PROBLEM ORIENTED MEDICAL RECORD

Problem List and

Cue and Clue Planning
Initial Diagnosis
Identity: P2/ Mrs. G/ 63 yo Emergency : - Planning Diagnosis:
- - CBC, Ur/Cr, SE, OT/PT, CRP,
Primary survey : Procalcitonin, Albumin, ECLIA,
Circulation: warm, Airway: patent Breathing: spontan UL
Secondary survey : Urgency - Fluid ascites culture
Chief complaint : Abdominal pain 1. Severe Hypokalemia
- Abdominal pain since 1 month ago, intermittently. Got worsened since 1.1. GI Loss Planning Treatment
the last 1 week. 1.2. Renal Loss - -Bed Rest
- Mass at abdomen since 6 months ago, got bigger with time. - Soft Diet 1700 kcal/day
2. Multiple Cystic Hepar + Polycystic - IVFD D10 % Loading 150 cc —
Accompanied with nausea and vomiting 1-2 times per day, contained Renal + Aneurism A. Iliaca Communis > Maintanance IVFD D10 %
fluid residue at about 100 cc per each. 2.1. Pyogenic Abscess Liver 1500 cc/24 hours
- Shortness of breath got better with sitting position. - Hypokalemia correction :
- Decreased body weight at about 5 kg in the last 3 months. 2.2. Autosomal Dominant Polycystic
Kidney Disease with liver involvement Kalium needed 78 mEq —>
- General weakness since 1 month ago. She can only do mild activity. Drip KCl 25 mEq in 500 cc NS
- Vaginal bleeding was denied. in 4 hours with the rate 10
- History of malignancy in her family was denied. Non Urgency mEq with perifer access (3
- Treatment from previous hospital : IV Ceftriaxone 2x1 gram, IV Novalgin 3. Myoma Uteri times)
3x1 gram, IV Ondansetron 3x4 mg, IV Ranitidine 2x50 mg. 4. Tend to Hypoglycemia - IV Metronidazole 3x500 mg
- IV Ceftriaxone 2x1 gram
4.1. Low Intake - IV Metoclopramide 3x10 mg
Objective: GA: Looked moderately Ill, GCS: 4-5-5; BP: 110/60 mmHg; PR: 5. Nausea + Vomiting related to No 1 (prn)
84 bpm, regular, RR: 20 tpm; Tax: 36,6 C; SaO2: 95 %- Room; Karnofsky 6. Geriatric Problem (Inanition, - PO Paracetamol 3x500 mg
Score : 60-70 %; VAS : 5/10 with provocation at Regio Abdomen; Barthel Immobility) - Planning for abscess drainage
Index : 45 (Partially Dependent) ; MNA : 5 (Malnourished)
Planning Monitoring:
Pulmo: Decreased Vesicular Sound + Dullness at Medio Basal Pulmo S - Abdominal Pain, VAS, VS
Abdomen : - RBS/ 4 hours, SE Post
- Mass at Regio Epigastrium – hypochondrium D size 8x8 – 10x11 cm, the Correction
consistency solid, Mobile, clear edge, flat surface, Tenderness (+), Bruit
(-)
- Mass at Supra Pubic, size 13x16 cm, solid, Mobile, flat surface, clear
edge, Tenderness (+), Bruit (-)

Ekst : Odem at Bilateral Inferior Extremities

 PROBLEM ORIENTED MEDICAL RECORD
Problem List and
Cue and Clue Planning
Initial Diagnosis
Laboratory Findings (30/09/2020) - -
Hb: 11,1 g/dL; WBC: 11550/uL; HCT: 33,9 %; PLT: 527000/uL; MCV: 71,1 fL; MCH: 23,3
pg; Diff: 5/0/71/15/8 %

RBS (00.00) : 66 mg/dL

Laboratory Findings (01/10/2020) (Critical Result from the laboratory by phone)

K: 2,1 mmol/L

ECG (30/09/2020) : Sinus Rhythm HR 75 bpm, Incomplete RBBB

CXR (30/09/2020)
- Pleural thickening ec chronic inflammation

Abdominal USG (16/09/2020)

Conclusion :
- 2 large mass at lobus sinistra liver (12 cm) and lobus dextra (8,5 cc) with liquification
inside,susp liver abscess with small nodule at lobus dextra liver, 1,5 cm - 2 cm dd
hepatoma
- Uterus myomatous, the size 3 cm - 7 cm

Abdominal CT Scan with Contrast (23/09/2020)

- Multiple cyst at lobus dextra and sinistra liver, clear edge, capsulation (+), size 11,3 x
12,9 x 11,8 cm, with normal echoparenchym
- Solid Mass at uterus, heterogen, calcification (+), without contrast enhancement
- Ren D and S : multiple small cystic
- Dilatation fusiform A. Iliaca comunis D size 4,2 x 3,1 x 4,1 cm
Conclusions:
- Hepatomegaly ec multiple abscess lobus D/S
- Myoma uteri
- Multiple simple cyst ren bilateral
- Minimal Ascites
- Pleural thickening D/S
 PROBLEM ORIENTED MEDICAL RECORD
Problem List and War
Cue and Clue Planning
Initial Diagnosis d
Identity: P2/ Mr D/40 y.o Emergency: PLANNING DIAGNOSIS ER
Primary survey : - RT PCR naso-oropharyngeal swab
Circulation: warm, Airway: patent Breathing: spontan Sputum culture and DST
Secondary survey : Urgency:
Chief complaint : Shortness of Breath 1. Pneumonia PLANNING THERAPY
- SOB since 5 days before admission. It worsened with activity. 1.1. Probable Covid 19 - Bed Rest
Cough (-) 1.2. Pneumonia CAP - O2 NRBM 10 lpm
- Fever since 10 days before admission. It was low grade fever - Diet 1700 kkal/day with high
and intermitten. Non Urgency: Kalium
- Sorethroat since 6 days before admission 2. Mild Hypokalemia - IVFD NS 1500 cc/24 jam
- Nausea (-). Vomiting (-), diarrhea (-). 2.1. Low intake - IV Levofloxacin 1x750mg
- His parent was hospitalized because of probable covid 19 - IV Vit C 3x200 mg
- P.o. Hydroxychloroquin 1x400
Objective : mg
KU: look moderately ill, GCS : 456; BP : 128/73 mmHg N: 132 bpm ; - P.o. Oseltamivir 1x75 mg
RR : 32 tpm T: 37,2⁰C; Sat O2 : 97% NRBM 10 lpm - P.o. Paracetamol 3x500 mg
-
Laboratory 6/9/2020 : DL : 13,70/4.940/39,10/344.000; MCV/MCH PMo:
: 78,40/27,50 ; diffcount : 0,0/0,2/77,5/17,0/5,3; Fibrinogen 346,4; S, VS, sign of ARDS
D dimer : 0,47 ; Anti Sars CoV 2 : Reactive; Procalcitonin : 0,15
SE : 125/3,16/97
BGA : 7,44/31,8/53,5/21,8/-2,5/88,8%

CXR 28/9/2020 Pneumonia ec viral

ECG : Sinus Tachycardia 132 bpm

References:
PAPDI 4th ed
Pedoman Covid-19 Rev 4