PROBLEM ORIENTED MEDICAL RECORD

Problem List and

Cue and Clue Planning W
Initial Diagnosis

Identity: P2/ Mrs.T/49 yo Emergency Planning Diagnosis ER

Primary survey : - - CBC, blood smear, LDH,
Airway: patent , Breathing: spontant, Circulation: Warm coomb's test
Urgency
Secondary survey :
1. Bicytopenia + incompatible Planning Therapy
Chief complaint : General weakness cross match - bed rest
General weakness for the last 3 days, decreased of appetite (+), 1.1 AIHA - HCHP diet 1800 kcal/day
nausea(-), vomiting (-), Fever (-), SOB(-).Patient looked pale. Black - IVFD NS 1500 cc/day
stooll(-), bleeding gum (-), red patches (-) Non urgency - IV PRC transfusion 1 bag/day,
- with premed:
- IV Methylprednisolone 125
Objectives: look moderate ill, GCS 456 CM, BP: 110/70 mmHg, HR:
mg
92 bpm, RR: 16 tpm, tax: 36,1 C, SpO2: 99% room air
- IV Dipenhidramine 10 mg
H/N: anemic (+)
Thorax: symmetric, ret (-), Rh (-/-), Wh (-/-) Planning Monitoring
Abdomen: soefl, flat, BS 8 tpm, liver span 10 cm, spleen unpalpable - TRALI, TACO
Extremities: warm acrale, edem (-/-)

LAB( 2/11/2019) CBC: 5,7/7.940/18,2%/26.000, MCV/MCH: 94/29,7

diffcount: 78/14/5/3/0, RBS: 176, Na/K/Cl: 139/3,6/101, BUN/Cr:
25/0,7

Crossmatch (2/12/19)
major +2 / minor +2 / auto control +2 / DCT +3

ECG (2/12/19)
sinus rhythm 96 bpm References:
PAPDI 4th ed
Sabbatine
 PROBLEM ORIENTED MEDICAL RECORD
Problem List and
Cue and Clue Planning W
Initial Diagnosis
Identity: Mrs M/ 47 yo/ P2 Emergency Planning Diagnosis: E
Primary survey : - SE, Ur, Cr CXR R
Airway: patent , Breathing: spontan, Circulation: Warm Planning Therapy :
Urgency
Secondary survey : - Bed rest
-
Chief complaint : Rigth jaw swollen - HCHP Soft Diet 2100 kkal/hari
- IVFD Rehydration NS 0.9% 500
Right jaw swollen and difficult to swallow solid food since 4 days Non Urgency CC  NS 0.9% 1500 CC/day
ago, Fatigue since 3 days ago without nausea nor vomitting. 1. AML M1 - PO Paracetamol 3X500mg
Bleeding was denied. Diagnosed with AML M1 since may 2019 and 2. Anemia related to no. 1 - IV Transfusion of PRC 2 bags/day
got 2 times chemoterapy Daunorubicin and Cytarabine and did not 3. Cephalgia, related to 1 with target Hb 10 g/dL
4. Right Submandibula Abscess
continued it because there is not a family who accompanied her to
Planning Monitoring:
got control. S, VS, UOP, Leucostatic
Objective : symptom, CBC, BMP
look moderately ill, GCS 456 CM, BP: 100/57 mmHg, HR: 74 bpm,
RR: 18 tpm, Tax 36,1 C, SpO2: 99% NRBM 10 lpm, VAS 3/10
H/N: anemic (+), edema regio submandibular D, 4x6 cm. Thorax:
symmetric, ret (-/-), wh (-/-), rh (-/-). Abdomen: soefl, flat,
tenderness (-), Extremities: warm acral, edem (-/-)
LAB: Hb 6.8, MCV/MCH : 81/33.4 fl/pg, Leu 82850, Hct 16.44% , Plt
32000.
ECG: SR, HR 75 bpm
BMP (17/5/2019) : AML M1 (AML Without maturation)

References:
PAPDI 4th ed
Sabbatine