耳鼻喉科POMR 範本
一、【POMR 範本】NSD s/p SMP
2011/01/11 10:30 AM
S: Nasal pain and stuffness, throat discomfort after operation
O:conscious: clear, no fever or chills
Physical exam
Eyes: freely movable, no pain at movement
Ear: drum and EAC intact
Nose: no active bleeding, nasal packing and nasal air way in place
Pharynx: no post nasal drip or bleeding
Problem #1: NSD s/p SMP
A: condition stable, s/p SMP, post op day N
P: 1.IV fluid supplement and on cold liquid diet
2.Prevent from dehydration
3.Adequate pain relief (Ponstan PO qid)
4.Add transamin and control blood pressure if in need
5.Monitor vital sign closely
二、【POMR 範本】CPS s/p FESS+SMP
2011/01/11 10:30 AM
S: Nasal pain and left side nasal discharge after operation
O: conscious: clear, no fever or chills
Physical exam
Neck: supple
Eyes: freely movable, ROM: full, no diplopia
Ear: drum and EAC intact
Nose: no active bleeding ,
Lt side blood clot at suture site, nasal packing and nasal air way in place
Pharynx: post nasal drip, mild , (-) active bleeding
Chest: clear breathing sound
Abdomen: soft and flat, tenderness (-)
Extremities: freely movable
Problem #1: CPS s/p FESS+SMP
A: condition stable, s/p FESS+SMP, post OP day N
P: 1.IV fluid supplement (1000 ml/day) , NPO 4hrs then cold liquid diet
2.Prevent from dehydration
3.Adequate pain relief (Ponstan PO qid + Demerol prn)
4.Add transamin and control blood pressure
5.Cefazolin 1gm Q8H + Gentamycin 80mg Q12H
三、【POMR 範本】COM s/p tympanoplasty
2011/01/11 10:30 AM
S: post-auricular pain and mild dizziness
O: conscious: clear, no fever or chills
Physical exam
No faical palsy, no vertigo
Neck: supple, no neck rigidity
Eyes: freely movable, no nystagmus
Ear: mastoid dressing in place, no bleeding, no discharge
Nose: NSD+CHR; Pharynx: post nasal drip, mild
Chest: clear breathing sound; Abdomen: soft and flat, tenderness (-)
Extremities: freely movable
Problem #1: COM s/p tympanoplasty
A: condition stable, s/p tympanoplasty, post-op day N
P: 1.IV fluid supplement (1000 ml/day) , NPO 4hrs then on full diet
2.Adequate pain relief (Ponstan PO qid + Demerol prn)
3.Cefazolin 1gm Q8H
四、【POMR 範本】s/p LMS
2011/01/11 10:30 AM
S:Sore throat after operation
O: conscious: clear, no fever or chills
Physical exam
Neck: supple, no neck rigidity
Eyes: freely movable, ROM: full
Ear: ear drum intact
Nose: NSD+CHR
Pharynx: injected throat, no bleeding
Chest: clear breathing sound
Abdomen: soft and flat, tenderness (-)
Extremities: freely movable
Problem #1: s/p LMS
A: condition stable, s/p LMS
P: 1.IV fluid supplement (1000 ml/day) , NPO 4hrs then on cold diet
2.Medication (prednosolone, transamin, endase, gasgel 1# po qid)
3. Voice rest
五、【POMR 範本】Deep neck infection s/p debridement
2011/01/11 10:30 AM
S:Sore throat, neck swelling and tenderness, wound discharge
O: conscious: clear, fever subsided
Physical exam
Neck: swelling with tender, wound no oozing, clear discharge, no pus formation
Penrose / CWV drain in place
Eyes: freely movable, ROM: full
Ear: ear drum intact
Nose: NSD+CHR
Pharynx: injected throat,
Chest: clear breathing sound
Abdomen: soft and flat, tenderness (-)
Extremities: freely movable
Problem #1: Deep neck infection s/p debridement
A: deep neck infection s/p debridement, condition stable
P: 1.IV fluid supplement (1000 ml/day)
2.Keep intravenous antibiotics use
3.Medication for pain control
4.Wound change dressing / wet dressing
5.Follow lab data (WBC, CRP)