PROBLEM ORIENTED MEDICAL RECORD

Planning Planning Planning

Cue and Clue Problem List Initial Diagnosis Planning Therapy
Diagnosis Monitoring Education
Mr. S/ 74 yo/ER 1 Shortness of 1. Pneumo Non Farmakologi : -Subjective. -Edukasi
Anamnesis: breath Thorax Dextra Bed Rest -Vital Sign. penyakit, terapi,
Shortnes Of Breath, since 6 2 Chest Pain O2 NRBM 10 lpm - CxR Post dan prognosis.
days ago, worsened 4 days 3 Acute cough Chest Tube insertion Pemasangan -Edukasi
ago, SOB isn’t related to Farnakologi : Chest tube Penyakit dan
activity, usually sleeps with IVFD NaCl 0,9% kemungkinan
one pillow 1500cc / 24 jam penyebab
Productive cough (+) since 6 Paracetamol 500mg -Edukasi
days ago with withish 3x1 if in pain Berhenti merokok
sputum
Chest Pain (+) since 4 days
ago
History of Smoking 1-2
packs since 60 years ago
Physical examination:
BP: 140/90 mmHg
HR : 88x/min
RR: 28x/min
Temp: 36,3OC
SPO2: 99% NRBM 10 lpm
Breathing sound
Ant Post
BV B BV B
V V
↓V V ↓V V

↓V V ↓V V
Stem Frenitus
 Acute cough 2. Community 1.Sputum Non Farmakologi : -Subjective -Edukasi
Ant Post Lung Infection Acquired Culture O2 NRBM 10 lpm -Vital Sign penyakit, terapi,
N N N N Pneumonia 2.Blood Bed Rest dan prognosis.
Culture Farmakologi : -Edukasi
↓N N ↓N N IVFD NS 0,9% 20 tpm Penyakit dan
↓N N ↓N N Inj. Ceftriaxone 2x1 gr kemungkinan
IV penyebab
Inj. Levofloxacin 1 x 750 -Edukasi
Percussion mg Berhenti merokok
Ant Post PO Codein 3x10mg
PO Paracetamol
 S S S S 3x500mg

 H S H S
S S
 H S H S
S S

Diagnostic:
CxR : Pneumothorax D,
Acute Infection of Lung, Lung Mass S 3. Lung Mass S 1.CxR Lateral Non Farmakologi : -Subjective -Edukasi
Lung Mass S O2 NRBM 10 lpm -Vital Sign penyakit, terapi,
Laboratory Result (7-01- 2.CT Scan Bed Rest dan prognosis.
2019) : Thorax Farmakologi : -Edukasi
Leucocyte : 12.530 /µL ↑ - Penyakit dan
Limphocyte count: 5.237 kemungkinan
DL : 0,9/ 0,5/ 53,7/ penyebab
41,8/3,2% -Edukasi
Berhenti merokok
Na/K.Cl: 135/4,32/112
mmol/L
According to chest X-Ray this is a picture of a Male patient
Age and Identity unknown
The Chest X-ray quality enough Kv, and penetration.
There is enough Inspiration.
The Chest is Symetrical, This is a AP picture from the Closed
Scapulae D & S.

The Soft tissue appeared normal there were no mass or fibrotic

Imaging on the picture.
The Chest’s bone appeared normal, there is no osteolytic lesion
There is no Osteophyte, there is no fracture line, there is no
Disalignment on the Claviculae, Costae, and Scapulae.

The Trachea in the middle

The Aorta appeared normal, there is no Aortic Dilatation, no

Elongation, Calsification.

The Heart appeared normal the CTR is 50%

From the left Lung, Broncho Vesicular pattern increased.

there is a radiopaqe mass in the upper lobe of left lung, there is a
infiltrate in the left lung

From the right lung, There was pleural visceral line in the lower lobe of the lung, its difficult to assess the broncovascular
pattern of the patient.

The Hemidiapraghm D&S is doom shaped with sharp costophrenic and cardiac-diapraghm angle on both lung
BGA
Pasien menggunakan NRBM 10 lpm
pH : 7,31
pCO2 : 34,1
pO2 : 108,9
HCO3 : 17,2
BE : -9,4
SpO2 97,8%

Kesimpulan Acidosis metabolic Partially compensated

- True O2 = (0,21/Fraksi O2 yang dipakai) x pO2

True O2 = (0,21/0,99) x 108,9 = 23,1% ~ severe hypoxemia

- PaO2 = (713x fraksi O2 yang dipakai) – (pCO2/0.8)

PaO2 = (713x 0,99) – (108,9/0.8)
= 569,74

- A-a O2 = PaO2 – pO2

A-a O2 = 569,74 – 108,9
= 460,84

- FiO2 needed = ((A-a O2 + 150)/760) x 100%

FiO2 needed = ((460,84 + 150)/760) x 100%
= 80% ~ 8-9 lpm NRBM
SOFA SCORE

PaO2 : 569,75 mmHg [0]

FiO2 : 80% [0]

On Mechanical Ventilation : - [0]

Plateletes : >150x103/µL [0]

GCS : 15 [0]

Bilirubin : no lab result [0]

MAP : >70mmHg , no Vasoactive agent [0]

Creatinine : No lab Value [0]

0 Point SOFA Score (≤ 9 SOFA Score Predict 33.3 % mortality rate on patient)
PSI/PORT SCORE

Result : 102 points – Class IV High Risk; 8,2-9,3% Mortality Risk; require Inpatient Patient Admission