POMR (Problem

POMR (PROBLEM Oriented Medical

ORIENTED MEDICAL Record)
RECORD)
CUE AND CLUE PL Idx PDx PTx PMo&Ed
Mr. LP /36 yo/ Ward DOC + Shock 1.1 Hypoxic Non Pharmacology PMo:
Ciliwung Condition Encephalo - Temporary fasting S, VS, UOP,
pathy - NGT Insertion sign of
Subjective 1.2 dt - Equal fluid balance- respiratory
- DOC since yesterday (+) lethal Line 1: rehidrasi NaCl failure, SpO2,
- SOB (+) ascidosis 0,9% 15-20 GCS
- Dhiarrea (+) 1.3 cc/kg/jam
Hyperglice PEdu:
Objective mya crisis Pharmacology Education
GCS : 345 -Drip NE 0,05-2 about
BP 85/50 mmHg ; mcg/kgBB/jam, start possible
HR 58 bpm dosis 0,1, if arter cause of DOC,
RR 25 tpm (kussmaul) rehydration MAP prognosis,
SpO2 100% RA <65mmHg and
Uop: 150cc/2 jam -HD Cito dt severe treatment
metabolic acidosis
Laboratorium - Consult to anastesi
BGA : pH 6,81/ pCO2 17,6/ department for ICU
pO2 91,2/ HCO3 2,9/ BE - Observation
31,7
Conclusion : severe
metabolic acidosis
P/F Ratio: 434 mmHg (not
ARDS)
 POMR (Problem
POMR (PROBLEM Oriented Medical
ORIENTED MEDICAL Record)
RECORD)
CUE AND CLUE PL IDx PDx PTx PMo&Ed
Mr. LP /36 yo/ Ward 2. Hyperglycemic 2.1 C-peptide, Non Pharmacology PMo:
Ciliwung State Hyperglycemic keton serum, - Temporary fasting RBS per
Crisis keton urin - NGT Insertion hours, BGA
Subjective 2.1.1 HHS - Equal fluid balance- and SE per 6
- DOC (+), SOB (+) 2.1.2 KAD Line 1: rehydration hours
-Diagnosed with DM 2.2 NaCl 0,9% 15-20
since 12 years ago, take Hyperglycemic cc/kg/hour continue PEdu:
lantus 12 unit and apidra in Critically Ill with IVFD Wida KN Possible
3x4 unit 1500cc/24hour causes of high
during drip insulin blood glucose
Objective Monitoring of
GCS : 345 BP 85/50 Pharmacology laboratory
mmHg ; - Line 2: drip Insulin findings
RR 25 tpm (kussmaul) 0,14unit/kg titration
SpO2 100% RA according to RBS ~
Uop: 150cc/2 jam -Line 3: Nabic Infusion 75
BB: 65 kg | TB: 170 kg | meq dalam NS / 8 hour
BMI: 22,5 kg/m²GDS -HD Cito dt severe
Laboratorium metabolic acidosis
POCT (14.00) : HI
POCT (19.50) : HI
SE : 127 /4,63/100
Osm : ??
Laboratorium
BGA : pH 6,81/ pCO2
17,6/ pO2 91,2/ HCO3
2,9/ BE -31,7
Conclusion : severe
metabolic acidosis
 POMR (Problem
POMR (PROBLEM Oriented Medical
ORIENTED MEDICAL Record)
RECORD)
CUE AND CLUE PL IDx PDx PTx PMo&Ed
Mr. LP /36 yo/ Ward 3. SOB  3.1 dt lethal NT pro bnp Non Pharmacology PMo:
Ciliwung acidosis    - O2 suplementation S, VS, UOP,
3.2 related to HF - Equal fluid balance- sign of
Subjective respiratory
-SOB (+) since this Pharmacology failure, SpO2,
morning -HD Cito dt severe GCS
- HT(+) Since 5 month metabolic acidosis
routinely consumed - Treat HF PEdu:
amlodipin 1x10mg, Education
captopril 3x35, concor about
1x2,5mg possible
cause of SOB,
Objective prognosis,
RR 25 tpm (kussmaul) and
SpO2 100% RA treatment
Laboratorium
BGA : pH 6,81/ pCO2
17,6/ pO2 91,2/ HCO3
2,9/ BE -31,7
Conclusion : severe
metabolic acidosis

CXR
11/4/2022Cardiomegaly
 POMR (Problem
POMR (PROBLEM Oriented Medical
ORIENTED MEDICAL Record)
RECORD)
CUE AND CLUE PL IDx PDx PTx PMo&Ed
Mr. LP /36 yo/ Ward 4. CKD stage 5     4.1 DKD    - Non Pharmacology PMo:
Ciliwung newly 4.2 HTN - O2 suplementation S, VS, UOP,
diagnosed - Equal fluid balance sign of
Subjective respiratory
Diagnosed with DM since Pharmacology failure, SpO2,
12 years ago -HD Cito dt severe GCS
-HT(+) Since 5 month ago metabolic acidosis
PEdu:
Objective Education
UOP : about
possible
Laboratorium cause of CKD,
Ur/Cr : 165,1/6,25 prognosis,
Ca/Pho : 8,4/ 11,9 and
BGA : pH 6,81/ pCO2 treatment
17,6/ pO2 91,2/ HCO3
2,9/ BE -31,7
Conclusion : severe
metabolic acidosis

CXR
11/4/2022Cardiomegaly

USG Abdomen
12/1/22Parenchymatous
renal bilateral
 POMR (Problem
POMR (PROBLEM Oriented Medical
ORIENTED MEDICAL Record)
RECORD)
CUE AND CLUE PL IDx PDx PTx PMo&Ed
Mr. LP /36 yo/ Ward 5. HF Stage C 5.1 HHD    Non Pharmacology PMo:
Ciliwung FC III    5.2 DCM Echocardiogr - O2 suplementation S, VS, UOP,
aphy - Equal fluid balance- sign of
Subjective respiratory
-SOB (+) when doing mild Pharmacology failure, SpO2,
activity -PO Amlodipin 1x10mg GCS
- HT(+) Since 5 month -PO Captopril 3x25 mg
routinely consumed -PO Concor 2,5mg-0-0 PEdu:
amlodipin 1x10mg, Education
captopril 3x35, concor about
1x2,5mg possible
cause of SOB,
Objective prognosis,
RR 25 tpm (kussmaul) and
SpO2 100% RA treatment

CXR 11/4/2022
Cardiomegaly

ECG 11/4/2022
Sinus Bradikardi, 58 bpm