心脏内科标准病历范本.doc

心臟內科標準病歷範本-POMR 一、【POMR 範本】Acute STEMI, inferior wall 2011/01/11 10:30 AM S: No dyspnea and chest pain got improved O:Con`s: clear Vital sign: 脈搏81次/分 ;呼吸19次/分 ;血壓159/73mmHg;體溫36.6 Breath sound : fine rales over bilateral lower chest regions Heart sound : RHB Gr 2/6 sm over apex Ext:L`t hand punture wound clear Problem#1: Acute STEMI, inferior wall A: AMI with STE type, inf. Wall killip II s/p primary PCI day 2, no post infarction angina. keep Heparinization, chest pain got improved P: 1. Diagnostic plan： *Arrange cardiac echo *Lipid profile evaluation *Follow up cardiac enzyme and EKG ?? 2.Therapeutic plan： *Try taper Millisrol infusion for chest pain got improved *Heaprinization for 48 hours, then DC *Dual antiplatelet treatment *ACEI/ARB, and B-blocker treatment ?? 3. Educational plan： *wound care *予以AMI and 心導管術後衛教,規則服藥之重要性及定期門診追蹤 *NTG medication education  【POMR 範本】Acute pulmonary edema 2011/01/11 10:30 AM S: Dyspnea got improved O:Con`s: clear Vital sign: 脈搏81次/分 ;呼吸19次/分 ;血壓159/73mmHg;體溫36.6 Breath sound : fine rales over bil lower chest regions Heart sound : RHB Gr 2/6 sm over apex Ext:L`t hand punture wound clear Cath: CAD 3-V-D S/P with patent RCA-M, LCX-P stent S/P PTCA for LAD Problem#1: Acute pulmonary edema, CAD related A: CAD 3-V-D S/P with patent RCA-M, LCX-P stent S/P PTCA for LAD post cath, day 2. Dyspnea got improved P: 1. Diagnostic plan： Arrange cardiac echo Follow up CXR, if need ?? 2.Therapeutic plan： *Try taper Millisrol infusion for dyspnea got improved *Diuretic agent shifted to oral form *Dual antiplatelet treatment *ACEI/ARB, and B-blocker treatment ?? 3. Educational plan： *wound care *予以CAD, CHF and 心導管術後衛教,規則服藥之重要性及定期門診追蹤 *NTG medication education  三、【POMR 範本】Congestive heart failure with acute pulmonary edema 2011/01/11 10:30 AM S: Dyspnea got worsen O:Con`s: clear Vital sign: 脈搏81次/分 ;呼吸29次/分 ;血壓159/73mmHg;體溫36.6 Chest wall: symmetrical