感染科標準病歷範本-POMR
一、
【POMR 範本】Dengue fever
2011/01/11 10:30 AM
S: Skin rash
O:
Body temperature was 37.5 degrees of Celsius
BP was 112/60mm Hg; PR 100/min
Clear consciousness
Rash over four limbs and trunk, stationary in number.
Problem #1: Dengue fever
A: Dengue fever, without hemorrhagic complication, improving
P: Stay in mosquito net.
Continue antipyretic therapy with acetaminophen.
二、
【POMR 範本】Meningoencephalitis
2011/01/11 10:30 AM
S: Headache
O: GCS was E4V4M4; arousible.
Can open eyes to sound stimulus like calling his name and answer questions like asking
how he feels.
Kernig’s and Brudzinski’s signs: negative
Skin: no skin rash
Problem #1: Meningoencephalitis
A: Meningocephalitis, without seizure, improving
P: Keep ceftriaxone 2gm iv drip q12h
三、
【Admission 範本】Necrotizing fasciitis
December 2010,張純誠醫師/李健明醫師
Chief complaint: Swelling and pain on his right hand for one day
Present illness:
The 46 year-old man was presented to the Emergency Department of Chi Mei Medical Center with
a chief complaint of abrupt onset of swelling and pain in his right hand. The patient, a delivery man,
has alcoholic liver cirrhosis. He had been in his usual state of health until the day before presenting
to the ED, when he went fishing at the nearby seashore of Tainan city. His right finger was
accidentally injured by a fish he caught. A few hours later his right hand and arm rapidly became
swollen, accompanied with reddish change involving his entire right hand, and proximal right
forearm, with several purple hemorrhagic bullae. He also complained of short of breath and
palpitation. There was none of fever, chills, headache, blurred vision, hand tremor, chest pain, short
of breath, diarrhea, abdominal pain, dysuria, and urinary frequency.
On physical examination, the patient was alert, cooperative, and agonizing for the pain of right
upper limb. His blood pressure was 90/45 mm Hg; temperature, 35.6℃; pulse, 110 beats/minute;
and respiration, 19 breaths/minute. His right hand was warm, swollen, and erythematous, with three
hemorrhagic bullae measuring 3 cm in diameter for the biggest one, and underling crepitus.
Blood tests showed a white cell counts of 14,800/mm3 with 3% band forms, 80% segmented
cells, 11% lymphocytes, and 2% monocytes; a red blood cells count of 4.53×106 /mm3; hemoglobin
of 12 g/dL; platelets of 130, 1000/mm3. Biochemical tests revealed a C-reactive protein level of
13.3 mg/L; a fasting glucose of 225 mg/dL; sodium of 127.5 mEq/L; potassium of 3.78 mEq/L;
BUN of 9 mg /dL; creatinine of 0.8 mg/dL; aspartate aminotransferase of 114 IU/L; and analine
aminotransferase of 94 IU/L. Chest film was essentially negative. Electrocardiogram revealed sinus
tachycardia. X-ray of the right hand showed the presence of numerous gases inside the soft tissues.
Two sets of blood were performed for bacterial cultures. The patient underwent an emergency
fasciotomy two hours after arrival at ED. Shortly he was admitted to the Infection Diseases ward for
the antiinfective therapy to control the necrotizing fasciitis caused probably by Vibrio vulnificus.
Impression:
1. Necrotizing fasciitis
2. Alcoholism
3. Cirrhosis of liver
Plan:
Diagnostic plan
1. Follow culture result and adjust antibiotic according
2. Follow liver function tests and estimate the severity of cirrhosis using Child score
3. Confirm the absence of other possibility for cirrhosis like HBV and HCV infection.
4. Record input/output daily for the first 3 days.
5. Check the quaiac test of stool.
Therapeutic plan
1. Emergency fasciotomy done.
2. Combination therapy with ciprofloxacin and minocycline.
3. Pain control with opiates
4. Beware of alcoholic withdrawal syndrome
Educational plan
Inform the patient and his family member for the possibility of further fasciotomy.
三、
【POMR 範本】Necrotizing fasciitis
2011/01/11 10:30 AM
S: Pain over surgical location
O: Consciousness, clear. Pain scale 8/10.
Temperature, 37 C.
Extremity: One surgical incision wound over right index finger, 2-3cm in length, erythematous
and oozing without pus formation
Problem #1: Necrotizing fasciitis
A: Necrotizing fasciitis s/p fasciotomy, improving
P:
Continue use of ciprofloxacin and minocycline
Keep wound care with iodine and wet dressing
Close contact with plastic surgeon.
四、
【POMR 範本】Chronic wound
2011/01/11 10:30 AM
S: Mild wound pain
O: Consciousness, clear.
Temperature, 37 degrees of Celsius.
BP: 150/80mmHg
Finger stick after awakening: 200mg/dL
Wound: left anterior shin, 2x2x2 cm, without pus discharge
Peripheral pulsation:
Right pedis dorsalis ++; left pedis dorsalis ++
Right posterior tibial ++; left posterior tibial ++
Right popliteal ++; left popliteal ++.
Problem #1: Chronic wound, DM-related
A: Pyogenic gangrenosum, still poor-healing
P: Continue use of clindamycine and minocycline
Wound care using wet dressing.
五、
【POMR 範本】Cellulitis with necrotizing fasciitis
2011/01/11 10:30 AM
S: Left leg wound pain
O:
Consciousness, clear.
Temperature, 36.5 degrees of Celsius.
BP: 110/56 mm Hg.
Left leg: 2 longitudinal incision wound 7-10 cm long on left leg,
Erythematous, swelling with clear discharge
Problem #1: Cellulitis, complicated with necrotizing fasciitis
A: Necrotizing fasciitis s/p debridement, improving
P: Continue use of Augmentin IV form
Wound care daily with normal saline wet dressing
六、
【POMR 範本】bacteremia and soft tissue infection
2011/01/11 10:30 AM
S: Right leg pain
O: Clear consciousness, GCS: E4V1M6
Temperature 36 degrees of Celsius; BP: 120/63 mm Hg
Right leg: swelling, tenderness, pitting edema 2+ with a casting.
Problem #1: GNB bacteremia
A: GNB bacteremia, without shock, stationary
P: Continue cefuroxime treatment
Follow blood culture report and adjust antibiotic accordingly
Problem #2: Right distal tibia and fibular fracture
A: Right distal tibia and fibula fractures without progression
P: Leg elevation to reduce lower-limb swelling
Pain control with acetaminophen qid
七、
【POMR 範本】Cystitis
2011/01/11 10:30 AM
S: No chest pain now
O: Clear consciousness, afebrile, BP: 152/63mmHg
Chest: regular heart beat, systolic murmur over left lower sternal region grade 2/6
U/A: WBC: 5-10/HPF
Problem #1: Cystitis
A: Cystitis with improvement under antibiotic treatment
P: keep cefuroxime treatment
Problem #2: Unstable angina
A: unstable angina is improved, no more chest pain
P: keep medication adjusted by CV doctor with diovan and sorbitrate
八、
【POMR 範本】Cellulitis, suspect PAOD
2011/01/11 10:30 AM
S: Puncture wound pain
O: Clear consciousness, afebrile, BP: 122/50mmHg
Peripheral arterial pulsation:
+/- over bilateral dorsalis pedis artery
2+ over right popliteal artery; + over left popliteal artery
Limb: painful swelling over right foot, the extension is not progressed
Problem #1: Cellulitis, suspect PAOD
A: Cellulitis, suspect PAOD. the condition is stationary
P: Follow arterial angiography report
Keep minocycline and clindamycin
九、
【POMR 範本】Sepsis, suspect cellulitis or infective endocarditis
2011/01/11 10:30 AM
S: Foot pain
O: Clear consciousness, BP: 136/80mmHg afebrile
Chest region: Clear breath sounds
Heart: Regular heart beat,
Systolic murmur Gr 4/6 over apex region
PMI: over the 5th intercostals region
Problem #1: Sepsis, suspect cellulitis or infectious endocarditis
A: Sepsis, condition is stationary under current antibiotic regimen
P: Follow-up heart echo report to exclude infective endocarditis
Keep current vancomycin + gentamicin
Keep close clinical condition monitoring to exclude sudden onset of heart failure
十、
【POMR 範本】Fever
2011/01/11 10:30 AM
S: Mild headache remained
O: Clear consciousness afebrile, BP: 100/51mmHg
Clear breath sounds, no wheezing or crackles
Regular heart beat without murmur
Soft abdomen without tenderness
Freely movable limb
No skin rash or petechiae
Parasite was found by peripheral blood smear favor P. vivax
Problem #1: Malaria
A: Malaria, active infection
P: Give chloroquine and premaquine
Educate she and her family to monitor any adverse effect