POMR

Afina Fitra Firdaus

PPDS IPD 50
 Summary of Database
Mrs. EH/ 58 y.o/ Ward 24a Bed 6
Autoanamnesa
Chief Complaint: Cough
History of Present Illness:
• She complained about productive cough with white yellowish sputum since 2 weeks ago followed
by fever since 1 week before admitted to the hospital.
• She also felt nausea and vomiting and sometimes felt epigastric pain, and also with decreasing of
appetite since 2 weeks ago. She ate 3 times a day, 2-4 tablespoon/ meal.
• History of swollen legs for the past 1 month, but it was not swelling anymore since last week, and
it’s gone by itself.
• She slept comfortably with two pillows, and sometimes all of sudden woke up during her sleep
because of shortness of breath that appeared. Shortness of breath also appeared when she walk
more than 50 meters. These complains happened for the last 4 months.
• History of hypertension 4 months ago, not routinely consume any medication, she consumed
Amlodipine 1x10 mg if only she felt headache.
 Summary of Database
Past Medical History:
Patient has no past medical history related to current condition.
Family History:
Her father also has hypertension.
Social History:
Patient is a housewife and lives with her husband and her 2 daughters.
Review of System:
‒ General: patient felt easily tired
‒ Skin: within normal limit
‒ Head and neck: within normal limit
‒ Respiratory: within normal limit
‒ Gastrointestinal: decrease appetite, nausea without vomit.
‒ Urinary : within normal limit
‒ Extremities: within normal limit
 Physical Examination
General appearance Look moderately ill Sat O2 90% on RA, 99% with O2 via NC 3 lpm
GCS 456 VAS 3/10
BW 80 kg, H 153 cm, BMI 34,17 kg/m 2 (Obese grade
2)
BP 110/99 mmHg HR 87 bpm regular strong RR 22 tpm Tax 36.7 oC
Head Conjuctiva Anemic (-), Sclera Icteric (-)
Neck JVP R+2 cmH20
Chest Symmetrical, retraction (-)
Lung Sonor | Sonor Vesicular | Vesicular Rhonkhi : Wheezing :
-|- -|-
Sonor | Sonor Vesicular | Vesicular -|- -|-
Sonor | Sonor Vesicular | Vesicular -| - - |-
Cardio Ictus invisible, palpable at ICS V 1 cm lateral MCL (S)
LHM ~ ictus, RHM ~ SL (D)
S1 S2 single, regular, murmur (-) gallop (-)
Abdomen Flat, soefl, bowel sound (+) normal, pressure pain (+)
Liver/ unpalpable, liver span 8 cm
Lien/ Traube space tymphany
Extremities Edema (-), MMT 5 | 5
5|5
 Laboratory Findings (10/08/2021)
LAB VALUE NORMAL LAB VALUE NORMAL

Leucocyte 3830 4.700 – 11.300 /µL Ureum 136,6 20-40 mg/dL

Hemoglobine 11.8 11,4 - 15,1 g/dL Creatinine 3,45 <1,2 mg/dL

Hct 33% 38 - 42% eGFR 18,612 Ml/mnt/1,73m2

Thrombocyte 320000 142.000 – 424.000 /µL Natrium 130 136-145 mmol/L

MCV 86,60 80-93 fl Kalium 3,01 3,5-5,0 mmol/L

MCH 30,80 27-31 pg Chlorida 87 98-106 mmol/L

Eo/Bas/Neu/ 0,0/0,0/86,6/ 0-4/0-1/51-67/ CRP Kuantitatif 4,02 <0.3

Limf/Mon 10,8/2,6% 25-33/2-5
Procalcitonin 0,99

Fibrinogen 360,7 200-400 mg/dL

D-dimer 12,38 0-0,4 mcg/mL

Chest X-Ray (10/08/2021)
 Chest X-Ray (10/08/2021)
Thorax AP
AP position, symmetric, enough KV, enough inspiration
Soft tissue and bones were within normal limit
Trachea in the middle
Hemidiaphragm D/S were dome-shaped
Costophrenic angles were sharp
Pulmo: thin infiltrates in middle of lung sinistra dominantly lateral
Cor : normal shape, CTR 48%, aorta calcification

Conclusion
Pneumonia
Aorta sclerosis
Electrocardiography (14/08/21)
 Electrocardiography (14/08/21)
• Sinus Rhythm, HR 87x/m
• Frontal Axis : Normal axis
• Horizontal Axis : Normal axis
• P wave : 0.08”
• PR interval : 0.12”
• QRS complex : RBBB Incomplete
• ST segment : Normal isoelectric
• QT interval : 0,32 s (0,385 QTc)
• T wave : Normal
• U Waves : U waves in V3 and V4
• Conclusion : Sinus Rhythm with HR 87 bpm and RBBB
Incomplete
 POMR (Problem Oriented Medical Record)
CUE AND CLUE PL IDx PDx PTx PMo&Ed

Mrs. EH/ 58 y.o/ Ward 24A 1. CAP PSI 1.1 Viral Blood culture, Non Pharmacology Pmo:
Bed 6A 87% RC. III 1.2 Sputum - Diet 1800 kcal/day with S,VS,SpO2
Subjective Bacterial Culture + Ab extra kalium
- Productive cough with
sensitivity test - O2 via Nasal Canula 2- Ped:
4lpm
white yellowish
• Educate the
sputum Pharmacology patient about her
- History of fever - IVFD NaCl 0,9% 1500 condition and
cc/ 24 hours
the
Objective - IV Levofloxacin
‒ Tax : 36.7 0C 750mg/24hours management.
‒ Spo2 : 90% RA, 98% - PO PCT 3x500 mg prn • Educate that this
condition might
with O2 via NC 3 lpm happen because
‒ RR : 22 tpm of infection.
‒ Pulmo : Ves/ves, Wh -/- • Educate that this
rh -/- condition can
make low intake
Laboratory (10/08/2021) of Oxygen into
her body that can
neutrofil : 86,6% effect to many
bad conditions.
Chest X Ray (10/08/2021)
Pneumonia
Aorta sclerosis

PCR SARS Cov2 :

11/08/2021 : Negative
12/08/2021 : Negative
 POMR (Problem Oriented Medical Record)
CUE AND CLUE PL IDx PDx PTx PMo&Ed
Mrs. EH/ 58 y.o/ Ward 2. HF stage 2.1 HHD Non Pharmacology Pmo :
24A C Fc III dt - Bed rest with semifowler S, BP,HR, UOP,
Bed 6A HHD position Echocardiography
- Diet 1800 kcal/day, low
Subjective salt <2 gr/ day
- Orthopnea (+)
- DoE (+) Ped :
- PND (+) Pharmacology Educate the
- History of Hypertension - IV Furosemide 2x40mg patient about
- PO Bisoprolol 1 x 2,5mg taking medication
Objective routinely.
BP : 110/99 mmHg Restrict salt
HR : 87 bpm consumtion < 2
RR : 22 tpm gram/day
UOP : 0,5 cc/kgBW/hour

ECG (10/08/2021)
Sinus Rhthym 87 bpm
RBBB incomplete

Chest X ray (10/08/2021)

Pneumonia
Aorta sclerosis
 POMR (Problem Oriented Medical Record)
CUE AND CLUE PL IDx PDx PTx PMo&Ed
Mrs. EH/ 58 y.o/ Ward 3. AKI stage 1 3.1. Septic USG Non Pharmacology Pmo:
24A MODS Abdomen - Bedrest evaluate
Bed 6A (Resolved) UOP/24 hours,
3.2. dt. Pharmacology
Ur, Cr/24
Renal ‒ Treat underlying
Subjective Hypoxia disease hours.
- Low urination ‒ IVFD NaCl 0,9% Complete urine
frequency 1500 cc/ 24 hours count

Objective Ped:
UOP: 0,5 cc/kgBW/hour Educate the
patient to
Laboratory (10/08/2021) monitor her
Ur/Cr 136,6/3,45 mg/dL UOP in 24
eGFR 18,612 hours to see
the respond of
the therapy and
to monitor the
disease.
 POMR (Problem Oriented Medical Record)
CUE AND CLUE PL IDx PDx PTx PMo&Ed
Mrs. EH/ 58 y.o/ Ward 4. Hypertension 4.1 Primary Funduscopy Non Pharmacology : Pmo :
24A on Treatment HT - Bed rest S, BP
Bed 6A 4.2 - Diet 1800 kcal/day,
Secondary HT low salt <2 gr/ day
Subjective
- History of Pharmacology :
hypertension since 4 ‒ PO Valsartan 1x80mg Ped:
month ago Educate
- History of consuming the patient
Antihypertension to take
medication
Objective routinely
BP : 110/80 mmHg
 POMR (Problem Oriented Medical Record)
CUE AND CLUE PL IDx PDx PTx PMo&Ed
Mrs. EH/ 58 y.o/ Ward 5. Nausea + 5.1 Acute - Non Pharmacology : Pmo : S, VS
24A vomiting + Gastritis - Diet 1800 kcal/ day
Bed 6A epigastric pain 5.2 PUD
Pharmacology :
Subjective ‒ IV Metoclopramide 3x10 Ped:
- nausea without mg • Educate the
vomiting ‒ PO Lansoprazole 1x30mg patient that
- History of epigastric her
pain condition
caused by
Objective her AKI.
VAS 3/10 • Educate to
Abdomen : epigastric pain eat in small
(+) portion but
frequent
 POMR (Problem Oriented Medical Record)
CUE AND CLUE PL IDx PDx PTx PMo&Ed
Mrs. EH/ 58 y.o/ Ward 6. Mild - - Non Pharmacology : Pmo :
24A Hypokalemia - Diet 1800 kcal/day S,VS, SE
Bed 6A with extra Evaluation
Potassium
Subjective
- General weakness Pharmacology : Ped:
(-) Educate the
Objective patient that
- her condition,
and to eat
Laboratory (10/08/2021) food that
Potassium : 3,01 mg/dL contain high
ECG: U wave in V4, V5 potassium
like banana
and etc.
 POMR (Problem Oriented Medical Record)
CUE AND CLUE PL IDx PDx PTx PMo&Ed
Mrs. EH/ 58 y.o/ Ward 7. Hypercoagulable - - Non Pharmacology : Pmo :
24A state dt Septic Faal
Bed 6A Condition Hemostasis,
Pharmacology :
Subjective ‒ SC Heparin for Bleeding
history of swollen leg prophylaxis 2x5000 signs and
with pain since 1 month IU sign of VTE

Objective
Padua Score: 6 (High Ped:
Risk VTE) -Educate the
Improved Bleeding patient about
Score : 2.5 giving
anticoagulan
Laboratory (10/08/2021) t drugs, side
D-Dimer : 12,48 effects and
monitor for
bleeding
signs.
 POMR (Problem Oriented Medical Record)
CUE AND CLUE PL IDx PDx PTx PMo&Ed
Mrs. EH/ 58 y.o/ Ward 8. - - Non Pmo :
24A Hyperphosphatemia Pharmacology : S, VS, Phosphor
Bed 6A dt decreased of renal -
excretion Pharmacology :
Subjective ‒ PO CaCO3
-low urination 3x500mg Ped:
frequency Educate the
patient that her
Objective condition might be
- caused by
reversible renal
Laboratory impairment
(10/08/2021)
Phosphor : 5,8 mg/dL
 POMR (Problem Oriented Medical Record)
CUE AND CLUE PL IDx PDx PTx PMo&Ed

Mrs. EH/ 58 y.o/ Ward 9. Obesity gr. 2 - - Non Pharmacology : Pmo :

24A - BW, BP, Blood
Bed 6A Pharmacology : Glucose, Profil Lipid
-
Subjective
- - Ped:
• Educate the patient
Objective to modify for healthy
BMI : 34,17 kg/m2 lifestyle like doing
some execise.
• Educate the benefit
of loosing body
weight and keep in
shape.
• Educate the risk
from being obese
can effect some
uncommunicable
diseases.
 Problem Analysis

AKI CAP

Septic Condition

Acute
PUD
Gastritis
Hyperphospatemia Hypercoagulable
State

Nausea Vomiting

Obese Grade II

Low Intake

Hypertension

Hypokalemia
Heart Failure
Risk Factor Analysis

Torres et all, 2013. Risk Factor of Community Acquired Pneumonia in

Adults in Europe in Literature Review.
 Risk Factor Analysis

Score : 2.5

Score : 6

William’s Hematology. 10th Edition.2018

 Key Message Pathophysiology

Respiratory Defense Mechanisms and Stages of Pathogenesis in CAP

Grossman S. Porth's pathophysiology: Concepts of altered health states. Lippincott Williams &
Wilkins; 2014 Aug 13.
Key Message
Diagnosis
Lim et all, Nottingham University
Hospital, BTS guidelines for the
management of community acquired in
pneumonia in adults.2019
Key Message Management

Toronto Notes. 2020. Infectious Diseases : Respiratory Infections

Key Message Management

Prina et all, Community-acquired pneumonia, Lancet Vol 386. 2015

 Key Message Therapy

Metlay JP,et al., Diagnosis and treatment of adults with community-acquired pneumonia. An official clinical practice guideline of the American Thoracic
Society and Infectious Diseases Society of America. American journal of respiratory and critical care medicine. 2019 Oct 1;200(7):e45-67.
Key Message Therapy

Prina et all, Community-acquired pneumonia, Lancet Vol 386. 2015

Key Message Therapy

Panduan Penggunaan Antimikroba Profilaksis dan Terapi Edisi V Tahun 2020 RSSA
 Key Message Social

● Educate the patient to routinely consume her

medication.
● Educate to always use mask to prevent another
respiratory infection.
● Good emotional support from the family, health care
provider, and spiritual support must be given to the
patient.
● Educate the patient to do light exercise such as walking
in the morning for 30 minutes a day and etc for a
healthy lifestyle and loosing bodyweight to prevent the
risk factors of some noncommunicable diseases.
 Condition This Morning

GCS : 456
BP : 110/70 mmHg
HR : 88 beats per minute
RR : 20 times per minute
Tax : 36,6 C
SpO2 : 99% with O2 via nasal canula 3lpm