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一、【POMR 範本】Diarrhea
2011/01/11 10:30 AM
S: Watery diarrhea improved
P: 1.Arrange computed tomography from neck to chest and UGI endoscopy for
examination and biopsy
2.Begin parenteral nutritional support if enteral route is not available
3.follow electrolytes included Na and K, and correct if any imbalance
4.Adequate pain control
5.Explain and discuss with the patient and family members about possible need of
gastrostomy or jejunostomy for the enteral nutrition; and consult general surgeon
for the evaluation and explain risks and benefits
三、【POMR 範本】Ileus
2011/01/11 10:30 AM
S: Abdominal fullness mild improved
O: Consciousness: clear
Vital signs: BT 36.6 °C; RR: 15 breaths/min
PR: 84 beats/min; BP: 108/64 mm Hg
Breath sounds: clear and equal bilaterally
Heart: RHB, no murmur
Abdomen: non-distended, normoactive bowel sounds:
trivial RUQ tenderness; no Murphy’s sign, guarding or rebound pain.
Lab data: K+ 3.01(12/19) 3.05(12/21)
O: Consciousness: clear
Vital signs: BT 36.6 °C; RR: 15 breaths/min
PR: 84 beats/min; BP: 108/64 mm Hg
Breath sounds: clear and equal bilaterally
Heart: RHB, no murmur
Abdomen: non-distended, normoactive bowel sounds:
Mild epigastric tenderness, no guarding or rebound pain.
O: Consciousness: clear
Vital signs: BT 36.6 °C; RR: 15 breaths/min
PR: 84 beats/min; BP: 108/64 mm Hg
Sclera: anicteric
Breath sounds: clear and equal bilaterally
Heart: RHB, no murmur
Abdomen: non-distended, normoactive bowel sounds:
trivial RUQ tenderness; no Murphy’s sign, guarding or rebound pain. PTCD:
30 ml (wound clean, no redness or discharge)
#2. Hypokalemia
A: potassium level still inadequate
Problem #1:
#1. Cirrhosis child ? (score: )
A: massive ascites with jaundice under lasix + aldacton use, disease wosening
Plan
- Fluid resuscitation with normal saline and blood products transfusion
- Check hemoglobin, platelet and coagulation profile
- Arrange upper GI endoscopy with intervention
- NG tube insertion for adequate drainage
- Airway protection if massive bleeding or consciousness loss
- Transfer to ICU if massive bleeding.
十一、【POMR 範本】LGI bleeding
2011/01/11 10:30 AM
S: Bloody stool passage / melena / brick stool passage for (duration)
O: Conciousness – clear/drowsy/loss
Vital signs – T/P/R – ? SpO2 – ?
Conjunctiva – pale/pink
Skin – cool/warm/dry/moist
Abdomen – soft/rigidity/flat/distended
Normo/hypo/hyperactive bowel sounds.
Tymphanic/dull/hyperesonance
Tenderness/No tenderness/Rebound tenderness
DRE – blood-stained glove / external hemorrhoids noted
Bloody stool passage amount – ( ) ml