.35, PO2: 120mmH2O, PCO2: 68mmH2O, HCO3: 18mmol/L, FiO2:50%
Problem #1: Chronic obstructive pulmonary disease with acute exacerbation.
A:Dyspnea episode with CO2 retention, consciousness clear but disorientated to
person, people and place intermitent. Poor responsive treatment to O2 supply with V-mask, bronchodilator and steroid using. Impending respiratory failure was noted.
P: Diagnostic plan:
*Follow up CXR, BNP, cardiac enzyme and echo, ammonia, electrolytes, blood sugar.
Therapeutic plan:
*Intubation if patient and family agree
*On BiPAP if patient andfamily disagree with intubation immediately.
*Adjust dosage of bronchodilator and steroid.
Educational plan:
*Inform critical condition and explain to patient and family aboutintubation was needed. *Compare the advantage and disadvantage between the decision of on BiPAP and intubation.
二、【POMR 範本】COPDwithsecondaryinfection.
2011/01/11 10:30 AM
S:Fever and intermittent short of breathe episode
O: T/P/R: 38.5C/98/22, BP:145/78mmHg
Consciousness: clear, GCS:E4V5M6
Breath sound: bilateral expiratory wheezing and inspiratory coarse crackles.
Heart sound: tachycardia, no murmur
Abdomen: active of bowel sound, soft, no tenderness
Lower leg: no pitting edema
ABG: PH: 7.38, PO2: 150mmH2O, PCO2: 48mmH2O, HCO3: 18mmol/L, FiO2:35%
WBC: 22000, Hb: 10mg/dl, PLT: 230000, Segment: 88%
CXR: bilateral mild alveolar infiltration at lower lobe of lung
Problem #1: Chronic obstructive pulmonary disease with secondary infection.
A:Fever up to BT 39C and partial relieved by panadol and antibiotic treatment
with Zinacef, laboratory data reveal leukocytosis with left shift. Mild improving of
bronchospasm condition after O2 supply with bronchodilator and IV steroid were given.
P: Diagnostic plan:
*Infection work up including sputum gram stain and culture, blood culture.
Therapeutic plan:
*Consider change antibiotics if fever persisting and consult ID.
*Adjust dosage of bronchodilator and IV steroid.
Educational plan:
*Inform infection status and mask wearing education.
三、【POMR 範本】Adenocarcinomaoflung,leftupperlobe
2011/01/11 10:30 AM
S: General malaise
O: T/P/R: 36.3C/82/18, BP:135/76mmHg
Consciousness: clear, GCS:E4V5M6
Breath sound: left upper fine crackles
Heart sound: regular, no murmur
Abdomen: active of bowel sound, soft, no tenderness
Lower leg: no lower leg pitting edema
WBC: 18000, Hb: 11mg/dl, PLT: 230000, Segment: 68%
Exon 19 deletions: negative, L858R point mutation in exon 21: negative
Problem #1: Adenocarcinoma of lung, left upper lobe, T3N3M0, stage IIIB.
A: Leukocytosis without left shift, no fever, no productive cough, favor due to leukemoid
reaction.
P: Diagnostic plan:
*Follow up sputum gram stain, culture and acid fast stain.
Therapeutic plan:
*On going Platinum plus Gemcitabine chemotherapy.
Educational plan:
*Inform post chemotherapy complication including risk of latent infection and others reaction
as nausea and vomiting.
四、【POMR 範本】Solitarypulmonarynodule,rightupperlobeoflung.
2011/01/11 10:30 AM
S: Intermittent dry cough
O: T/P/R: 36.5C/82/18, BP:135/68mmHg
Consciousness: clear, GCS:E4V5M6
Breath sound: bilateral clear
Heart sound: regular, no murmur
Abdomen: active of bowel sound, soft, no tenderness
Lower leg: bilateral no pitting edema
WBC: 9800, Hb: 12mg/dl, PLT: 260000, Segment: 64%
Problem #1: Solitary pulmonary nodule, right upper lobe of lung.
A:Solitary pulmonary nodule, right upper lobe of lung. Size less than 1cm but ground
class opacity, patient age 65 ==> high probability of malignancy.
P: Diagnostic plan:
*Chest CT C(+/-), brain CT (+/-), bone scan, tumor marker, sputum cytology.
Therapeutic plan:
*Pending the result of diagnosis plan. Symptomatic treatment.
Educational plan:
*Explain the complication of contrast CT
五、【POMR 範本】Pulmonarytuberculosis,active.
2011/01/11 10:30 AM
S: Productive cough and mild fever
O: T/P/R: 37.3C/86/18, BP:135/78mmHg
Consciousness: clear, GCS:E4V5M6
Breath sound: bilateral upper rhonchii
Heart sound: regular, no murmur
Abdomen: active of bowel sound, soft, no tenderness
Lower leg: bilateral no pitting edema
WBC: 16800, Hb: 11mg/dl, PLT: 190000, Segment: 74%, AFS (+++)
CXR: bilateral upper interstitial infiltration with fibrotic change, right upper partial
destructive change
Problem #1: Pulmonary tuberculosis, active.
A: AFS positive, CXR film and clinical presentations compatible with the diagnosis of active pulmonary tuberculosis.
P: Diagnostic plan:
*Sputum culture, TB PCR.
Therapeutic plan:
*Isolation, inform CDC, on anti-TB agents therapy.
Educational plan:
*Both patient and family mask wearing.
六、【POMR 範本】Community-acquiredpneumonia(CAP).
2011/01/11 10:30 AM
S:Fever episode with productive cough, short of breath
O: T/P/R: 38.7C/116/32, BP:132/75mmHg
Consciousness: clear, GCS:E4V5M6
Breath sound: bilateral lower coarse crackles
Heart sound: tachycardia, no murmur
Abdomen: active of bowel sound, soft, no tenderness
Lower leg: bilateral no pitting edema
WBC: 19800, Hb: 11mg/dl, PLT: 230000, Segment: 84%, Bun/Cr: 16/2mg/L
CXR: bilateral lower lobe of lung alveolar infiltration
Problem #1: Community-acquired pneumonia (CAP).
A: high age of 75 years old, dyspnea with RR>30, Cr>2 ==> indicated for hospitalization.
No rhinorrhea, no bone pain of common cold illness. Dyspnea episode, caution for acute
respiratory failure or ARDS developed.
P: Diagnostic plan
*Sputum gram stain, culture, AFS; mycoplasma, legionella and chlamydia Ab follow up.
Therapeutic plan:
*Moxifloxacin 400mg qd ivd, O2 supply, symptomatic treatment
Educational plan:
*Mask wearing, explain possibility of respiratory failure or ARDS change.
七、【POMR 範本】Healthcare-associatedpneumonia(HCAP)
2011/01/11 10:30 AM
S:Fever episode with productive cough, short of breath
O: T/P/R: 38.7C/116/32, BP:132/75mmHg
Consciousness: clear, GCS:E4VtM6
Breath sound: bilateral lower coarse crackles
Heart sound: tachycardia, no murmur
Abdomen: active of bowel sound, soft, no tenderness
Lower leg: bilateral no pitting edema
WBC: 21600, Hb: 10.8mg/dl, PLT: 260000, Segment: 86%, Bun/Cr: 18/1.4mg/L
CXR: bilateral lower lobe of lung consolidation change
Problem #1: Healthcare-associated pneumonia (HCAP)
A: Old CVA and bed ridden, poor self cough, febrile status.
P: Diagnostic plan:
*Sputum gram stain, culture, blood culture, ABG follow up.
Therapeutic plan:
*Tazocin 4.5g qd6h ivd, O2 supply with T-mask using, symptomatictreatment, intensive chest care including sputum suction.
Education plan:
*Explain possibility of respiratory failure change.
八、【POMR 範本】Bronchiectasis
2011/01/11 10:30 AM
S: Bloody sputum
O: T/P/R: 36.5C/72/18, BP:145/88mmHg
Consciousness: clear, GCS:E4V5M6
Breath sound: bilateral lower lung coarse crackles
Heart sound: regular, no murmur
Abdomen: active of bowel sound, soft, no tenderness
Lower leg: bilateral no pitting edema
WBC: 8600, Hb: 9.8mg/dl, Hct: 29.5, PLT: 240000, Segment: 66%
CXR: bilateral lower lobe of lung consolidation change
Problem #1: Bronchiectasis
A: Productive cough with hemoptysis, amount about 60cc/day. Anemia, may due to chronic disease.
P: Diagnosticplan:
*Chest CT, bronchoscopy as needed.
Therapeutic plan:
*Antibiotics and symptomatic treatment, add transamine for themoptysis.
Educational plan:
*Explain risk of massive hemoptysis, may emergency intubation as needed. Quit cigarette smoking.
九、【POMR 範本】Cylindricalbronchiectasis
2011/01/11 10:30 AM
S: Short of breath episode and productive cough
O: T/P/R: 36.5C/82/18, BP:135/78mmHg
Consciousness: clear, GCS:E4V5M6
Breath sound: bilateral fine crackles
Heart sound: regular, no murmur
Abdomen: active of bowel sound, soft, no tenderness
Lower leg: bilateral no pitting edema
WBC: 9600, Hb: 10.8mg/dl, PLT: 230000, Segment: 76%
HRCT: Airway dilatation, luminal airway diameter more than 1.5 times the adjacent
vessel is indicative of cylindrical bronchiectasis. Bronchial wall thickening observed
in dilated airways and contain mucopurulent plugs or debris accompanied by post- obstructive air trapping.
Problem #1: Cylindrical bronchiectasis
A:High resolution computed tomography (HRCT) of the chest has become the defining
test of bronchiectasis, her clinical symptoms was compatible with the prevalence of
bronchiectasis of cough (98 percent of patients), daily sputum production (78 percent),
dyspnea (62 percent). Dyspnea episode was responsive with O2 supply and medication
treatment but any impairment due to bronchiectais was unknown.
P: Diagnostic plan:
*Pulmonary function testing for functional assessment of impairment due to bronchiectasis.
Therapeutic plan:
*O2 supply, keep antibiotic of zinacef treatment for 5 days using, chest care.
Educational plan:
*Inform patients with bronchiectasis may have a mean annual decline in FEV1 of 50 to 55mL per year.
十、【POMR 範本】Rightpleuraleffusion
2011/01/11 10:30 AM
S:Right chest pain and fever episode
O: T/P/R: 38.4C/102/18, BP:145/90mmHg
Consciousness: clear, GCS:E4V5M6
Breath sound: right lower decrease
Heart sound: tachycardia, no murmur
Abdomen: active of bowel sound, soft, no tenderness
Lower leg: bilateral no pitting edema
WBC: 18200, Hb: 13mg/dl, PLT: 340000, Segment: 89%, Bun/Cr: 16/1.2mg/L
CXR: right lower lobe of lung opacities with blunting of costal angle
Problem #1: Right pleural effusion
A:Fever episode with right pleural effusion, no cardiamegaly, no common cold symptoms, uncomplicated heart failure and viral pleurisy was not likely, favor exudative pleural effusion.
P: Diagnostic plan:
*Arrange chest echo and thoracentesis for pleural fluid study.
Therapeutic plan:
*Antibiotics treatment, consider on pigtail drainage as needed.
Education plan:
*Explain to patient and family about risk and complication of thoracentesis.