內分泌科標準病歷範本-POMR
一、 【POMR 範本】HHS
2011/01/11 10:30 AM
S: Dry mouth
O: Consciousness clear
BP:130/80mmHg, TPR: 36.8°C,
82/min, 18/min
Dry oral mucosa and dry skin
BS:clear
Abd:soft, no tenderness
No legs edema
Urine amount 1500ml/day (I/O:+850)
F/S AC
PC
4PM 9PM
180
164
240
220
232
12/27
12/28
Problem #1: Newly diagnosed Type 2 DM with HHS episode
A: DM just noted, A1c:14.0%. Multiple insulin injection after admission
, AC sugar around 160+mg/dL. Polydipsia persisted.
P: 1.IV fluid with N/S 1000ml per day and keep I/O banlance
2.Lantus 20U HS sl
3.Actrapid 10U TID sl AC 30min, increased dose to 12U TID if PC sugar > 200mg/dL
二、【POMR 範本】Adrenal insuffieicny
2011/01/11 10:30 AM
S: Geneal soreness, no cold sweating
O: Consciousness clear
BP: 110/60mmHg,
TPR: 36.6°C,
72/min, 16/min
Moon face and flushing
Buffalo hump
Thin skin and ecchymosis over 4 limbs, small abrasive wound
over both forearm
F/S
AC
PC
4PM 9PM
90
109
124
89
12/11
76
12/12
Lab data :ACTH:18.2 pg/ml，Cortisol(8AM):3.1 ug/dl
Cortisol(4PM):3.9 ug/dl
Problem #1: Secondary adrenal insufficiency due to steroid used
A: Cushing appearance, stationary
P: 1.Prednisolone 2# , 1# BID po
2.Taper prednisolone at OPD
3.衛教病患勿服用來路不明藥物及定期門診追蹤
三、【POMR 範本】Other type DM with DKA episode and lung abscess
2011/01/11 10:30 AM
S: Intermittent severe cough and wound pain
O: Consciousness clear, no dyspnea
BP:113/63mmHg, TPR:36.3°C, 80/min, 18/min
Lung: coarse BS over right side
s/p right pig-tail drainage with 0ml of pus discharge, wound dry.
F/S
AC
PC
4PM
122
114
111
126
65
9PM
306
12/27
12/28
Problem # 1: Other type DM with DKA episode, and lung abscess
A: S/P right pig-tail on 12/20, drainage 0ml of discharge yesterday.
F/U CXR 有改善. A1c:10.5% on 98.9.9-->11.5% on 99.12.9
Blood sugar under controlled by insulin ump 0.8U/hr + Novorapid 10U TID sl AC.
P: 1.Tazocin 4.5gm iv drip q6h, day 12
2.Mero 1amp IM p.r.n if severe cough
3.Demeral 25mg IM q4hp.r.n if wound pain
4.Arrange chest echo (預計 6 天後拔管)
5.Novorapid 10U SC TID AC 改 6U TID for low PC sugar
6.Keep Inuslin pump 0.8U/hr
四. 【POMR 範本】Hyponatremia, suspect Natrilix and poor intake related
2011/01/11 10:30 AM
S: Felt better with increased food intake
O: Consciousness clear
BP:120/80mmHg TPR:36.5°C, 80/min, 18/min
Abd: soft, no tenderness
Extremeties: No legs edema
Lab data: Na:112.5129.8 mEq/L
Urine Osmolality:157 mOsm/Kg
Blood Osmolality:244 mOsm/Kg
T3:22.76 ng/dl，TSH:1.05 uIU/ml
Cortisol(臨時):20.7 ug/dl，Free T4:1.66 ng/dL
Problem #1: Hyponatremia, suspect Natrilix and poor intake related
A: Hyponatremia improved after IV fluid N/S 1000ml iv drip daily.
Normal thyroid and adrenal hormone data.
P: 1.Keep N/S 1000ml iv drip daily
2.Follow up serum Na 2 days later
3.Change anti-hypertension agents to Norvasc 1# QD
五、【POMR 範本】Thyrotoxic periodical paralysis with hypokalemia
2011/01/11 10:30 AM
S：Bilateral thigh weakness improves .
O：BP 116/70mmHg，PR 95/min
clear consciousness
Lab data k 2.0  3.5
Problem #1: Thyrotoxic periodical paralysis with hypokalemia
A：Hypokalemia, improving
P：1.Taper Slow-k supplement and keep ATD use
2.Educate the patient not to exercise rigorously or eat high carbohydrate foods or drink
3.Low iodine diet
4.Medications for hyperthyroidism
5.Closely follow up drug side effect (skin itching, throat ache or fever)
六、【POMR 範本】Hypoglycemia
2011/01/11 10:30 AM
S：General spirit improves and no more cold sweating or hunger sensation.
O：BP 116/70mmHg，PR 80/min
clear consciousness
HbA1C 5.8 , Cr 0.5 , GOT/GPT: 24/26
F/S 130-250-240-301
210-280
Problem #1: Hypoglycemia
A：Hypoglycemia, improved
P：1.Educate hypoglycemia symptoms and treatment modality for hypoglycemia
2.Stop IV glucose fluid if no more hypoglycemia
3.Add back oral anti-diabetic agents if elevated f/s is still noted after stopping
glucose-content fluid
七、【POMR 範本】Growth retardation
2011/01/11 10:30 AM
S：Cold sweating on insulin tolerance test
O：BP 116/70mmHg，PR 100/min
clear consciousness
F/S 90-60-40
Problem #1: short stature
A：Short status, r/o growth hormone deficiency
P：1.Feeding if hypoglycemia occurs
2.Check blood test according to insulin tolerance test protocol.
八、【POMR 範本】DM Foot with PAOD
2011/01/11 10:30 AM
S:
Still fever with chills last night
Appetite: fair
O:
Vital sign: BT:37.8℃
F/S:
HR 88 t/min
RR 20 t/min, BP: 130/78 mmHg
154(6AM), 286 (11AM), 312 ( 5PM), 283 ( 9PM)
Cons: clear
Conj: mild pale
Sclera: not icteric
Neck: supple, LAP (-), JVE (-)
Chest: symmetric expanse,
Heart sound: regular, no murmur,
Breath sound: clear, wheezing (-) , crackles (-)
Abd: soft, no tenderness
Shifting dullness (-),
L/L: no pitting edema, wound: 4X3 cm over left lower leg, with mild pus
redness (+) and heat over left lower leg
Problem #1: DM foot with cellulitis
A:
DM foot wound poor healing with cellulitis, active
P: 1.Wait for the result of blood culture and pus culture
2.Keep antibiotic treatment with Cefazoline (day 2)
3.Close monitoring for the sign of sepsis and observe the body temperature
4.Intensive sugar control. Shift to RI tid + Lantus
5.Fluid supply and supportive treatment
6.Explain the possible of local debridement .
九、【POMR 範本】DM with Acute Hyperglycemia
2011/01/11 10:30 AM
S: Polyuria and polydipsia recently
O: Vital sign:
BT:37.2℃
HR 80 t/min
RR 20 t/min
Cons: clear
Conj: not pale
Sclera: not icteric
Neck: supple, LAP (-), JVE (-)
Chest: symmetric expanse,
Heart sound: regular, no murmur,
Breath sound: clear, wheezing (-) , crackles (-)
Abd: soft, no tenderness
Shifting dullness (-),
L/L: no pitting edema
Problem #1: DM with Acute Hyperglycemia
A: DM with acute hyperglycemia, active
P: 1.N/S supply
2.Insulin pump with N/S 500cc + RI 100u keep 0.8u/hr + RI 6u sc tid
3.KCl 5cc in N/S for K supply
4.Close follow up sugar and K level
5.Well education of DM and hyperglycemia control
6.Diet control education
十、【POMR 範本】DM Nephropathy,
2011/01/11 10:30 AM
S: Bilateral lower leg still edema.
O: Vital sign:
BT:37.2℃
HR 92 t/min
RR 22 t/min, Urine amount: 750 cc,
I/O: +450 cc
Cons: clear
Conj: mild pale
Sclera: not icteric
Neck: supple, LAP (-), JVE (-)
Chest: symmetric expanse, bilateral basal rales(+)
Heart sound: regular, systolic grade II murmur (+)
Breath sound: clear, wheezing (-) , crackles (-)
Abd: soft, no tenderness
Shifting dullness (-),
L/L:
pitting edema, bilateral, 3+
Problem #1: DM Nephropathy
A: DM nephropathy with proteinuria, active
P: 1.Water and Salt retriction
2.Diet control and keep RI control for sugar
3.Collect 24 hrs urine amount for CCr and total protein loss
4.After urine collect, lasix for dieresis
5.Close follow up if further dyspnea attack and close follow up fluid status
6.Arrange renal echo