8/22/2019 POMR Intro for DC_2007
1/27
The Problem Oriented
Medical Record(POMR or POVMR)
Master Problem Lists
Writing SOAPs
Master Plan
8/22/2019 POMR Intro for DC_2007
2/27
The purpose of a POMR
Teaching & Learning Emphasize a systematic, analytic approach Help you learn patterns Review (learn)
Integrateproblems & causes Maintain focus on the patient & his/her problems Student evaluatione.g. in your clinical blocks
Communication among members of the medical team(optimize the quality of care and minimize the potential for mistakes)
Legal Record (sign your entries!)
8/22/2019 POMR Intro for DC_2007
3/27
Dr. Lawrence Weed: 1968
Medical Records that Guideand Teach
Patient focused
Problem oriented
8/22/2019 POMR Intro for DC_2007
4/27
POMR = part of an attempt to address the mostcommon problems in diagnosis & case management:
Inadequate hypothesis generation
Inattention or misinterpretation of findings
history, PE, laboratory data, etc.
Premature closure= the clinician stopsgenerating new hypotheses before the correct
diagnosis has been added to the list of DfDxs
The most common interpretive error= overinterpretation or misinterpretation of
findings in light of suspected disease
8/22/2019 POMR Intro for DC_2007
5/27
Common diseases occur commonly. Duh !
The Challenges:
The uncommon presentation of the common disease The common presentation of the uncommon disease
The disease (common or not)that you personally havenot seen before or at least not recognized before.
Pattern recognition.
A function of experience and
knowledge base.
Why are diagnosis USUALLY correct?
8/22/2019 POMR Intro for DC_2007
6/27
POVMR
8/22/2019 POMR Intro for DC_2007
7/27
Master Problem List
A PROBLEM is anything that potentially threatens thehealth of the animal (or herd)and may require medical
attention (at least eventually).
MPL is always kept at the front of the
recordfront and centerThe MPL is updated DAILY
(or at each submission during a DC).
8/22/2019 POMR Intro for DC_2007
8/27
Updating & Revising MPL
NEW problems are added(e.g. new discoveries & new developments)
Some problems are resolved
Problems are re-defined
Combined with other problems
Upgraded to another problem(defined at higher level of understanding)
Problems can be inactivated
Disposition of problems
8/22/2019 POMR Intro for DC_2007
9/27
Example:
1. Vomiting2. Hematemesis
3. Inappetance
4. Lethargy5. Pale mucous membranes
6. Tachypnea
13 year-old intact maleGerman Shorthaired Pointer
7. Anemianon-regenerative8. Azotemia
9. Isosthenuria
10. Hypoproteinemia
Upgrade to #7
Use slide showfunction & click to see
updating MPL
(next slide)
8/22/2019 POMR Intro for DC_2007
10/27
1. Vomiting
2. Hematemesis
3. Inappetance
4. Lethargy
5. Pale mucous membranes
6. Tachypnea
7. Anemianon-regenerative8. Azotemia
9. Isosthenuria
10. Hypoproteinemia
11. Gastric ulceration- endoscopy
12. Interstitial nephritis & fibrosis(end stage kidney)renal biopsy
Upgrade to #11 and/or 12
Upgrade to #11
Upgrade to #12
Upgrade to #12
Upgrade to #11
Upgrade to #11
13. Chronic renal failure (final Diagnosis)
Upgrade to #13
Upgrade to #13
Upgrade to #7
Upgrade to #13
Upgrade to #13
resolved 9/27
8/22/2019 POMR Intro for DC_2007
11/27
Diagnosis
Client Complaint
PROBLEMS
on MPL
Specific Rx
TREATMENT:
symptomatic
supportive
presumptive
8/22/2019 POMR Intro for DC_2007
12/27
S.O.A.P.
Subjective:
attitude, appetite, activity, improving?,
Unchanged? - include clients observations
Objective:
Summarizethe measurable clinical data(fever?, laboratory?, rads?, etc.)
8/22/2019 POMR Intro for DC_2007
13/27
Problem 1. Pale mucous membranes
SO: oral mucous membranes are pale on physicalexamination
Problem 2. Icterus
SO: Yellow tint to oral mucous membranes and scleraare indicative of icterus (accumulation of bilirubin intissues).
Problem 3. Tachypnea
SO: A respiratory rate of 44 is higher than expected ofa normal, inactive dog.
In the VTH, S.O. are often combined:
8/22/2019 POMR Intro for DC_2007
14/27
Problem 4. Diarrhea
SO:Diarrhea in this animal is chronic and appears to be progressing(getting worse). The high volume & low frequency suggests thatthe diarrhea is small intestinal in origin, as does the absence of freshblood, mucus, and tenesmus, which are the cardinal signs of largebowel diarrhea in small animals. The chronic small bowel diarrheaaccompanied by weight loss is most suggestive of a small intestinalmalassimilation syndrome, possibly with protein loss into the feces.
Problem 5. Hepatomegaly
SO: Physical examination revealed hepatomegaly characterizedby extension of the liver beyond the ribs and by rounded edges.The hepatomegaly appears to be diffuse, but further assessment(imaging) would be required to confirm.
8/22/2019 POMR Intro for DC_2007
15/27
S.O.A.P. continued
Assessment: = Analysis of the problem
3 components for each Assessment:[A]General pathophysiologic mechanisms for the
problem.
[B]Pathophysiologic mechanisms likely for THIS CASE.
[C]Differential Diagnoses (DfDx's) for THIS problem.
8/22/2019 POMR Intro for DC_2007
16/27
Considerations:
First: think & write about the problem by itself Before you think about other problems
Before you try to think about specific DfDxs
Then, think and write about the problem in relationto other problems on the MPL and other information.
The most common interpretive error =overinterpretation or misinterpretation offindings in light of suspected disease
e.g. Hypoproteinemia
8/22/2019 POMR Intro for DC_2007
17/27
Has your understanding of the problems changed?- notably changed in light of new data
How can you pull the case or problems together ?
CRITICAL THINKING & INTEGRATION
Can you localize the disease?
(e.g. to an organ system?) Is the signalment important or useful?
species, breed, age, sex
Duration & Course?
Are other animals affected? Was there previous treatment / response?
REMEMBER: The record should capture yourTHOUGHT PROCESSES
8/22/2019 POMR Intro for DC_2007
18/27
DfDxs for the Problem:
Localization
Process (e.g. DAMNIT)
Specific Diseases
Premature closure = the clinician stopsgenerating new hypotheses before the correctdiagnosis has been added to the list of DfDxs
One goal is to avoid:
8/22/2019 POMR Intro for DC_2007
19/27
Initial PLANto address THISproblem.
The plan should help rule in / rule out your
primary DfDx's, or treat the patient.
The initial plan can include: specific diagnostic tests specific treatments
doing nothing (wait & see) client communication plans (including questions)
The proposed plan may be stated as a sequenceof plans or possible courses of actions
S.O.A.P. continued
8/22/2019 POMR Intro for DC_2007
20/27
SOAP Example:Edema
a) General mechanisms
Increased hydrostatic pressure Heart failure, venous obstruction, overhydration
Decreased plasma oncotic pressure: d/t hypoalbuminemiaalbumin production d/t liver disease
intake (malnutrition or protein malabsorption)
protein loss
Renal, GI, skin (wounds & burns), body cavities
Lymphatic obstruction or hypertension (not common) Neoplasia, surgical or traumatic injury, lymphangitis, congenital
Vasculitis
8/22/2019 POMR Intro for DC_2007
21/27
b) This case: No evidence of GI disease
No evidence of heart disease or vasculitis
No obvious evidence of lymphatic disease
Good appetite
Accompanied by weight loss
Possible polyuria & polydipsia according to owners
c) DfDxs: Protein-losing nephropathy
(e.g. glomeronephritis or renal amyloidosis)
Loss in GI, but without producing other enteric signssuch as diarrhea (e.g. lymphangiectasia, chronicparasitism, intestinal neoplasia)
Chronic Liver diseasewould have to be severe
(>80% loss) to produce hypoalbuminemia & edema
8/22/2019 POMR Intro for DC_2007
22/27
RememberSOAPs are written daily
EACH DAY (or at each submission during a DC)
You should SOAP all NEW problems
AND
Re-SOAPall ACTIVE problems on your MPL
IMPORTANT
In particular, your SOAPs of pre-existingproblems should address your updatedanalysis/interpretation of the problem in light ofnew information and any changes in the case.
8/22/2019 POMR Intro for DC_2007
23/27
Also ..
Make sure everyone in the group is sharinghis/her SOAPs and teaching the others
what youve learned.
Otherwise, its like everyone has a PIECE ofthe puzzle, but maybe no one has enough of
the puzzle to pull it together in a cohesiveway.
8/22/2019 POMR Intro for DC_2007
24/27
Do NOT Just copy and paste your SOAP from
one day to the next or from oneproblem to another
unchanged from yesterday, page 12
See Problem #9
8/22/2019 POMR Intro for DC_2007
25/27
P: Initial Planto address this problem
Panel: R/O hypoalbuminemia assess renal function via BUN & creatinine access liver enzymes as evidence of liver disease
Urinalysis:
R/O proteinuria in conjunction with BUN-creatinine, assess renal function
Fecal floatation: R/O intestinal parasites causing protein or blood losss
Depending on results of minimal data base, considerfuturecardiac consultation to rule out congestive heartfailure (chest rads, ECG, echocardiography, stress testing)
Consider bile acids in future, as most sensitive measureof liver function
Talk to ownerabout a more appropriate diet
8/22/2019 POMR Intro for DC_2007
26/27
Master Plan
Panel
UrinalysisFecal Floatation
CBC
At the end of the days record, enter a:
This is what you really want to do NOW.
8/22/2019 POMR Intro for DC_2007
27/27
Questions ?Look at the examples you were
provided
file://Shared/DiagnosticChallenge/Medical_Records_DC
Top Related