POMR (Problem Oriented Medical Record)

CUE AND CLUE PL IDx PDx PTx PMo&Ed

Mr. T/86yo/ Ward 26 1. Decrease of 1.1 Uremic Head CT-scan Non Pharmacology: • S,VS
SUBJECTIVE conscoiusness encephalopathy - Proper Position FluidBalance
- Decease of consciousness, 1.2 Septic - Decubitus Matrase ,UOP, GCS,
gradualy since 2 days ago encephalopathy - NGT -> Fluid Diet 6x200cc Serial/24hr,
- Shortness of breath 5 day ago (2 1.3 Hypoxic - O2 suplementation BGA/24 hr
days after addmission in previous encephalopathy Maintain O2 >95%
hospital) 1.4 Hypertensive
Enchepalophaty • PDx:
OBJECTIVE Pharmacology: Education
GCS:435; HR: 110bpm; R: 24 bpm cito hemodyalis about the
SaO2: 98%NRBM 15llpm cause
Th: Rh +/+; Wh -/+ unconsciousne
Lateralisati (-) s can becuse
of severe
LABORATORY systemic
wbc: 23.000 infection,
Ur/Cr: 330,2/8,42
CRP: 16,2
Procalcitonin 13,59
BGA
pH 7,29/ pCO2 29,9/ pO2 136,5/
HCO3 14,5/ BE -12,2/ SaO2
98,4%
Conclusion: Uncompensated
metabolic ascidosis
P/F Rasio: 151 mmHg (Moderate
ARDS)

RADIOLOGY
-Pnemonia + Cardiomegaly
 POMR (Problem Oriented Medical Record)
CUE AND CLUE PL IDx PDx PTx PMo&Ed
Mr. T/86yo/ Ward 26 2. Septic 2.1 HAP - Blood Non Pharmacology: • S,VS, CBC
SUBJECTIVE condition culture - Proper position GCS, BGA/24
- Shortness of breath 5 day ago (2 - Sputum - IV Plug jam, CXR
days after addmission in previous culture and - O2 Suplementation Maintain
hospital), cough (+) DST O2 >95%
- Hystory of fever (+) • PDx:
• Educate the
OBJECTIVE - Pharmacology: cause of the
GCS:435 ; R: 24 bpm - IV Moxifloxacin 2x400mg infection can
SaO2: 98%NRBM 15llpm - IV Meropenem 2x1 gram be from
Th: Rh +/+; Wh -/+ pulmonary
Q-SOFA: 2 points infection.
• Educate the
LABORATORY patient
WBC : 23.400 About
Procalcitonin 13,59 planning and
BGA treatment
pH 7,29/ pCO2 29,9/ pO2 136,5/
HCO3 14,5/ BE -12,2/ SaO2
98,4%
Conclusion: Uncompensated
metabolic ascidosis.
Asam laktat : 4
P/F Rasio: 151 mmHg (Moderate
ARDS)
RADIOLOGY
-Pnemonia + Cardiomegaly
 POMR (Problem Oriented Medical Record)
CUE AND CLUE PL IDx PDx PTx PMo&Ed
Mr. T/86yo/ Ward 26 3. Shortness of 3.2 CAP dd HAP - Blood Non Pharmacology: • S,VS Balance
SUBJECTIVE breath + cough 3.2 COPD acute culture, - Bed rest semifowler Position cairan, UOP,
- Shortness of breath 5 day ago (2 + desaturation exaxerbation with sputum - IV Plug GCS, EKG
days after addmission in previous secondary infection culture + DST, - Negative fluid balance Serial/24jam,
hospital) 3.3 ALO NT pro BNP, - O2 suplementation, mantain BGA/24 jam
- DOE (+), PND (+), Orthopneu (+) 3.3.1 Non- O2 >95%
-History of Active somker (+), Cardiogenic dt.
previous dyspneu (+) Uremic Lung Pharmacology: • PDx:
- History of Hpertension (+) 3.3.2 - IV Moxifloxacin 2x400mg • Educate the
Cardiogenic dt. sambil menunggu hasil kultur patient
OBJECTIVE ADHF about the
TD : 186/121 diagnosis
R: 24 bpm • Educate the
SaO2: 98%NRBM 15llpm patient
Th: Rh ++/+-; Wh ++/-- About
JVP R+3cm H20 planning and
treatment
LABORATORY
WBC : 23.400
Ur/Cr: 330,2/8,42
CRP: 16,2
Procalcitonin 13,59
BGA
pH 7,29/ pCO2 29,9/ pO2 136,5/
HCO3 14,5/ BE -12,2/ SaO2
98,4%
Conclusion: Uncompensated
metabolic ascidosis
P/F Rasio: 151 mmHg (Moderate
ARDS)

RADIOLOGY
-Pnemonia + Cardiomegaly
 POMR (Problem Oriented Medical Record)
CUE AND CLUE PL IDx PDx PTx PMo&Ed
Mr. T/86yo/ Ward 26 4. HF stage C Fc 4.1 HHD - NT pro BNP Non Pharmacology: • S,VS, UOP,
SUBJECTIVE IV 4.2 DCM - - Bed rest proper positioning EKG
- DOE (+), PND (+) Orthopneu (+) Echocardiogra - IV Plug Serial/24jam,
- SOB even when rest. phy - Negative fluid balance
-History of hypertension since 10 - O2 suplementation, maintain • PDx:
years ago o2 • Educate the
patient
OBJECTIVE Pharmacology: about the
GCS:435; BP: 186/121 - IV Furosemide 3x40 diagnosis
HR: 110bpm; R: 24 bpm - Po Lisinopril 1x10mg • Educate the
SaO2: 98%NRBM 15llpm patient
JVP R+4cmH20 About
Th: Rh +/+; Wh -/+ planning and
Cor: ictus palpable at ics V 2cm treatment
lateral MCL S

EKG: Sinus aritmia 90bpm + RBBB

Incomplete

RADIOLOGY
-Pnemonia + Cardiomegaly
 POMR (Problem Oriented Medical Record)
CUE AND CLUE PL IDx PDx PTx PMo&Ed
Mr. T/86yo/ Ward 26 5. AKI Stage 3 5.1 Obstructive - Non Pharmacology: • S,VS, Balance
SUBJECTIVE dd acute On urophty Uroflowmetry - IV Plug cairan, UOP,
-DOC since 2 days ago CKD 5.2 Septic MODS - Equal fluid balance Ur/Cr, CBC,
- Shortness of breath 5 day ago (2 5.3 HTN - Consult to urology
days after addmission in previous departement
hospital) • PDx:
-Preeviously admitted in hospital Pharmacology: • Educate the
with nausea and vomiting - Cito Hemodyalisis patient
about the
-OBJECTIVE diagnosis
GCS 335 • Educate the
BP: 186/126 RR: 24 bpm patient
SaO2: 98%NRBM 15lpm About
Th: Rh +/+; Wh -/+, planning and
Q-SOFA: 2 points treatment
UOP : 0,4cc/kgBB/jam
LABORATORY
Ur/Cr: 330,2/8,42
BUN Cr/Ratio: 15,01 (Renal/Post
Renal Type)
Ca/Phospor: 7,7/6,1

USG 20/01/2021--RS Baptis

Kediri
Nephrolithiasis multiple bilateral
and mild hydronephrosis (grade
1) dextra
 POMR (Problem Oriented Medical Record)
CUE AND CLUE PL IDx PDx PTx PMo&Ed
Mr. T/86yo/ Ward 26 6. HT - - Non Pharmacology: • S,BP/hour,
SUBJECTIVE Emergency - Bed rest proper position EKG serial/12
-DOE (+),orthopneu (+), PND (+) TOD (Cardiac - IV Plug hour, GCS
- Hystory of Hypertension (+) and renal, - O2 supplementaton,
Brain) maintain O2>95 % • PDx:
OBJECTIVE - Equal fluid balance • Educate the
BP: 186/121, N 110 irreguler patient
JVP R+4Cm H2O Pharmacology: about the
Rh++/+- - Drip GTN 5-200mcg/menit diagnosis
EKG: Sinus aritmia 90bpm + RBBB target TDS <140 mmHg • Educate the
Incomplete - IV Furosemide 3x40 patient
About
RADIOLOGY planning and
-Pnemonia + Cardiomegaly treatment
 POMR (Problem Oriented Medical Record)
CUE AND CLUE PL IDx PDx PTx PMo&Ed
Mr. T/86yo/ Ward 26 7. Anemia 7.1 Fe Deficiency SI TIBC Ferritn Non Pharmacology: • Oxygen
SUBJECTIVE Hipokrom 7.2 Chronic Disease transferin Bed rest proper Position Hunger, CBC
-Fatigue 1 week before admisson mikrositer saturation - Fluid diet 6x200cc Post
- Nausea and vomiting, decrease - Equal fluid balance Tranfusion
of appetite (+)
Pharmacology:
OBJECTIVE - Transfusi 1 PRC pack/day or • PDx:
H/N: anemic conjungtiva (+) 2 pack durante HD • Educate the
patient
about the
LABORATORY diagnosis
Hb: 6,6 • Educate the
MCV/MCH: 61,6/20,6 patient
Ur/Cr: 330,2/8,42 About
planning and
treatment
 POMR (Problem Oriented Medical Record)
CUE AND CLUE PL IDx PDx PTx PMo&Ed
Mr. T/86yo/ Ward 26 8. Geriatric - - Non Pharmacology: • S,VS
SUBJECTIVE problems - Bed rest properr Position
-DOC since 2 days ago (infection, - Equal fluid balance • PDx:
- Shortness of breath 5 day ago (2 instability - NGT • Educate the
days after addmission in previous immobilization) - Fluid Diet 6x200cc patient
hospital), Cough (+) -Maintain O2 >95% about the
-History of fever (+) -Decubitus Mattress diagnosis
• Educate the
Pharmacology: patient
-OBJECTIVE - IV Moxifloxacin 2x400mg About
GCS:335; BP: 186/121 planning and
HR: 110bpm; R: 24 bpm treatment
SaO2: 98%NRBM 15llpm
Q-SOFA: 2 points

LABORATORY
WBC: 23.400
CRP: 16,2
Procalcitonin 13,59

RADIOLOGY
-Pnemonia + Cardiomegaly