PROBLEM ORIENTED MEDICAL RECORD

Cue and Clue Problem List and Planning Ward

Initial Diagnosis
Identity: Mr. S/66yo/P2 Regular ER Emergency Planning therapy and diagnosis ER
Primary survey: -  Digestive surgery:
Circulation: warm, Airway: patent , Breathing: spontant • Insert NGT, for decompression
Secondary survey: Chief complaint: Abdominal pain Urgency • fluid diet 6x200 cc
He suffered from abdominal pain since 3 days ago, pain felt 1. Change of bowel habbit + • IVFD Tutosol 1500 cc/24 jam
continously. Accompanied with constipation since 5 months partial bowel obstruction • IV Ranitidine 2x50 mg
ago, intermittently, getting better with laxative. Defecation 1.1 Colorectal malignancy • IV Metamizole 3x1 gram
like goat-feces since 2 months ago. History of bloody 1.2 Adenocarcinoma recti • IV Ciprofloxacin 2 x 400 mg
defecation (-). Nausea and vomit since 3 days ago, vomit • IV Metronidazole 3x500 mg
everytime he ate food. Decrease of appetite (+) decrease of Non-Urgency • Elective colonoscopy
body weight (-). History of hypertensionwas denied, 2. AKI stage 2
malignancy (-). 2.1 Volume depletion Planning Therapy :
2.2 decrease renal perfusion 1. Fluid rehidration with NS 500-
Objective: Looked moderately ill, GCS 456. BP 147/76 mmHg, 3. Hypertension stage 1 1000 cc/ hour, maintenance with
PR 62 tpm RR 20 tpm. Tax 36.0 C. SaO2 98% RA 4. Nausea + vomiting + 1500 cc/24 hours
abdominal pain 2. Equal fluid balance, with urine
positif findings : 4.1 related to no.1 output target 0.5-1cc/KgBW/hour
Abdomen : Soefl (+), convex, tymphani in all area, 5. Mild hypokalemia dt low 3. Avoid nephrotoxic drug, suggest
tenderness (+) UOP : 500 cc/10 hours intake substitute metamizole with
6. Geriatric problems (inanition, paracetamol and ranitidine with
Laboratory : CBC : 14.7/ 14.030 /41.40%/ 134.000 instability) omeprazole
MCV/MCH : 90.20/32.0 fl/pg, Ur/Cr : 96.5/2.83 mg/dL, eGFR 4. PO Amlodipin 1x10 mg
: 22,35, RBS : 83 SGOT/SGPT : 20/26 U/L, Albumin : 2.91 g/dL,
CRP : 3.38, CEA 2.43, SE : 142/ 3.21/118 mmol/L Planning Monitoring:
S, VS, Urine production/24 hours,
CXR 22/6/21 : within normal limit Ur/Cr/24 hours, potassium every 3
BOF 3 position 23/6/21 : Meteorismus days

Patient will be collaborative care

with Nephrology division