小兒外科標準病歷範本-POMR
一、【POMR 範本】Postoperative fever
2011/01/11 10:30 AM
S: Fever
O:BT 39.5°C, BP 106/70 mmHg, HR 120/min, RR 15/min
U/O: 150 ml/8hr
Throat: not injected, Chest: BS clear
Abdomen: distended and tympanic, bowel sound hypoactive
wound clear, no erythema, no discharge; drain: yellowish, scanty
Problem #1: Ruptured appendicitis s/p appendectomy
A: Ruptured appendicitis with peritonitis s/p appendectomy, post-op day 2,
suspect residual peritonitis or sepsis, active
P: Blood culture(aerobic + anaerobic).
Follow-up CBC + CRP.
Keep present antibiotics(Cefazolin 1g Q8H + Gentamycin 80 mg Q8H).
Voltaren supp(12.5 mg) st.
二、【POMR 範本】Postoperative vomiting
2011/01/11 10:30 AM
S: Severe bilous vomiting
O: BT 36.5°C, BP 106/70 mmHg, HR 120/min, RR 15/min
Abdomen: distended and tympanic, bowel sound hypoactive
wound clear, no erythema, no discharge
Problem #1: Ileocolic intussusception s/p laparotomy
A: Ileocolic intussusception s/p laparotomy and reduction, post-op day 1,
Suspect postop paralytic ileus or recurrence of intussusception, active
P: Abdominal X-ray and echo.
Insert NG tube for decompression.
Menthal packing.
Primperan 1/2 amp iv push st and q8H.
三、【POMR 範本】Postoperative oliguria
2011/01/11 10:30 AM
S: Decreased urine output(100 ml/8H) from Foley
O: BT 36.5°C, BP 106/70 mmHg, HR 100/min, RR 18/min
Chest: BS clear
Abdomen: soft and flat, bowel sound hypoactive, no bladder distension
wound clear, no erythema, no discharge
Urine: pink without blood clot in Foley or bag
Problem #1: Bilateral VU reflux s/p ureteroneocystostomy
A: Bilateral VU reflux s/p ureteroneocystostomy, post-op day 2,
Suspect bilateral UVJ obstruction due to post-op swelling(post-renal failure), active
P: Record I/O and keep I/O balance.
Check serum Bun/creatinine, albumin, Na, K, Cl.
Lasix 20 mg iv push.
四、【POMR 範本】Postoperative foley obstruction
2011/01/11 10:30 AM
S: Decreased urine output(50 ml/8H) from foley and irritable crying
O: BT 36.5°C, BP 96/60 mmHg, HR 150/min, RR 30/min
Abdomen: soft, bowel sound hypoactive, bladder distension(+)
wound clear, no erythema, no discharge
Urine: bloody with blood clot in foley and bag
Problem #1: Right VU reflux s/p ureteroneocystostomy
A: Right VU reflux s/p ureteroneocystostomy, post-op day 4,
Obstruction of foley by blood clot, suspect bladder temponade, active
P: Bladder echo to identify urine retention or bladder temponade.
Foley irrigation.
Consider change of foley in case of persistent obstruction.
五、【POMR 範本】Wound infection
2011/01/11 10:30 AM
S: red swelling with pus discharge from the wound
O: BT 36.5°C
Abdomen: soft and flat, BS normoactive
Wound: erythematue with purulent discharge from lateral portion
Drain: yellowish, scanty
Problem #1: Ruptured appendicitis s/p appendectomy
A: Ruptured appendicitis s/p appendectomy, post-op day 5, wound infection, active
P: Insertion drainage of wound.
Keep oral antibiotics(Keflex 2# Qid).
六、【POMR 範本】Acute urine retention
S: No urine output for 12 hour and irritable crying
O: BT 36.5°C, BP 96/60 mmHg, HR 150/min, RR 30/min
Abdomen: bladder distension with tenderness, BS normoactive
Scrotal wound: clear, mild swelling
Problem #1: Bilateral inguinal hernia s/p herniorrhaphy
A: Bilateral inguinal hernia s/p herniorrhaphy, post-op day 2.
Oliguria due to acute urine retention, active
P: Single catheterization.
Keep analgesics(Panadol syrup 5 ml Qid).
七、【POMR 範本】Postoperative wound bleeding
S: Fresh blood from penile wound just now
O: BT 36°C, BP 96/60 mmHg, HR 120/min, RR 28/min
Penile wound: active bleeding from 5 o’clock position of circumcision wound, mild ecchymosis and swelling of prepuce at 3~8 o’clock
Problem #1: Paraphimosis s/p circumcision
A: Paraphimosis s/p circumcision today, wound bleeding, active
P: Circumferential compression of penile wound with Bosmin gauge.
八、【POMR 範本】Neonatal jaundice
S: Severe jaundice(mocrobilirubin 18 mg/dL)
O: BT 37°C, BP 90/58 mmHg, HR 120/min, RR 32/min
Generalized icterus
Activity: good, skin: not dry
Abdomen: soft and flat, anal wound clear
Stool: yellow muddy
Problem #1: Imperforate anus, high type s/p sigmoid colostomy
A: Imperforate anus, high type s/p sigmoid colostomy, post-op day 3, physiological jaundice, stationary
P: Adequate hydration.
Start phototherapy.
九、【POMR 範本】Loss of drain
S: Loss of abdominal drain
O: BT 37°C
Abdomen: soft and flat, BS normoactive
wound clear
drain hole: scanty yellowish discharge
Problem #1: Hirschsprung’s disease s/p Duhamel’s procedure
A: Hirschsprung’s disease s/p Duhamel’s procedure, post-op day 6, loss of abdominal drain, stationary
P: Keep close observation.
Close monitoring of vital signs
十、【POMR 範本】Prolapse of colostomy
S: Protrusion of bowel from colostoma
O: Abdomen: soft and flat, BS normoactive
Colostoma: long-segment prolapse about 15 cm long with pink mucosa
Problem #1: Imperforate anus, high type s/p posterior sagittal anorectoplasty
A: Imperforate anus, high type s/p posterior sagittal anorectoplasty, post-op day 10, prolapsed of sigmoid colostomy, stationary
P: Manual reduction of prolapsed colostomy.
Keep close observation of abdominal condition.