兒科標準病歷範本-POMR
一、【POMR 範本】Pneumonia, right middle lobe
2011/01/11 10:30 AM
S: Fever (+)
Productive cough persisted, night cough improved
O: Vital sign:
BT:39.0℃ HR 102 /min
Activity: fair
RR 24 /min
Appetite: improving
Throat: mild injected, no ulcers or vesicles
Heart: regular heart beat, no tachycardia
Chest: no tachypnea, no retraction sign
breath sounds: rales over right lung
air entry : slightly decreased over right side
Abdomen: soft, no pain or tenderness, normoactive bowel sound
Skin: no skin rash noted
Lab: Mycoplasma pneumonaie Ab: pending
Problem #1: Pneumonia, right middle lobe
A: Pneumonia, active
→ Fever with body temperature around 39-39.5 degrees,
rales with poor air entry over right lung filed,
no retraction sign or tachypnea
P: 1.Chest x-ray will be followed up this morning
2.Antibiotics with Ilosone will be added if the Mycoplasma pneumonaie Ab is elevated
3.Keep antibiotic with Augmentin ( Day 3)
4.Keep current symptomatic treatment with robitussin, fluimucil,nasco berotec, alusa
5.Encourage CPT with bisolvon and bricanyl inhalation and .therapy
6.Explain possible complication of pneumonia and enhance the importance of chest
physiotherapy to the Family.
二、【POMR 範本】#1. Acute gastroenteritis with dehydration
#2. Diaper dermatitis
2011/01/11 10:30 AM
S: Fever (+)
Diarrhea with mucoid & blood-tinged stool 8 times
Poor oral intake, intermittent abdominal pain
Rednness over diaper area
O: Vital sign:
BT:38.0℃ HR 102 /min
Activity: fair
Appetite: decreased
Throat: dry mucosa
RR 24 /min
Heart: regular heart beat, no tachycardia
Abdomen: distension, no tenderness or rebound pain,
bowel sound: hyperactive
Skin:erythmea and erosion over perianal region
Problem #1: Acute gastroenteritis with dehydration
A: Acute gastroenteritis with dehydration , active
→ Fever with body temperature around 38 degrees persisted but degrees &
frequency reduced, Still diarrhea but no peritoneal sign occurred.
Dry mucosa but fair urine output were noted.
P: 1.Wait for the result of blood culture and stool culture
2.Close observation for possible sign of peritonitis and dehydration
3.Intravenous fluid supply for dehydration
4.Keep Antibiotics therapy with Ampicillin and Gentamycin ( Day 2)
5.Keep symptomatic treatment: Kaopectin, Bismuth, Vioment and Gascon
6.Light diet & Wash hands well after each diaper change
Problem #2: Diaper dermatitis
A: Diaper dermatitis, under the treatment ( improving)
P: 1.Continue Epiderm ointment usage.
2.Frequently change diaper and clean it gently and thoroughly with soap and water
三、【POMR 範本】Acute purulent tonsillitis
2011/01/11 10:30 AM
S: Still frequent spiking fever up to 39oC recent 2 days ( 5th day of illness)
Sore throat persisted,
Mild non-productive cough
Increase oral intake after mandol used
O：Vital sign : T/P/R/:38.1 / 108 / 23
Consciousness：alert
Activity : fair
Mouth: mild dry
Throat : injected, grade III swollen tonsils with diffuse pus coating,
no ulcers or vesicles
Neck: palpable lymph node ( bilateral)
Chest : regular heart beat without obvious heart murmur
breathing sound: coarse, no rales, no wheezing
Abdomen : soft and flat, no palpable mass, no tenderness, normal bowel sounds
Skin: no rash
Problem #1: Acute purulent tonsillitis
A：Acute purulent tonsillitis, still spiking fever with decrease oral intake due to sore throat
P：1.Check Adenovirus IgG & IgM and EB-VCA IgG & IgM
2.Wait for the result of throat culture
3.Do virus isolation of throat
4.Keep antibiotic with penicillin G (Day2)
5.Keep symptomatic treatment with cofsoline, Endase
6.Add regular panadol for pain control
7.Encourage to gargle with warm salt water and eat soft cold foods, such as jelly or ice
cream and drink lots of water or other clear liquids
四、【POMR 範本】Urinary tract infection, suspect acute pyelonephritis
2011/01/11 10:30 AM
S: No fever , no dysuria or urgent urination
O: Vital sign:
BT:36.5℃ HR 80 /min RR 20 /min
Activity: fair
Appetite: fair
Abdomen: soft, no palpable mass, normoactive bowel sound
Back: knocking pain over right flank region
Lab: Urinalysis: Nitrite (+), Leukoesterase (+), WBC 50-60/HPF
Problem #1: Urinary tract infection, suspect acute pyelonephritis
A: Urinary tract infection, suspect right acute pyelonephritis, active
→ No fever but still right back knocking pain was noted
P: 1.Arrange renal echo for suspect acute pyelonephritis
2.Keep Antibiotics with Cefazolin and Gentamycin (day 2)
3.Keep intravenous hydration
4.Encourage to drink plenty of water or clear liquids
5.Explain the possible complication of urinary tract infection to the Family
6.Education about the possible causes of UTI, such as holding urine for a
long time, not drinking enough water, poor toilet and hygiene habits.
五、【POMR 範本】Respiratory distress
2011/01/11 10:30 AM
S: Tachypnea, intermittent
O: Vital sign: BT:37.2℃ HR 128 /min RR 48 /min
Activity: fair; body weight: 3356 gm (↓ 56 gm)
Appetite:40 ml/meal/q4h with breast milk or 14% regular formula
Chest: regular heart beat with grade I-II/VI heart murmur
intercostal & subcostal retraction (+) . Tachypnea with intermittent retraction.
Abdomen: soft, mild distension, normoactive bowel sound; Skin: icteric
Lab: capillary gas: PH[7.352]，PCO2[44.6]，PO2[45.0]，O2 Satu.[78.7]，HCO3[24.2]，
ABG-Base Excess[-1.6]; Urine GBS Ag : pending
Problem #1: Respiratory distress:
A: Respiratory distress , suspect transient tachypnea, suspect pneumonitis, improving
P: 1.Wait for the result of urine GBS Ag
2.Keep Antibiotics with Ampicillin and Gentamycin (day 3)
3.Increase fluid amount for 3 day of life
4.Chest physiotherapy
5.Explain the possible causes of neonatal respiratory distress to the Family
Problem #2: Heart murmur, cause to be determined
A: Heart murmur, active
-> Grade I-II/VI over LSB and tachypnea were noted
P: 1.Arrange echocardiogram
2.Record intake and output &.Close monitoring the sign of possible heart failure
Problem #3: Neonatal jaundice
A: Neonatal jaundice, suspect hyperbilirubinemia, active
P: 1.Check capillary bilirubin this morning
2.Workup for hyperbilirubinemia including bil D/T, G-6PD, Coomb's test (D/I),
Reticulocyte count, RBC morphology, U/A, U/C (prn)
3.Phototherapy will be started if the capillary bilirubin is more than 15 mg/dL.
4.Inform family about neonatal jaundice and how to check baby for jaundice.
5.F/u clinical response after phototherapy
六、【POMR 範本】Croup
2011/01/11 10:30 AM
S: Still frequent barking cough when not in mist tent
Poor oral intake yesterday
O：Vital sign : T/P/R/:37.1 / 108 / 23
Consciousness：alert
Activity : fair
Throat : injected, no swollen tonsils, no ulcers or vesicles
Neck: no palpable lymph node
Chest : regular heart beat without obvious heart murmur
breathing sound: coarse, slight rales, no wheezing
barking cough, slight suprasternal retraction
Abdomen : soft and flat, no palpable mass, no tenderness, normal bowel sounds
Skin: no rash
Problem #1: Croup
A： Croup with decrease oral intake and still frequent barking cough
P：1.Continue IV hydration and solumedrol treatment
2.Continue O2 tent with cool humidification
3.Encourage mother to give child more liquids.
4.Close monitoring of the clinical condition, if deteriorates give epinephrine inhalation and
consider transfer to PICU.
5.Explain his unstable condition to the family
七、【POMR 範本】UTI
2011/01/11 10:30 AM
S: Fever last night, still mild dysuria
O: Vital sign:
BT:37.2℃ HR 92 t/min RR 20 t/min
Activity: fair
Appetite:fair
Chest: clear breathing sounds
Abdomen: soft non-distended, normal bowel sounds
Bilateral flank region: no knocking pain
Problem #1: UTI
A: UTI, still febrile
P : 1.Continue Cefazolin and Gentamycin treatment (day 2)
2.Perform renal echo to r/o congenital renal anomaly
3.Close monitoring for the symptoms of acute pyelonephritis
4.Continue IV hydration
5.Instruct the parents and patient about the importance of proper hygiene
八、【POMR 範本】Enterovirus infection
( H-F-M disease or Herpnagina with dehydration)
2011/01/11 10:30 AM
S: Fever, sore throat, poor feeding, changed wet diaper 4 times yesterday
O: Vital sign:
BT:37.2℃ HR 100 /min RR 24 /min
Activity: fair
Appetite: reduced by ½ the usual amount
body weight: 12 Kg ( no change)
Chest: regular heart beat
symmetric expansion, clear breath sound
Abdomen: soft, mild distension, normoactive bowel sound
Skin: no rash or vesicles
Problem #1: Herpangia with mild dehydration
A: Herpangia with dehydration, active
→ fever, still poor oral intake with normal urine output
P: 1.Increase Intravenous fluid amount for dehydration
2.Keep symptomatic therapy with voren for pain
3.Keep apply Mandol for oral ulcers
4.Closely monitor for the sign of possible complication of enterovirus infection
And for dehydration
5.Encourage to take cold foods, such as ice cream, ice milk or jelly...
6.Explain the course of enterovirus infection
7.Wash hands thoroughly before eating, after going to the toilet or handling diaper.
8.Inform the family to avoid sharing of food to prevent spread of disease.
九、【POMR 範本】Young infant fever
2011/01/11 10:30 AM
S: No fever
O: Vital sign:
BT:37.2℃ HR 100 /min RR 28 /min
Activity: fair
Appetite: Feeding amount 120 ml/q4h with breat milk or 14% regular formula
Neck: supple
Anterior fontanelle: flat
Chest: regular heart beat, symmetric expansion, clear breath sound
Abdomen: soft, mild distension, normoactive bowel sound
Skin: no rash or vesicles
Lab: Blood culture & urine culture: pending
Problem #1: Young infant fever
A: Young infant fever, improved
→ No fever and good activity and appetite were noted
P: 1.Wait for the result of blood culture and urine culture
2.Keep antibiotic treatment with Ampicillin and Gentamycin (day 3)
3.Close monitoring for the sign of sepsis and observe the body temperature
4.Explain the possible causes of young infant fever to the family members.
5.Educate the family about correct concept of fever.
十、【POMR 範本】Preorbital cellulitis
2011/01/11 10:30 AM
S: No fever, swelling and redness of the right upper and lower eyelid
yellowish discharge over right eye
O: Vital sign:
BT:37.2℃ HR 92 /min
Activity: fair
Appetite: fair
RR 20 /min
Eyes: normal vision (OU), EOM intact
conjunctiva: hyperemia (OD),
pus-like discharge (+)
Skin: erythema, tenderness, swelling over the right eye
Problem #1: Preorbital cellulitis
A: Periorbital cellulitis, OD, active
→ No fever but the inflammation surrounding the eye (OD) persisted.
P: 1.Take cultures of the discharge from the eye
2.Consultation with the ophthalmologist
3.Keep antibiotic treatment with Augmentin (day 2)
4.Continue Gentamycin eye drop use
5.Close monitoring for the symptoms of orbital infection
6.Explain the possible complication of periorbital cellulitis
7.Instruct the parents and patient about proper hygiene