胸腔外科標準病歷範本-POMR

一、【POMR 範本】Corrosive injury of upper gastrointestinal tract

2011/01/11 10:30 AM
S: Epigastric pain improved in the morning.

O: BP: 112/68 mmHg, PR: 82/min

Clear consciousness, afebrile, no dyspneic
Panendoscopy: Erythematous change of esophageal mucosa.
Some shallow gastric ulcer found, grade I.
Abdomen: soft and flat, no tenderness, no rebound tenderness.
No tarry stool passage.

Problem #1: corrosive injury of upper gastrointestinal tract

A: Mild corrosive injury of UGI, improved.

P: Start to try soft diet in the morning

Observation of abdominal tenderness after intake
Decrease IV hydration of intake smoothly
Discharge when the patient could have full amount soft diet
二、【POMR 範本】Esophageal stricture and gastric outlet obstruction
2011/01/11 10:30 AM
S: Diarrhea due to colon prepare.

O: BP: 122/73 mmHg, PR: 62/min

Clear consciousness, afebrile, no dyspneic
Lung function test: normal lung function
Abdomen: soft and flat, no tenderness, no rebound tenderness.

Problem #1: esophageal stricture and gastric outlet obstruction, admission for esophageal
reconstruction surgery
A: esophageal stricture and gastric outlet obstruction, planed to have esophagectomy,
gastrectomy and esophageal reconstruction with supercharged jejunal graft

P: Colon prepare
PPN nutritional support
Consult plastic surgeon for supercharged jejunal graft vessel anastomosis
Inform consent
Patient education about surgery and post operative chest care
三、【POMR 範本】Left 8-9th ribs fracture
2011/01/11 10:30 AM
S: Left chest wall pain, exacerbate when cough
Difficulty of sputum expelling

O: BP: 102/65 mmHg, PR: 92/min

Clear consciousness, afebrile, tachypneic, shallow respiratory pattern
Left chest wall pain(+)
Breath sound: bilateral clear, no decrease
Abdomen: soft and flat, no tenderness, no rebound tenderness.

Problem #1: Left 8-9th ribs fracture

A: Left 8-9th ribs fracture with severe pain, with shallow and rapid respiratory pattern

P: Adjust the analgesic medication for better pain control

Encourage the patient to have pulmonary toilet activity
Educate the patient to use triflo
Monitor respiratory pattern. If respiratory pattern keep worsening, early intubation
for prevention of complication should be considered.
四、【POMR 範本】Right spontaneous tension pneumothorax
2011/01/11 10:30 AM
S: Right chest tube wound pain
The feeling of difficulty of deep breath improved.

O: BP: 112/68 mmHg, PR: 72/min

Clear consciousness, afebrile
Smooth breath pattern
Right chest tube wound pain(+), wound clear, no discharge
Chest tube: pinkish discharge, clear, 50ml, no air leak
Breath sound: bilateral clear, no decrease
Abdomen: soft and flat, no tenderness, no rebound tenderness.

Problem #1: Right spontaneous tension pneumothorax s/p chest tube

A: Right spontaneous tension pneumothorax s/p chest tube with good
drainage function and improvement of pneumothorax symptoms but with
wound pain

P: Adjust the analgesic medication for better pain control

Encourage the patient to have pulmonary toilet activity
Educate the patient to do regular activity and exercise
Educate the patient about importance of smoking cessation
五、【POMR 範本】Spontaneous pneumomediastinum
2011/01/11 10:30 AM
S: Sorethroat and neck pain mild improved
Short of breath improved

O: BP: 110/65 mmHg, PR: 82/min

Clear consciousness, afebrile
Smooth breath pattern
Subcutaneous emphysema over neck: improved, no skin erythema,
palpation pain improved.
Breath sound: bilateral clear, no decrease
Abdomen: soft and flat, no tenderness, no rebound tenderness.
Lab data: WBC:12000/uL, CRP:2.5mg/L.

Problem #1: Spontaneous pneumomediastinum

A: Spontaneous pneumomediastinum with improved pain and dysphagia, no
evidence of esophageal perforation.

P: Start try oral intake

Monitor clinical signs after intake trial
Keep pain relief
Supportive care