整形外科標準病歷範本(1)
編者: R3 洪敏翔/CR 顏伯璁/Chief 黃國峯
Plastic Surgery (PS) Example 1 for Problem Orientated
Medical Record-Covered Admission Note
(POMRCAN)
Diagnosis: Second to third degree scald burns on the right forearm, left thigh and
abdomen, 4% total body surface area (TBSA).
Chief Complaint: Redness, painful swelling and bullae formation on the right forearm,
abdominal wall and left thigh, on all of which hot soup spill on 11th December,
2010.
Present Illness: This 3-year-old girl was healthy before. According to her mother, she
sustained redness, painful swelling and bullae formation on the right forearm,
abdominal wall and left thigh, on all of which hot longan soup spill was on 11th
December, 2010 when she tripped in front of her mom carrying the soup. (媽媽端
熱龍眼湯,病患走在前方不慎摔倒,熱湯灑在病患身上). On the same day, she
brought to the emergency department had the impressive second degree burns
over the right forearm and left thigh with bullae formation. After wound care with
Flamazine ointment, she was to have post discharge follow up at our plastic
surgery department.
When she returned for follow up three days later, eschar formation over the
right forearm was found. With the impression of second to third degree scald
burns on the right forearm, left thigh and abdomen and eschar formation on the
right forearm, she was admitted.
Impression: Second to third degree scald burns on the right forearm, left thigh and
abdomen, 4% TBSA with eschar formation on right forearm.
Plan:
1. Diagnosis plan: To collect wound culture.
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2. Therapeutic plan:
1. To ply flamazine cream.
2. To control pain.
3. To exert hydrotherapy.
4. To execute debridement for eschar.
3. Educational plan:
1. To offer wound care and infection prevention.
2. To prevent joint stiffness by rehabilitation.
3. To encourage sufficient diet intake for wound improvement.
4. To encourage the parents to accompany the patient for her mental support
and better medical compliance.
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整形外科 Admission Note 範本(2)
編者: R3 洪敏翔/CR 顏伯璁/Chief 黃國峯
PS Example 2 for POMRCAN
Diagnosis: Left medial canthus laceration with lacrimal canaliculi rupture.
Chief Complaint: Left lower eyelid pain, swelling and bleeding after the traffic
accident tonight.
Present Illness: This 28-year-old male was healthy before complaining of left lower
eyelid pain, swelling and bleeding after accidentally falling off the scooter about
30 minutes ago when riding it(騎機車不慎滑倒). Consequently, he came to the
emergency department on his own. On physical examination, his consciousness
was clear; there was no memory loss; multiple abrasions on the face and a deep
laceration about 2 cm in length in the left medial canthus were noted; there was no
other injury. The ophthalmic doctor consulted noticed no blurred vision, diplopia
or visual defect. However, the rupture of the lower limb of the lacrimal canaliculi
was diagnosed, so he was admitted for their surgical repair.
Impression: Left medial canthus laceration with lacrimal canaliculi rupture.
Plan:
1. Diagnosis plan: To have preoperative evaluations.
2. Therapeutic plan:
2.1. To arrange bicanalicular stenting with the silicone tube, beside the informed
consent.
2.2. To implement wound care.
2. 3. To relieve symptoms.
3. Educational plan:
3.1. To educate the patient to avoid removing the surgery-placed silicone tube in
the nasal cavity after the operation.
3.2. To disclose probable complications such as bleeding, hematoma, infection,
and lacrimal canalicular restenosis, asides from corresponding treatment.
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整形外科 Admission Note 範本(3)
編者: CR 顏伯璁/Chief 黃國峯
PS Example 3 for POMRCAN
Diagnosis: Diabetic foot (DM foot).
Chief Complaint: Persistent unhealed wound on right foot smelling foul and
discharging pus for 2 weeks.
Present Illness: This 60-year-old madam with history of diabetes mellitus type II,
medical control of which was irregular, was brought to our plastic surgery
outpatient department and complained of the persistent unhealed wound on the
right foot with foul smell and pus discharge for 2 weeks. The patient said it was
initially only a small scratch wound on the right big toe and the traditional herbal
dressing for wound care was used but the wound kept deteriorating.
Upon physical examination, the patient’s consciousness was clear; the fever
was mild (38℃). On wound inspection, localized warmth, redness, and swelling
on her right foot with pus discharge and foul smell were noted. As for the
surrounding area away from the primary site, the cyanotic skin and cold sensation
were also noted. The pulsatile strength of the posterior tibial artery and dorsalis
pedis artery was weak. The elevated white cell count (9700/μL) and C-reactive
protein level (90mg/L) were remarkable on the blood test. The roentgenographical
lytic radiolucent lesion on the right big toe proximal phalanx compatible with
osteomyelitis was also noted.
For the above findings, the patient was admitted for antibiotic control and
surgical treatment and averred peripheral arterial occlusive disease in DM foot and
osteomyelitis of the right foot.
Impression:
1. Peripheral arterial occlusive disease in DM foot and osteomyelitis of the right
foot.
2. Poorly-controlled diabetes mellitus type II.
Plan:
1. Diagnostic plan:
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a. To perform bacterial wound culture for proper antibiotic selection.
b. To arrange angiogram for evaluating the circulation of the right lower
extremity later.
c. To do preoperative evaluations.
2. Therapeutic plan:
a. To exercise empirical antibiotic treatment.
b. To exert wound care.
c. To arrange sequestrectomy and debridement.
d. To well control the underlying diabetes mellitus.
e. To arrange the endocrinology specialist and the dietitian consultations.
3. Educational plan:
a. To inform the patient and family of the necessity of medical
compliance.
b. To avoid foot contamination and smoking.
c. To explain to the patient and family multiple-stage treatment necessity
for wound settlement.
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整形外科 Admission Note 範本(4)
編者: CR 顏伯璁/Chief 黃國峯
PS Example 4 for POMRCAN
Diagnosis: Right index cut with extensor tendon rupture.
Chief Complaint: Painful right index cut with extension function loss from the knife
cut 1 hour ago.
Present Illness : This 50-year-old madam was quite healthy before she had the right
index knife cut about 1 hour ago which caused right index extension function loss
but with no sensory deficit, so she came to our emergency department.
On physical examination, a laceration, 1 cm in length, on the dorsal side of the
proximal phalanx of the right index which failed to extend and flexed normally, in
addition to no right hand fracture radiographically. Operation for tendon repair
was indicated. Therefore, she was admitted for tendon repair operation.
Impression: Right index cut with extensor tendon rupture.
Plans:
1. Diagnostic plan: To do preoperative evaluations.
2. Therapeutic plan:
1. To arrange tendon repair.
2. To have wound care.
3. Educational plan:
1. To explain to the patient and family probable complications such as bleeding,
hematoma, infection and recurrent tendon rupture.
2. To exert wound care education.
3. To give approximately four weeks education for keeping splinting.
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整形外科 Admission Note 範本(5)
編者: CR 顏伯璁/Chief 黃國峯
PS Example 5 for POMRCAN
Diagnosis: Replantation.
Chief Complaint: Right middle finger total amputation at the distal interphalangeal
joint level by the cutting machine about one hour ago.
Present Illness: This 45-year-old worker had no history of diabetes mellitus,
hypertension or other systemic diseases. About one hour ago, he had his right
middle finger totally amputated at the distal interphalangeal joint level by the
cutting machine when working before rushing to our emergency department with
his colleagues.
Upon physical examination in the emergency department, the patient’s
consciousness was clear with the only injuries of the right middle finger. On
wound inspection, the cutting edge of the amputated stump was clear and sharp.
The Roentgenography of his right hand showed the right middle finger with the
distal phalangeal base bone loss and distal interphalangeal joint injury. The blood
test was unremarkable. So, he was admitted for right middle finger replantation.
Impression: Right middle finger total amputation at the distal interphalangeal joint
level.
Plan:
1. Diagnostic plan: To do preoperative evaluations.
2. Therapeutic plan:
a. To arrange replantation as soon as possible.
b. To have wound care.
c. To provide medication for symptom relief.
3. Educational plan:
a. To inform the patient and family of the necessity of postoperative
medical compliance for maintaining the replant circulation.
b. To avoid drinking and smoking.
c. To explain to the patient and family complications such as persistent
bleeding, replantation failure, infection and replant motion limitation.
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整形外科 Admission Note 範本(6)
編者: R3 廖國鈞/CR 顏伯璁/Chief 黃國峯
PS Example 6 for POMRCAN
Diagnosis: Zygomatic tripod fracture.
Chief Complaint: Painful swelling and ecchymosis of the left periorbital area and
cheek after traffic accident on 11th November, 2010.
Present Illness:
This 19-year-old male with no remarkable history complained of the left cheek
contusion on 11th November, 2010, after falling off a scooter, hitting his left cheek on
the ground and taken to our emergency department at 9:00 am.
On physical examination, his consciousness was clear; vital signs, stable; body
temperature, 37℃; pulse rate, 98 times per minute; respiratory rate, 20 times per
minute; his blood pressure, 144/84 mmHg, asides from remarkable tender swelling
and ecchymosis of his left periorbital area and cheek. Moreover, he denied
infraorbital numbness. The range of motion of the bilateral temporomandibular joints
was normal. The ophthalmologic examination revealed no abnormalities.
The brain CT showed no intracranial hemorrhage and the left zygomatic tripod
fracture. He stayed in the emergency department for observation and was referred to
our plastic surgery outpatient department. In a recent follow-up on 29th November,
his facial swelling decreased. After discussion, he chose surgical treatment. So, he
was admitted for open reduction internal fixation for the zygomatic fracture.
Impression: Left zygomatic tripod fracture.
Plan:
1. Diagnostic Plan:
1.1. To do preoperative evaluations like hematology tests and biochemical tests.
1.2. To do preoperative evaluations like chest Xray and facial bone CT.
2. Therapeutic Plan:
a. To primarily prescribe medicines like Broen-C 1# TID PO and Panadol 1# QID
PO for symptom relief.
b. To arrange open reduction internal fixation of the left zygoma fracture, besides
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the informed consent.
c. To provide wound care.
3. Educational plan:
a. To manipulate ice packing for reducing edema.
b. To supply preoperative health education.
c. To disclose the probable complications and their treatment.
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整形外科 Admission Note 範本(7)
編者: R3 廖國鈞/CR 顏伯璁/Chief 黃國峯
PS Example 7 for POMRCAN
Diagnosis: Left first metacarpal fracture.
Chief Complaint: Left hand localized swelling and pain after falling injury in the
afternoon on 7th December, 2010.
Present Illness:
The 13-year-old boy falling from about two-meter height sustained the left hand
contusion, the swelling and tenderness on the thenar area, and no head contusion. He
was then brought to our emergency department.
On physical examination, his consciousness was clear; there was no memory loss;
there were tenderness and swelling in the thenar area without open wound. The
motion and sensation of the left thumb were basically intact but the limited motion
was noted due to severe pain when his thumb was moved. The anteroposterior and
oblique X-ray series demonstrated the oblique fracture of the left first metacarpal
bone. So he was admitted for his fracture surgery.
Impression: Left first metacarpal closed fracture.
Plan:
1. Diagnostic plan:
1.1. To do preoperative evaluations like hematology tests and biochemical tests.
1.2. To do preoperative evaluations like chest Xray and facial bone CT.
2. Therapeutic plan:
2.1. To arrange open reduction internal fixation.
2.2. To prescribe medicines for symptom relief.
3. Educational plan:
3.1. To elevate the left hand for reducing swelling.
3.2. To maintain forearm splinting for about four weeks after surgery.
3.3. To use hand rest after surgery.
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整形外科 Admission Note 範本(8)
編者: R4 施博淳/CR 顏伯璁/Chief 黃國峯
PS Example 8 for POMRCAN
Diagnosis: Right index cut with radial digital nerve injury.
Chief Complaint: Painful right index cut with sensory loss after knife cut about 1 hour
ago.
Present Illness: This 50-year-old madam was quite healthy before she complained of
the right index finger knife cut about 1 hour ago and the fingertip numbness. So, she
came to our emergency department.
On physical examination, a laceration, 1 cm in length, at the radial half of the
middle phalanx of the right index finger was noted; there was no active bleeding from
the wound; the fingertip circulation was intact; the flexion and extension of the right
index finger were normal. The two-point discrimination test revealed abnormal
sensory feedback on the radial half of the right index finger, leading to the impression
of radial digital nerve injury. There was no fracture on the right hand X-ray. Therefore,
she was admitted for nerve repair surgery.
Impression: Right index cut with radial digital nerve injury.
Plans:
1. Diagnostic plan: To do preoperative evaluations.
2. Therapeutic plan:
2.1. To arrange nerve repair.
2.2. To supply wound care.
3. Educational plan:
3.1. To explain to the patient and family the probable complications such as
bleeding, hematoma and infection.
3.2. To utilize wound care education.
3.3. To explain to the patient and family the improbability of immediate sensory
recovery and the necessity of outpatient department follow-up.
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整形外科 Admission Note 範本(9)
編者: R4 施博淳/CR 顏伯璁/Chief 黃國峯
PS Example 9 for POMRCAN
Diagnosis: Lipoma.
Chief Complaint: An enlarged soft mass in the right thigh noted for six months.
Present Illness:
This 50-year-old man was quite healthy before he complained of an enlarged soft
mass in the right thigh noted for six months. So, he came to our outpatient department
which noticed no pain, local heat, sensory or motor impairment in his right thigh.
On physical examination, a mass in the right medial thigh was found; the mass
was unmovable, soft, and round; there was no Tinel sign, tenderness or motion
limitation; no lymphadenopathy was found in the right groin area. Ultrasonography in
the right thigh revealed a subcutaneous hypoechoic tumor, 2x5x8 cm3, favored lipoma.
Therefore, he was admitted for lipoma resection.
Impression: Lipoma.
Plan:
1. Diagnostic plan: To do preoperative evaluations.
2. Therapeutic plan:
2.1. To arrange resection of lipoma with the informed consent.
2.2. To pursue formal pathology reports.
3. Educational plan:
3.1. To explain to the patient and family probable complications such as bleeding,
hematoma and infection.
3.2. To throw wound care education.
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整形外科 Admission Note 範本(10)
編者: R2 洪章桂/CR 顏伯璁/Chief 黃國峯
PS Example 10 for POMRCAN
Diagnosis: Necrotizing fasciitis with sepsis.
Chief Complaint: Progressive redness and pain of right forearm since two days ago.
Present Illness:
According to the patient’s family and medical record, this 65-year-old man had
history of diabetes mellitus type II and end-stage renal disease under regular
hemodialysis in a local clinic. He sustained stabbing injury by the wood stick in the
right volar forearm at the seashore about two days ago. Sea water contact history was
recognized. Initially he did not pay too much attention to the wound cared by himself.
However, the progressive redness and pain of the right forearm were noted; so was the
fever. Therefore, he was brought to our emergency department.
In the emergency department, the fever (38℃), tachycardia (110 beats per
minute), and tachypnea (24 times per minute) were noted. The blood pressure was
100/60 mmHg. His consciousness was clear but the slow response was noted. The
erythema and swelling of almost the entire right volar forearm were noted; so were
the palpation tenderness and hemorrhagic bullae. The laboratory data showed
leukocytosis with left shift and elevated C-reactive protein levels. The gas formation
was also revealed on the X-ray film of the right forearm. With the impression of the
necrotizing fasciitis of the right forearm, the emergent fasciotomy and debridement
were arranged and he was admitted to the intensive care unit.
Impression: Necrotizing fasciitis with sepsis.
Plans:
1. Diagnostic plan:
1.1. To do preoperative evaluations.
1.2. To collect blood culture and wound culture.
1.3. To follow up the patient’s consciousness, vital sign and wound condition
intensively.
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2. Therapeutic plan:
2.1. To arrange emergent fasciotomy and debridement.
2.2. To administer empirical antibiotic and consult infection specialists.
2.3. To apply wound care.
2.4. To relieve symptoms.
2.5. To control underlying diabetes mellitus and consult dietitians.
2.6. To arrange postoperative hemodialysis and consult nephrologists.
2.7. To be on the large-bore intravascular access route in case of shock.
3. Educational plan:
3.1. To inform the patient and family of probable postoperative disease
progression and the necessity of secondary emergency operation.
3.2. To inform the patient and family of chances of having septic shock and
mortality.
3.3. To consider defect reconstruction when infection and wound condition are
stabilized.
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