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  • Tabel POMR Sabtu Malam 141023

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    1. The patient is a 67-year-old female presenting with cough, shortness of breath, bloody cough, and weight loss. Imaging shows a left lung mass. 2. The patient develops pneumonia in addition to the lung mass. She is treated with antibiotics, oxygen, IV fluids, and pain medications. 3. The patient begins experiencing grade 1 hemoptysis related to the lung mass. She receives additional treatments to manage bleeding including oxygen, IV fluids, and tranexamic acid if needed.

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    tabel POMR Sabtu Malam 141023

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    1. The patient is a 67-year-old female presenting with cough, shortness of breath, bloody cough, and weight loss. Imaging shows a left lung mass. 2. The patient develops pneumonia in addition to the lung mass. She is treated with antibiotics, oxygen, IV fluids, and pain medications. 3. The patient begins experiencing grade 1 hemoptysis related to the lung mass. She receives additional treatments to manage bleeding including oxygen, IV fluids, and tranexamic acid if needed.

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    7 views5 pages

    Tabel POMR Sabtu Malam 141023

    Uploaded by

    bondkaboom
    1. The patient is a 67-year-old female presenting with cough, shortness of breath, bloody cough, and weight loss. Imaging shows a left lung mass. 2. The patient develops pneumonia in addition to the lung mass. She is treated with antibiotics, oxygen, IV fluids, and pain medications. 3. The patient begins experiencing grade 1 hemoptysis related to the lung mass. She receives additional treatments to manage bleeding including oxygen, IV fluids, and tranexamic acid if needed.

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    © All Rights Reserved
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    of 5

    POMR

    PPL IDX PDX PTX PMO

    1. Sri Utami/67 yo/11593375 1. Lung tumor 1. Lung Tumor S T3NxMx - Sputum Sitologi - PO Codein 3x20 mg • Vital sign
    Ps 1-2 Kx Hemoptoe - CT Scan Thorax + - PO Paracetamol 3x500 mg • Clinical features
    Anamnesa Kontras
    • Intermittent SOB (+) since 1 month ago, DOE - FOB/TTNA
    (+), Cough (+), Bloody cough (+)
    • Decreased of appetite (+) and weight loss (+)

    Physical examination
    GA moderate GCS 456
    BP 134/88 mmHg HR 87 x/min
    RR 18 x/min Tax 36,5 oC
    SpO2 99% on 2 lpm NC
    Pulmo :
    I : Static D=S ; Dinamic D=S
    P : SF Normal/Normal
    P : Sonor/Sonor
    A : BS vvv/vvv Rh ---/--- Wh +--/+--
    BW 60 kg BH 155 cm

    CXR:
    Pulmo S : Opacity with irregular margin at
    the upper and middle area of the lung
    Conclusion : Left lung mass
    POMR
    PPL IDX PDX PTX PMO

    2. Sri Utami/67 yo/11593375 2. Acute lung infection 2.1 Pneumonia obstructive - Sputum Gram Kultur - O2 2 lpm NC if needed • Vital sign
    2.2 CAP PSI 87 RC III DST - IVFD NS : Bfluid = 2:1 = 1500 cc/24 • Clinical features
    Anamnesa hours • Lab evaluation
    • Intermittent SOB (+) since 1 month ago - IV Levofloxacin 1x750 mg • CXR evaluation
    worsening in the last 2 days, DOE (+), Cough - PO Codein 3x20 mg
    (+) since 2 days ago, Bloody cough (+)

    Physical examination
    GA moderate GCS 456
    BP 134/88 mmHg HR 87 x/min
    RR 18 x/min Tax 36,5 oC
    SpO2 99% on 2 lpm NC
    Pulmo :
    I : Static D=S ; Dinamic D=S
    P : SF Normal/Normal
    P : Sonor/Sonor
    A : BS vvv/vvv Rh ---/--- Wh +--/+--
    BW 60 kg BH 155 cm

    Lab RSUB 14/10/23


    CBC 12,6/13.210/39,9/134.000
    DC 0,4/0,8/73,5/7,3/18

    CXR:
    Pulmo S : infiltrate airbronchogramat the
    upper and middle area of the lung.
    Conclusion : Pneumonia
    POMR
    PPL IDX PDX PTX PMO

    3. Sri Utami/67 yo/11593375 3. Hemoptoe grade 1 3.1 dt Lung Tumor S - - O2 2 lpm NC if needed • Vital sign
    T3NxMx Ps 1-2 Kx - IVFD NS : Bfluid = 2:1 = 1500 cc/24 • Clinical features
    Anamnesa Hemoptoe hours
    • Intermittent SOB (+) since 1 month ago, - IV Tranexamic Acid 3x500 mg if needed
    Cough (+), Bloody cough (+) - PO Codein 3x20 mg

    Physical examination
    GA moderate GCS 456
    BP 134/88 mmHg HR 87 x/min
    RR 18 x/min Tax 36,5 oC
    SpO2 99% on 2 lpm NC
    Pulmo :
    I : Static D=S ; Dinamic D=S
    P : SF Normal/Normal
    P : Sonor/Sonor
    A : BS vvv/vvv Rh ---/--- Wh +--/+--
    BW 60 kg BH 155 cm

    Lab RSUB 14/10/23


    CBC 12,6/13.210/39,9/134.000
    DC 0,4/0,8/73,5/7,3/18
    FH 27,9/9,8 INR 0,8

    CXR:
    Pulmo S : Opacity with irregular margin at
    the upper and middle area of the lung
    Conclusion : Left lung mass
    POMR
    PPL IDX PDX PTX PMO

    4. Sri Utami/67 yo/11593375 4. Hematemesis 4.1 dt Susp Varises - USG abdomen - O2 2 lpm NC if needed • Vital sign
    Esophagus (improved) - IVFD NS : Bfluid = 2:1 = 1500 cc/24 • Clinical features
    Anamnesa hours
    • Nausea (+), vomiting (+) blood (+) - IV Tranexamic Acid 3x500 mg if needed
    • Decreased of appetite (+) and weight loss (+) - IV Ranitidine 2x50 mg
    - Consult to Internal Medicine dept
    Physical examination
    GA moderate GCS 456
    BP 134/88 mmHg HR 87 x/min
    RR 18 x/min Tax 36,5 oC
    SpO2 99% on 2 lpm NC
    BW 60 kg BH 155 cm

    Lab RSUB 14/10/23


    CBC 12,6/13.210/39,9/134.000
    DC 0,4/0,8/73,5/7,3/18
    FH 27,9/9,8 INR 0,8
    POMR
    PPL IDX PDX PTX PMO

    5. Sri Utami/67 yo/11593375 5. Hypertension 5.1 Primary hypertension - - PO Valsartan 1x160 mg • Vital sign
    5.2 Secondary - PO Herbeser 1x200 mg • Clinical features
    Physical examination hypertension
    GA moderate GCS 456
    BP 134/88 mmHg

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