泌尿科標準病歷範本-POMR
一、【POMR 範本】BPH
2011/01/11 10:30 AM
S：Nocturia two times every night
O：DRE: Moderate prostate enlargement ; No hard nodule
Hesitancy,small caliber of u-stream,terminal dribbling,
nocturia:3/night for 6 month. IPSS:20'
Problem #1: BPH
A：Prostate enlargement with moderate lower urinary tract symptom, active
P：Arrange the TRUS echo
PSA and DRE
Uroflowmetry (CMG)
二、【POMR 範本】Renal stone
2011/01/11 10:30 AM
S：Rt flank dull pain and hematuria for 2 days
O：PE:Knocking tenderness over Right CV angle.KUB: Right ureteral stone
Problem #1: Renal stone
A：Right renal stone with hematuria, active
P：Check serum BUN/ creatinine
Arrange IVP and renal echo
三、【POMR 範本】Prostate Ca
2011/01/11 10:30 AM
S: Hesitancy,small caliber of u-stream,terminal dribbling
O：Echo: Enlarged prostate, 80 Gm. No hydronephrosis,
DRE: Hard nodule at left lobe of prostate
PSA, F/T: 1.6/9.47/ Recheck PSA
DRE: prostate 3x3 cm, firm, hard nodularity(+)
Problem #1: Prostate Ca
A: Suspected Prostate Ca, active
P: Arrange the TRUS Biopsy
Colon preparation with Glycerin enema
Follow up PSA and DRE
四、【POMR 範本】RCC
2011/01/11 10:30 AM
S：Right flank dullness pain for one months
O：Right flank dullness pain without hematuria
Body weight loss (+) poor appetite (+) Fever (-)
KUB: no obvious occupy lesion or impacted stone
Echo : Right burging mass with heterogenic component suspected RCC
Problem #1: RCC
A：Right renal tumor suspected RCC, active
P：Arrange CT for further staging
Pain control
Adequate IV hydration and admitted for further pre-op preparation
五、【POMR 範本】TCC
2011/01/11 10:30 AM
S：Painless gross hematuria for weeks
O：No flank dullness pain;
Painless gross hematuria (+)
Body weight loss (+) Poor appetite (+) Fever (-)
KUB: no obvious occupy lesion or impacted stone
Echo: Right hydronephrosis with blood clot obstruction
Problem #1: TCC
A：Suspected Right renal pelvis TCC with blood clot obstruction, active
P：Arrange CT for further staging
Adequate IV hydration and admitted for further pre-op preparation
Diagnostic URS for tissue proof
Inform patient the need for operation if malignancy was confirm
六、【POMR 範本】Bladder stone
2011/01/11 10:30 AM
S：Hematuria with irrigative symptom for two days
O：Hematuria (+) with urinary frequency; LUTS(+)
KUB: A 2x3cm urinary bladder stone
Echo: No bilateral hydropnephrosis
Problem #1: Bladder stone
A：Bladder stone with obstructive and irrigative symptom, active
P：Pain control
IV Hydration and arrange cystolithotripsy for treatment
七、【POMR 範本】Inguinal hernia
2011/01/11 10:30 AM
S：Right inguinal area burging mass with pain
O：PE:
Right inguinal area bulging mass, reducible
No hydrocele
No hematuria and no right flank pain
Problem #1: Inguinal hernia, right
A：Right inguinal hernia suspectedindirect type, active
P：Pain control
Arrange the herniarrphy for treatment