急診病歷記錄的陷阱 學習目標 - disaster.org.tw

1 A. B. ( ) C. ( )D. ( )E. Chief Complaint Present Illness Past Hx / Personal Hx / Family Hx PE Laboratory Data / Image Impression Plan + Painful swelling over left knee joint for 4 hours since March 21, 2008 Present Illness chief complaint The 7 + why? 7 + why?1. (Chronology) (When) (How) 2. (Location) (Where) 3.

2 / (Onset / setting) (What) 4. (Quantity) (How) 5. (Quality) (How) 6. (Modifying factor) (What) 7. (Associated symptoms) (What) (What) (positive and negative findings) (Why) LQQ-OPERA L-LocationQ- QualityQ- Quantity (severity)O- OnsetP- Pattern (duration, frequency)E- Exacerbating factorsR- Relieving factorsA- Associated symptoms (Past Hx) AMPLE ( ) Allergy - Medication coumadin theophylline digoxin Plavix aspirin beta-blocker OHA .. Past history / pregnancy DM HTN ca.

3 Last meal (NPO ) Event (mechanism of trauma) ( ) (Person Hx) present illness Birth & Development (Social Hx) Illicit drugs Sexual history Eating habits Interpersonal interactions home, workplace (Family Hx) not contributory pedigree (family tree) cancer, DM, heart diseases, hypertension, CVA, gout, liver diseases, hepatitis B and C, TB, kidney disease (PKD), etc. (PE) organ system PE (PE) PE vital signs (Lab Data) Hematological examination Chemical analysis test of blood Urine analysis Stool analysis CSF study Culture study EKG, EEG, EMG/NCV (Image Studies) CXR, KUB, Plain abdomen CT, CTA MRI, MRA Echo Endoscope Bone scan, SPECT.

4 (Impression) [3] [2] , [1] [1] Symptomatic diagnosis Abdominal pain, caused to be determined?[2] Anatomical diagnosis Duodenal ulcer[3] Etiological diagnosis NSAID induced gastric ulcers (Impression) final diagnosis , Liver mass, favor liver abscessR/O hepatocelluar carcinomaR/O (rule out) R/O Fever, R/O pneumonia 1. RLQ pain, favor PIDR/O UTI3. Dyspnea, probable pulmonary embolismR/O Asthma4. Right APN with sepsisR/O acute appendicitis (Plan) (problem oriented) Diagnostic plan Therapeutic plan Patient education / instructionProgress Note: SOAP (1)Progress Note: SOAP (2) 8 9 = 8 musculoskeletal chest pain.

5 Ill looking, lethargic and URI Voren = + 8 negative findings no neck stiffness, no photophobia, no LOC, no vomiting, no radiation pain, no negative findings positive findings 8 3/21, 10 am9 2010/03/21, 09:58 8 Lethargic / floppy child Conscious clear Tremor9 8 MBD MBD9 MBD vitals 2 MBD always recheck vital signs 8 9 8 R/O Aortic dissection R/O Pneumothorax R/O Dengue fever R/O HIV or AIDS9.

6 8 X Non displaced fracture Occult hemorrhage9 Preliminary report Not confirmed by radiologist 8 X 9 2 PACS log 8 ( ) 9 8 Sedatives / anxiolytics narcotics 8 (AAD) 9 / AAD 8 9 = = 8 Activity: fair Appetite: ok9 ER 123 8CC / PI Suicidal attempt 9 P t (P t) 30.

7 8 .. 9 susp. R/O LMD: R/O HCC RLQ tenderness, susp. Acute appendicitis Peptic ulcer dz (?) 8 Consult GS 14:43 consult GS Dr. XX for surgery R/O appendicitis 14:55 GS Dr. XX 8 AAD AAD 9 AAD AAD AAD ( ) 8 15:09 vital signs XX order 15:25 2 XX 16:30 XX order Keto 1 amp iv Keto 1 amp iv drip st. (for epigastric pain) NS 300 cc iv bolus st.

8 ( dehydration) Consult Neuro st. ( myoclonus) 8 9 8 9 ( ) HIS ( ) ( ) 8 OR / ICU 9 (ICU / POR / ward) double check Q & A