胃腸科POMR範本
一、【POMR 範本】Diarrhea
2011/01/11 10:30 AM
S: Watery diarrhea improved
O: PR: 90 BPM ; BP: 110/80 mmHg
Normal skin turgor
Abdomen: normoactive bowel sounds, flat abdomen, soft without tenderness
Tympanic percussion
Na: xxx mEq/l K: xxx mEq/l
Problem #1: Diarrhea
A: Diarrhea, improving
P: 1.Keep Kaopectin medication prn if still diarrhea
2.Follow electrolytes included Na and K, and correct it if any imbalance
3.Consider to try light liquid diet if tolerated and educate about enteral nutrition
4.Education about hand-washing to prevent possible infection
二、【POMR 範本】Dysphagia
2011/01/11 10:30 AM
S: Difficulty in swallowing persisted
O: T: ; PR: ; RR: ; BP:
Clear conscious and no specific neurologic change
No oral ulcer or palpable neck mass, but the patient has still difficulty in swallowing even liquid and easy choking
Chest: symmetric expansion, bilateral clear breath sounds
Abdomen: normoactive bowel sounds, flat abdomen, soft without tenderness
Tympanic percussion
Na: xxx mEq/l K: xxx mEq/l
Problem #1: Dysphagia
A: Suspected esophageal cancer, stationary
P: 1.Arrange computed tomography from neck to chest and UGI endoscopy for examination and biopsy
2.Begin parenteral nutritional support if enteral route is not available
3.follow electrolytes included Na and K, and correct if any imbalance
4.Adequate pain control
5.Explain and discuss with the patient and family members about possible need of gastrostomy or jejunostomy for the enteral nutrition; and consult general surgeon for the evaluation and explain risks and benefits
三、【POMR 範本】Ileus
2011/01/11 10:30 AM
S: Abdominal fullness mild improved
O: PR: 90 BPM ; BP: 110/80 mmHg
EKG: Normal sinus rhythm
Flatus(+); Stool passage(+)
Abdomen: normoactive bowel sounds, mild distended abdomen,
soft without tenderness; Tympanic percussion, no shifting dullness
No murphy sign
Na: xxx mEq/l K: xxx mEq/l Ca: xxx mEq/l
KUB: Diffuse ileus of abdomen
Problem #1: Ileus
A: Ileus, improving
P: 1.Arrange abdominal sonography and/or computed tomography
2.Follow electrolytes and correct if any imbalance
3.Keep NG decompression and use of prokinetic agents
4.Education about high fiber diet and adequate exercise
5.Consult GS surgeon, if prolonged ileus with peritoneal sign(+)
四、【POMR 範本】Acute cholecystitis
2011/01/11 10:30 AM
S: RUQ abdominal pain improved, less nausea.
Fever subsided
Started liquid diet this morning.
O: Consciousness: clear
Vital signs: BT 36.6 C; RR: 15 breaths/min
PR: 84 beats/min;BP: 108/64 mm Hg
Breath sounds: clear and equal bilaterally
Heart: RHB, no murmur
Abdomen: non-distended, normoactive bowel sounds:
trivialRUQ tenderness; no Murphy’s sign, guarding or rebound pain.
Lab data: K+ 3.01(12/19) 3.05(12/21)
Problem #1: Acute cholecystitis
A:day 4, improved, food intake started today.
P: 1.Allow ambulation and advance to soft diet today if tolerated
2.Shift to oral antibiotics tomorrow if no further abdominal pain or fever
3.Keep recording I/O and maintaining adequate iv hydration until full diet
4.Pain relief prn
5.Educate patient to avoid high-fat diet intake
Problem #2: Hypokalemia
A: potassium level still inadequate
P: Add 20 meq KCL to every 500 ml of IV fluid
Recheck K+ tomorrow
五、【POMR 範本】Acute pancreatitis
2011/01/11 10:30 AM ( day ? after admission)
S: central/epigastric pain improved, less nausea.
Started liquid diet this morning.
O: Consciousness: clear
Vital signs: BT 36.6 C; RR: 15 breaths/min
PR: 84 beats/min;BP: 108/64 mm Hg
Breath sounds: clear and equal bilaterally
Heart: RHB, no murmur
Abdomen: non-distended, normoactive bowel sounds:
Mild epigastric tenderness, no guarding or rebound pain.
Problem #1: Acute pancreatitis
A:day 4, improved, food intake started today.
P: 1.Allow ambulation and advance to soft diet today if tolerated
2.Abdominal CT prn if abdominal pain worsened or fever occurred
3.Keep recording I/O and maintaining adequate iv hydration until full diet
4.Pain relief prn
5.Educate patient to avoid high-fat diet intake
六、【POMR 範本】Jaundice
2011/01/11 10:30 AM ( day ? after admission)
S: RUQ abdominal pain improved, less nausea.
Fever subsided, no chills today
Started liquid diet this morning.
O: Consciousness: clear
Vital signs: BT 36.6 C; RR: 15 breaths/min
PR: 84 beats/min;BP: 108/64 mm Hg
Sclera: anicteric
Breath sounds: clear and equal bilaterally
Heart: RHB, no murmur
Abdomen: non-distended, normoactive bowel sounds:
trivial RUQ tenderness; no Murphy’s sign, guarding or rebound pain. PTCD: 30 ml (wound clean, no redness or discharge)
Lab data: K+ 3.01(12/19) 3.05(12/21)
Bilirubin total 3.5(12/19) 1.1(12/21)
Problem #1: Acute cholangitis
A:day 4, improved, anicteric sclera, food intake started today.
P: 1.Allow ambulation and advance to soft diet today if tolerated
2.Arrange ERCP tomorrow for CBD stone removal.
3.Shift to oral antibiotics tomorrow if no further abdominal pain or fever
4.Keep recording PTCD&I/O and maintaining adequate iv hydration until full diet
5.Pain relief prn
#2. Hypokalemia
A: potassium level still inadequate
P: Add 20 meq KCL to every 500 ml of IV fluid
Recheck K+ tomorrow
七、【POMR 範本】Cirrhosis
2011/01/11 10:30 AM ( day ? after admission)
S: abdominal fullness for ? days
O: Consciousness: clear/ alert/ irritable/ drowsy/ coma , E?V?M?
Vital signs: BT ?C; RR: ? breaths/min
PR: ? beats/min;BP: ?/? mm Hg
Breath sounds: clear/ rales(pleural effusion?) bilateral or unilateral?
Heart: RHB, no murmur
Abdomen: distended, hyperactive bowel sounds, whole abdominal tenderness
Shifting dullness. No palpable mass, no guarding or rebound pain.
Abdominal sonography:
PES:
AFP: Albumin: PT: Ammonia: Bil. T:
Problem #1:
#1. Cirrhosis child ? (score: )
A:massive ascites with jaundice under lasix + aldacton use, disease wosening
P: 1. Keep diuretic use + Alubumin or FFP supply
2. correct coagulopathy
3. If advanced stage, discuss hospice care to patient and family
4. consider EVL for prevent variceal bleeding
5. consult dietician for nutrition support
6. Inderal use for portal hypertension.
7. keep I/O balance
8. ascites tapping if diuretic is insufficient.
八、【POMR 範本】Colon cancer
2011/01/11 10:30 AM ( day ? after admission)
S: consipation for ? days
O: Consciousness: clear, E?V?M?
Vital signs: BT ?C; RR: ? breaths/min
PR: ? beats/min;BP: ?/? mm Hg
Breath sounds: clear and equal bilaterally
Heart: RHB, no murmur
Abdomen: distended, hyperactive bowel sounds, whole abdominal tenderness
No palpable mass, no guarding or rebound pain.
KUB:
Abdominal sonography:
Abdominal CT:
Colonoscopy
CEA: Albumin:
Problem #1: Colon cancer, still staging
A:constipation and ileus, suspect tumor obstruction, disease wosening
P: 1.Consult GS for relief of obstruction, consider colonostomy
2.Consult oncologist for CCRT or chemotherapy
3.If advanced stage, discuss hospice care to patient and family
4.NPO if complete obstruction and adequate nutrition support.
5.Explain the staging result with the patient and family
九、【POMR 範本】Hepatoma
2011/01/11 10:30 AM ( day ? after admission)
S: poor appetite
O: Consciousness: clear, E?V?M?
Vital signs: BT ?C; RR: ? breaths/min
PR: ? beats/min;BP: ?/? mm Hg
Breath sounds: clear and equal bilaterally
Heart: RHB, no murmur
Abdomen: non-distended, normoactive bowel sounds:
No palpable mass, no guarding or rebound pain.
Abdominal sonography:
Abdominal CT:
AFP: PT: Albumin: Bil. T.:
Problem #1: Hepatoma
A:no abominal pain, no jaundice, BCLC ?, Child score ? still poor appetite
P: 1.Consult GS if resection is indicated, or RFA/PEI if BCLC (A)
2.If not resection, consider TACE if BCLC (B)
3.If advanced stage, discuss hospice care to patient and family
4.Consult dietician for nutrition support.
5.Sympatic treatments for his multiple discomforts
十、【POMR 範本】Variceal bleeding or UGI bleeding
2011/01/11 10:30 AM
S: Bloody vomitus / hematemesis for (duration)
O: Conciousness – clear / drowsy / loss
Vital signs – T/P/R – ? SpO2 – ?
Conjunctiva – pale/pink
Skin – cool/warm/dry/moist
Chest – rales/wheezing
Abdomen – soft/rigidity/flat/distended
Normo/hypo/hyperactive bowel sounds.
Tymphanic/dull/hyperesonance
Tenderness/No tenderness/Rebound tenderness
Bloody vomitus amount – ( ) ml
Problem #1: Upper gastrointestinal bleeding
Assessment– Variceal (EV or GV) bleeding or active peptic ulcer bleeding
Plan
-Fluid resuscitation with normal saline and blood products transfusion
-Check hemoglobin, platelet and coagulation profile
-Arrange upper GI endoscopy with intervention
-NG tube insertion for adequate drainage
-Airway protection if massive bleeding or consciousness loss
-Transfer to ICU if massive bleeding.
十一、【POMR 範本】LGI bleeding
2011/01/11 10:30 AM
S: Bloody stool passage / melena / brick stool passage for (duration)
O: Conciousness – clear/drowsy/loss
Vital signs – T/P/R – ? SpO2 – ?
Conjunctiva – pale/pink
Skin – cool/warm/dry/moist
Abdomen – soft/rigidity/flat/distended
Normo/hypo/hyperactive bowel sounds.
Tymphanic/dull/hyperesonance
Tenderness/No tenderness/Rebound tenderness
DRE– blood-stained glove / external hemorrhoids noted
Bloody stool passage amount – ( ) ml
Problem #1: Low gastrointestinal bleeding
Assessment – Low gastrointestinal bleeding,
suspected colon tumor / rectal tumor / hemorrhoidal bleeding
Plan
-Fluid resuscitation with normal saline and blood products transfusion
-Check hemoglobin, platelet level and coagulation profile
-Colon preparation and arrange colonoscopy
-Consult general surgeon for evaluation.
-Arrange TAE if massive bleeding despite endoscopic therapy.