POMR

PPL IDX PDX PTX PMO

1. Mrs. Nurul Hidayati/ 66yo/ 10894244 1. Acute lung infection 1.1 CAP PSI 86 RC III - Sputum gram culture - O2 tappdown SM 7 lpm (~ FiO2 needed • Vital sign
DST 0,6) • Clinical features
Anamnesa - IVFD NS 0,9% 1000cc/24 hours • Lab evaluation
• SOB (+) 1 day ago - IV Moxiflocaxin 1x400 mg • CXR evaluation
• Cough 2 weeks and yellowish sputum (+) - PO NAC 3x400 mg

Physical examination
GA : Moderate GCS : 456
BP : 188/117 mmHg RR : 26 x/min

HR : 79 x/min Temp : 36,9

⁰C
SpO2 :90 % on RA  99% on NRBM 10lpm
Pulmo : BS bvbvv/bvbvv Rh ++-/++- wh ---/---

Laboratorium finding
CBC 8,7/6860/27,7/317000
DC 3,4/0,3/65,7/18,2/12,4
BGA on NRBM 10 lpm
7,46/34,1/278,1/24,5/0,4/97,7%

CXR:
Pulmo D : Infiltrat airbronchogram (+) at the
middle area of the lung
Conclusion : Pneumonia
 POMR
PPL IDX PDX PTX PMO

2. Mrs. Nurul Hidayati/ 66yo/ 10894244 2. Chronic lung infection 2.1 Susp. Lung TB, TCM - Sputum TCM - O2 tappdown SM 7 lpm (~ FiO2 needed • Vital sign
unknown, HIV unknown - Culture MGIT 0,6) • Clinical features
Anamnesa - PITC - IVFD NS 0,9% 1000cc/24 hours • Lab evaluation
• SOB (+) 1 days ago - PO ATD 4FDC 1x4 tabs if TB established • CXR evaluation
• Cough (+) since 2 weeks ago with yellowish - PO Vit B6 1x25 mg if ATD administered • BTA smear 2nd month
sputum
• Decreased appetite (+)

Physical examination
GA : Moderate GCS : 456
BP : 188/117 mmHg RR : 26 x/min

HR : 79 x/min Temp : 36,9

⁰C
SpO2 :90 % on RA  99% on NRBM 10lpm
Pulmo : BS bvbvv/bvbvv Rh ++-/++- wh ---/---

Laboratorium finding
CBC 13.10/9500/40.10/271,000
DC 1.4/0.20/77.50/12.0/8.90
BGA on 4lpm NC 7.47/39.2/71.7/28.7/4.9/94.4

CXR:
Pulmo D et S : Infiltrat milier (+) at all area of
both lung
Conclusion : Lung TB
 POMR
PPL IDX PDX PTX PMO

3. Mrs. Nurul Hidayati/ 66yo/ 10894244 3. Heart failure 3. HF St C FC III - NT Pro BNP - O2 tappdown SM 7 lpm (~ FiO2 needed • Vital sign
- ECG 0,6) • Clinical features
Anamnesa - Echocardiography - IVFD NS 0,9% 1000cc/24 hours
• SOB (+) 1 days ago - Consult to cardiology dept
• History of HT since younger age

Physical examination
GA : Moderate GCS : 456
BP : 188/117 mmHg RR : 26 x/min

HR : 79 x/min Temp : 36,9

⁰C
SpO2 :90 % on RA  99% on NRBM 10lpm
Pulmo : BS bvbvv/bvbvv Rh ++-/++- wh ---/---

CXR:
Cor Size CTR 61%/Site Normal/Shape
Cardiomegaly
 POMR
PPL IDX PDX PTX PMO

4. Mrs. Nurul Hidayati/ 66yo/ 10894244 4. Hipentension stage 2 4.1 Primary Hypertension - PO Amlodipin 1x10 mg • Vital sign
4.2 Secondary • Clinical features
Anamnesa Hypertension
• History of HT since younger age

Physical examination
BP : 188/117 mmHg
HR : 79 x/min

CXR:
Cor Size CTR 61%/Site Normal/Shape
Cardiomegaly
 POMR
PPL IDX PDX PTX PMO

5. Mrs. Nurul Hidayati/ 66yo/ 10894244 5. Bone Fracture 5.1 Close Fracture 1/3 - - O2 tappdown SM 7 lpm (~ FiO2 needed • Vital sign
proksimal os femur D 0,6) • Clinical features
Anamnesa - IVFD NS 0,9% 1000cc/24 hours
- History of fell down 1 week ago at her room - Consult to Orthopaedi dept
with sitting position
- Right leg pain (+)

Physical examination
Extremities: Warm acral, CRT < 2 seconds,
Femur D oedem (+) tenderness (+) palpable
warmth (+) limited ROM

Xray Femur D RS Prima Husada 14/9/23

Fracture of the right femoral column
 POMR
PPL IDX PDX PTX PMO

6. Mrs. Nurul Hidayati/ 66yo/ 10894244 6. Hyperglicemia 6.1 dt reactive - FBG, BG2PP, HbA1c - Antidiabetic drugs (waiting for diagnose • Vital sign
6.2 dt DM type 2 to be established) • Clinical features
Anamnesa - Consult to Internal Dept Medicine • Blood glucose
- History of previous illness DM (+) monitoring
uncontrolled

Laboratorium finding
RBG 275
 POMR
PPL IDX PDX PTX PMO

7. Mrs. Nurul Hidayati/ 66yo/ 10894244 7. Azotemia 7.1 dt dehydration - IVFD NS 0,9% 1000cc/24 hours • Clinical features
7.2 dt reactive - Consult to Internal Dept • Vital sign
Laboratorium finding • Urine Output
Ur/Cr 59,0/2,18 eGFR 22,86 • Ureum and creatinin

PPL IDX PDX PTX PMO

8. Mrs. Nurul Hidayati/ 66yo/ 10894244 8. Anemia 8.1 Low intake - Blood smear - Pro transfusi PRC 1 bag/day until Hb >10 • Clinical features
8.2 Chronic disease • Vital sign
Laboratorium finding • Lab evaluation post
Hb 8,7 transfusion
MCV /MCH/MCHC 89,6/28,2/31,4

PPL IDX PDX PTX PMO

9. Mrs. Nurul Hidayati/ 66yo/ 10894244 9. Moderate 9.1 dt Low intake - Vip Albumin 3x2 caps • Clinical features
Hypoalbuminemia 9.2 Hypercatabolic state - Extra white egg Diet • Albumine evaluation
General weakness (+)
Decreased of appetite (+)

Laboratorium finding
Alb 2,56
Answer from Orthopaedi dept
Answer from Cardiology dept
Answer from Internal Medicine dept
 Patient’s Condition this Morning
S O A P

‐ GA : Moderate IDx : PDx :

1. CAP PSI 86 RC III - Sputum gram culture + DST
2. Susp. Lung TB, TCM unknown, HIV unknown - Sputum TCM
‐ GCS : 456 3. HF St. C FC II dt HHD - Culture MGIT
4. HT St. II uncontrolled - PITC
5. Close Fracture 1/3 proksimal os femur D - FBG, BG2PP, HbA1c
‐ BP : mmHg 6. Hyperglicemia dt susp. DM type 2 dd reactive - CRP, Procal
7. Pre renal Azotemia
8. Anemia NN PMo :
‐ HR : Bpm 9. Moderate hypoalbuminemia - Lab evaluation 3 days post AB
- CXR evaluation 5-7 days post AB or if there is worsening condition
‐ RR : x/min PTx :
- O2 tappdown SM 7 lpm (~ FiO2 needed 0,6)
‐ Temp - IVFD NS 0,9% 1000cc/24 jam
: o
C - IV Moxiflocaxin 1x400 mg
- PO NAC 3x400 mg
‐ SpO2 : - PO Amlodipin 1x10 mg
- PO Vip Albumin 3x1
- PO ATD 4FDC 1x4 tabs if TB diagnosed
Pulmo - PO Vit B6 1x25 mg if ATD given
- Pro transfusi PRC 1 bag/day until Hb >10
‐ Insp ‐ Aus - Consult to Cardiology Dept at ward with HF and HT
bV bV
-Consult to Orthopaedi Dept at ward with CF Femur
- Consult to Internal Medicine with Azotemia and hyperglycemia
Static D=S bV bV - Extra white egg Diet
Dynami D=S V V
c

‐ Palp N N Rh - -
SF

N N - -

N N - -

‐ Perc S S Wh - -

S S - -

S S - -
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