兒科POMR.doc - -POMR POMR Pneumonia right middle lobe...

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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 RR 24 /min Activity: fair 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,
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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.
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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 RR 24 /min Activity: fair Appetite: decreased Throat: dry mucosa 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.
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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.
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