POMR

Afina Fitra Firdaus

PPDS IPD 50
 Summary of Database
Mrs. S/ 59 y.o/ Ward 28 Bed 13
Autoanamnesa and Heteroanamnesa
Chief Complaint: Pain on her double lumen insertion
History of Present Illness:
‒ The patient came to the hospital with the chief complaint pain on her double lumen insertion area on her right
neck. Pain has been felt since 10 days ago. Her family said at first it only looked red. Patient and her family just
realized that there was pus in the double lumen during routine hemodialysis 2 days ago. At that time the
hemodialysis nurse advised to be hospitalized but the patient refuse it.
‒ Patient said for the last 1 week she felt feverish. The fever was getting better after she took paracetamol. The
patient also felt pain in the right shoulder every time she moved her hand.
‒ Patient was diagnosed with CKD since January this year and has been undergoing hemodialysis with double
lumen access since then. Previously, the patient underwent hemodialysis in Jember and for the past 4 months
the patient has undergone hemodialysis at RSSA with a schedule of 2x a week, Tuesday and Friday.
‒ Patient said that she sometimes felt shortness of breath for the last 1 month. Especially when she was sweeping
the yard or when she was sleeping on her back. The patient sleeps with 2 pillows.
‒ Patient was diagnosed with hypertension since 5 years ago and regularly consumes Furosemide 3x40mg,
Amlodipine 1x10mg, and Captopril 3x25mg.
‒ Patient had a double lumen reinsertion today on her left neck.
 Summary of Database
Past Medical History:
Patient has no past medical history related to current condition.
Family History:
Patient has no family with the same disease as her.
Social History:
Patient is a housewife and lives with her son and daughter-in-law. Her husband deceased 4 years ago.
Review of System:
‒ Patient felt easily tired and tends to be pale.
‒ Decreased appetite.
‒ Patient drink 500cc of water per day.
‒ Reduced urination (about half a glass of aqua per day).
‒ Defecations within normal limit.
 Physical Examination
General appearance Look moderately ill Sat O2 93% on RA
GCS 456 VAS 2/10
BW 50 kg, H 160 cm, BMI 19,5 kg/m2 (normoweight)
BP 184/99 mmHg HR 105 bpm regular strong RR 22 tpm Tax 36.7 oC
Head Conjuctiva Anemic (+), Sclera Icteric (-)
Neck JVP R+2 cmH20, local status of colli (D) : hyperemic, feels warm, tenderness (+),
colli (S) double lumen (+)
Chest Symmetrical, retraction (-)
Lung Sonor | Sonor Vesicular | Vesicular Rhonkhi : - | - Wheezing : -|-
Sonor | Sonor Vesicular | Vesicular -
|- -|-
Sonor | Sonor Vesicular | Vesicular
-| - - |-
Cardio Ictus visible, palpable at ICS VI AAL (S)
LHM ~ ictus, RHM ~ SL (D)
S1 S2 single, regular, murmur (-) gallop (-)
Abdomen Flat, soefl, bowel sound (+) normal
Liver/ unpalpable, liver span 8 cm
Lien/ Traube space tymphany
Extremities Edema (-), pale (+), MMT 5 | 5
5|5
 Laboratory Findings (29/07/2021)
LAB VALUE NORMAL LAB VALUE NORMAL

Leucocyte 9.040 4.700 – 11.300 /µL Ureum 121,7 20-40 mg/dL

Hemoglobine 9,00 11,4 - 15,1 g/dl Creatinine 10,37 <1,2 mg/dL

Hct 26,60% 38 - 42% eGFR 3,619 Ml/mnt/1,73m2

Thrombocyte 175.000 142.000 – 424.000 /µL Natrium 134 136-145 mmol/L

MCV 81,80 80-93 fl Kalium 5,67 3,5-5,0 mmol/L

MCH 27,70 27-31 pg Chlorida 105 98-106 mmol/L

Eo/Bas/Neu/ 0,6/0,2/75,1/ 0-4/0-1/51-67/ Albumin 4,10 3.5-5.5 g/dL

Limf/Mon 13,6/10,5% 25-33/2-5
Chest X-Ray (23/07/2021)
 Chest X-Ray (23/07/2021)
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: Bronchovascular pattern was normal, no infiltrate or opacity
Cor : normal shape, CTR 68%, aorta calcification

Conclusion
Cardiomegaly with aorta sclerosis
 POMR (Problem Oriented Medical Record)
CUE AND CLUE PL IDx PDx PTx PMo&Ed
Mrs. S/ 59 y.o/ Ward 28 1. Infected - Double Non Pharmacology Pmo:
Bed 13 double lumen lumen pus - Bed rest VAS,
Subjective culture - Hemodialysis as patient
- Patient felt pain on her scheduled complain,
double lumen insertion - Renal diet 1700 CBC
for the past 10 days. kcal/day, low salt <2 gr/
- Patient felt fever and got day, protein 1-1,2 Ped:
better with paracetamol gr/kgBW/day Educate the
- She was diagnosed with patient
CKD since 7 months ago Pharmacology about
and underwent HD with - IV Ampicilin Sulbactam double
double lumen access 2x1,5 gr lumen area
since then. - PO Paracetamol 3x500 hygiene,
mg prn and HD as
Objective scheduled.
‒ Tax : 36.7 0C
‒ Head and neck : local
status of colli (D) :
hyperemic, feels warm,
tenderness (+). VAS 2/10

Laboratory
WBC : 9.040
Neutrofil : 75,1
 POMR (Problem Oriented Medical Record)
CUE AND CLUE PL IDx PDx PTx PMo&Ed
Mrs. S/ 59 y.o/ Ward 28 2. CKD Stage 2.1 - USG Non Pharmacology Pmo : BP,
Bed 13 V on routine Hypertension Abdomen - Bed rest UOP, Ur, Cr
Subjective HD Nephrosclerosis - Hemodialysis as
- Patient was diagnosed 2.2 Glomerulo scheduled Ped : Educate
with CKD since 7 months nefritic Chronic - Renal diet 1700 the patient
ago and underwent HD kcal/day, low salt <2 about
with double lumen access gr/ day, protein 1-1,2 importance
since then. gr/kgBW/day of performing
- Diagnosed with HT since HD, drug
5 years ago and routinely Pharmacology compliance,
consume Furosemide - IV Furosemide and daily
3x40mg, Amlodipine 3x40mg water
1x10mg, and Captopril - PO Amlodipine consumption.
3x25mg. 1x10mg

Objective
BP : 184/99 mmHg
UOP : 0,05 cc/ kgBW/ day

Laboratory
Ur/Cr 121,7/10,37 mg/dL
eGFR 3,619
 POMR (Problem Oriented Medical Record)
CUE AND CLUE PL IDx PDx PTx PMo&Ed
Mrs. S/ 59 y.o/ Ward 28 3. HF Stage 3.1 HHD ‒ Echo Non Pharmacology Pmo:
Bed 13 C FC III 3.2 CRS cardio - Bedrest semifowler BP, HR, RR,
Subjective type IV graphy position Sat O2,
- Shortness of breath for the last - O2 nasal canul 2-3 lpm patient
1 month. complaint
- Shortness of breath felt when Pharmacology
she was sweeping the yard or - IV Furosemide 3x40mg Ped:
when she was sleeping on her ‒ PO Amlodipine 1x10mg Educate the
back. ‒ PO Bisoprolol 1x2,5mg patient
- Diagnosed with HT since 5 ‒ PO Candesartan 1x8mg about
years ago and routinely planning
consume Furosemide 3x40mg, diagnostic
Amlodipine 1x10mg, and for heart
Captopril 3x25mg. failure.
- Diagnosed with CKD since 7 Educate the
months ago. patient
Objective about drug
BP : 184/99 mmHg, HR : 105x/m, compliance
RR : 22x/m, SpO2 : 93% RA and
Cor: Ictus visible, palpable at ICS VI limitation
AAL (S) activity.
Ekst: Edema (-)
CXR (23/07/2021) : Cardiomegaly
Laboratory
Ur/Cr 121,7/10,37 mg/dL
eGFR 3,619
 POMR (Problem Oriented Medical Record)
CUE AND CLUE PL IDx PDx PTx PMo&Ed
Mrs. S/ 59 y.o/ Ward 28 4. HT Urgency - - Non Pharmacology Pmo : BP,
Bed 13 - Bed rest funduscopy,
Subjective - Renal diet 1700 ecg
- Diagnosed with HT since 5 kcal/day, low salt <2
years ago and routinely gr/ day, protein 1-1,2 Ped:
consume Furosemide gr/kgBW/day Educate the
3x40mg, Amlodipine patient
1x10mg, and Captopril Pharmacology about
3x25mg. ‒ PO Amlodipine hypertension
1x10mg and how to
Objective ‒ PO Candesartan manage it
BP : 184/99 mmHg 1x8mg with diet
HR : 105x/m control and
good drug
Laboratory compliance
-
 POMR (Problem Oriented Medical Record)
CUE AND CLUE PL IDx PDx PTx PMo&Ed
Mr. AS/28 y.o/Ward 27 5. Anemia - - Non Pharmacology : Pmo : O2
Bed 5 normokrom - Bed rest hunger, Hb,
Subjective normositer - Renal diet 1700 patient
- Patient felt easily tired related to renal kcal/day, low salt <2 gr/ complaint
and tends to be pale. day, protein 1-1,2
- Patient was diagnosed gr/kgBW/day Ped:
with CKD since 7 months Educate the
ago and underwent HD Pharmacology : patient that
with double lumen (-) her
access since then. complaint
caused by
Objective anemia due
Conjungtiva anemic (+) to her CKD
Pale acral (+) condition

Laboratory
Hb 9,00
MCV/MCH 80,70/27,90
 POMR (Problem Oriented Medical Record)
CUE AND CLUE PL IDx PDx PTx PMo&Ed
Mr. AS/28 y.o/Ward 27 6. Mild - - Non Pharmacology : Pmo : SE,
Bed 5 Hyperkalemia - Bed rest ecg, patient
Subjective dt decreased - Renal diet 1700 complaint
- Shortness of breath for renal excretion kcal/day, low salt <2 gr/
the last 1 month. day, protein 1-1,2
gr/kgBW/day Ped:
Objective Educate the
BP : 184/99 mmHg Pharmacology : patient that
HR : 105x/m ‒ PO Kalitake 3x5gr her
RR : 22x/m condition
caused by
Laboratory her CKD.
K+ = 5,67