VMII--Nephrology & Urology

Some additional info on Problem-Oriented Medical Records

(also please refer to the handout Dr. Squires gave you last year) POMR and writing SOAPS is not about good-record keeping. It is an instructional tool for teaching problem-based medical diagnosis and therapeutics. There's no way you'll see enough cases in your senior year such that you'll see one of every sort of thing. Because of this, you need to get as much as possible out of everything you see. Having to write a thorough SOAP allows the clinician to break down a case into problems to be solved; simultaneously, it requires the whole of the patient's problems be addressed. The POMR format is highly structured--this makes it a bit hard at first, but later it's easier once you know the component parts. Novice clinicians are tempted to tell about their cases as if they are telling a story; probably this comes about because we start with the history and that does occur in a time sequence. In my experience, this makes it tempting for senior students to use rounds presentations to tell others only how the animal is doing and what they did with their cases. Instead, we want to know what you're thinking about your case and why you did what you did. Doing good POMR formatted records will force you to think about your cases rather than observing what goes on. I think this a key element in a meaningful senior year...'nuff said.
A PROBLEM is anything that has required, does require, or may require health care management.

4 phases of medical action:

  • database collection -- This provides the source of information for problem formulation (history, PE, previous lab data, RDVM info.)
  • problem definition -- All identified problems are compiled to make a problem list. Combinations of problems are acceptable if they can be defended with reasonable certainty on the basis of current knowledge of the patient. For example, dehydration and anorexia might be lumped with vomiting. The problem is then vomiting characterized by anorexia and dehydration.
  • plan formulation -- Plans are generally divided into diagnostic plans, therapeutic plans, and client education. The diagnostic plans are dictated by your assessment of the cases and the plan of action to rule in or out your various differentials. Plans for monitoring your patient need to be included here. I generally recommend to students that they classify their therapeutic plans. You will understand the whys of your therapies better if you can identify them as supportive, specific, palliative, or symptomatic. Also, you need to actively consider your in-patients food and fluid needs in most cases. Monitoring plans demonstrate that you are aware of what complications might arise for your patient. Client education plans include such things as patient discomfort, diagnostic and therapeutic risk, and prognosis. In your POMR, this is one of the key ways we'll know how well you understand your case.
  • follow-up plans -- These are written as progress notes (SOAPs). They are based on the concept that each unresolved problem should be re-evaluated periodically (usually daily while patients are in the hospital) in consideration of new information as it is obtained.

    Approaching Problems

    Verify -- Localize -- Disease Process -- Specific Disease

    If you remember these four steps in the approach to all patient's problems it will serve you well. In creating a set of hypotheses about what may be causing a problem (i.e. formulating a differential diagnosis) it is tempting to skip forward to disease process (DAMNIT). Resist this temptation until you consider localization of the problem. In the handout from Dr. Squires it mentions definition of a body system. This is not the only way to localize problems. Many problems, in fact, are localized mechanistically.

    Examples:
    hypoalbuminemia**azotemia**icterus
    decreased production**prerenal**prehepatic (hemolysis)
    increased loss**renal**hepatic
    compensatory**post renal**post hepatic

    Chapter 3 of Ettinger is great for this.

    Understanding disease processes is critically important for clinicians, but localizing problems is much more helpful in pointing diagnosticians along the right diagnostic path.

    And something for all you dog aficionados....
    "Not only is life a bitch, it has puppies." - Adrienne E. Gusoff

    Sample POMR and SOAP

    Case Signalment: K9 5 yo, f/s, Miniature Schnauzer "Tessa"

    Hx/PE: Tessa ate a pork chop 2 days ago. Approximately 8 hours ago, he became depressed and started vomiting. She has vomited a clear, yellow fluid 6 to 8 times. She is completely anorexic now. She has no previous medical illness or surgery except for spay after one litter at 3 years of age. She has had no known adverse drug reactions nor is there any history of trauma or toxin exposure. She is an indoor dog and current on vaccinations and heartworm preventative. She eats Kibbles and Bits free choice and some people food. No C/S/D/PUPD.

    PE: 10 kg. QAR, 7%deH2O, T=102.0, P=140, R=40, mm-pink, 1-2 sec
    2cm SC soft mass on the right flank
    tense abdomen, resentful of palpation
    no other abnormal findings

    IPL:
    1. Vomiting (ch by anorexia, deH2O, abdominal pain, depression)
    2. Subcutaneous mass (right flank)

    (this is what you do after you've seen the patient in the exam room)
    PROBLEMSDxR/ODxPlansRxPlansCE
    1. vomitingprimary GI (eg. obstruction, inflammation, toxic)
    vs. secondary GI (pancreatic, renal, adrenal, hepatic)    		abdominal rads, pretx CBC, UA, chem panel w/ lipase NPO, IV LRS (700 cc replace, 600 cc maint., 100 cc ong. loss)need supportive care, minimal dx risk
    2. subcutaneous massinflammation; benign or malignant neoplasia, traumaFNA w/ cytologynonepending results

    								Signature
								------------------

    Evening SOAP:

    1. Vomiting

    S Tessa has not changed appreciably in since this morning attitude. She is depressed, but responsive and resting comfortably in her cage. She vomited small amount of fluid only once today.
    O TPR - normal
    Abnormal Labs: ALB 4.5, ALP 298, ALT 310, AMY 6900 U/L, T.BILI 3.2, LIPASE 7400 U/L, TP 9.9, Na 139, Cl 99
    WBC 19,500/Bands 2,950 (mild toxic change), Hct 58.6
    UA shows moderate bacteruria, USG=1.058, 2+ bili
    RADS: fluid and gas-filled stomach, poor contrast R upper quadrant
    A The laboratory data are consistent with secondary GI, specifically acute pancreatitis. The amylase, lipase and radiographic findings are supportive. The elevated ALT, ALP, Tbili suggest either inflammation to the liver or probably post-hepatic jaundice associated with inflammatory swelling impeding bile flow through the bile duct. The hyponatremia and hypochloremia can be explained by vomiting and the drinking of electrolyte-free water (hypotonic dehydration). The high Hct and TP reflect hemoconcentration assoc. w/ deH2O. Bacteruria is unlikely to be related and has been made a separate problem (#3). Problem 1 may be redefined as acute pancreatitis with biliary stasis.
    P Monitor for complications of pancreatitis including ARF (body weight, approx. ins and outs), DIC (ACT, check venipuncture sites), and cardiorespiratory complications (TPR and character)

    Monitor for resolution of acute pancreatitis and biliary disease. Repeat lipase, amylase, Tbili, ALT, ALP and lytes tomorrow _______.

    Assess resolution of deH2O with body weight and PCV/TP tomorrow _____.

    Rx: specific--keep NPO until no vomiting and lipase is WNL
    supportive -- continue fluid rx but switch to NaCl because of hyponatremia and hypochloremia add maintenance KCl (8 meq since running at 3x maintenance rate for first 24 hours)
    no need to worry about provision of calories with NPO at this time since we expect to be able to feed the dog again within the week
    symptomatic -- could consider antiemetics only if vomiting becomes more severe CE: short-term prognosis is good unless the dog develops a complication. We expect her to be in the hospital for 3 days if all goes well, perhaps up to a week. Long-term we need to avoid risk for recurrent disease by minimizing dietary indiscretion (esp. fats).

    2. Subcutaneous mass
    Ssee problem 1
    OFNA shows only fat
    AAs no cells were seen on FNA the mass is constant with lipoma and the problem will be inactivated.
    PNo dx or rx plans. Advise the client that the mass is benign and can be left alone unless it gets significantly larger and bothers the dog.

    3. Bacteruria
    STessa has urinated several times and no dysuria or pollakiuria was noted.
    O UA showed moderate bacteruria, 0 -2 WBC
    ANeed to verify bacteruria, especially since no significant pyuria nor signs of lower urinary tract disease have been seen.
    PAerobic culture with sensitivity if grows. Advise the client of the possibility of UTI but need to confirm the problem.

    								Signature
								------------------

    Return to the VMII Nephrology & Urology course page