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EProblem Oriented Medical Record Patient
1. PPL IDX PDX PTX PMO
1. Mrs. O/63yo/11605451
Anamnesa
• Cough (+) with sputum since 4 months
ago, history on OAT 4th months (+), loss
of body weight (+)
Physical examination
GA: moderate GCS: 4x6
BP: 108/89 mmHg HR : 189 x/min
RR : 24 x/min Temp : 36,9⁰C
SpO2: 89% on RA
Pulmo: BS vvv/vvv Rh ---/--- Wh ---/---
Laboratorium finding
CBC 9.3/10,300/29.1/103000
DC 0/0.1/80.4/10.2/9.3
CXR: Infiltrat (+) at the lower area, fibrosis
(+)
1. Chronic lung infection 1.1 Clinically diagnosed
Lung TB, TCM
Unknown, HIV Unknown
on OAT 4th month
- Sputum TCM
- PITC
- O2 4-5 lpm NC
- PO OAT Hepar Regimen Lfx 1x500
mg + E1000 mg (postponed)
• Vital sign
• Clinical features
• Lab evaluation LFT,
RFT
• Sputum BTA at 5th
month
• CXR evaluation at
6th month
POMR
2. PPL IDX PDX PTX PMO
2. Mrs. O/63yo/11605451
Anamnesa
• Enlargement of right lymphnode, History
on OAT 4th months (+), loss of body
weight (+)
Physical examination
GA: moderate GCS: 4x6
BP: 108/89 mmHg HR : 189 x/min
RR : 24 x/min Temp : 36,9⁰C
SpO2: 89% on RA
Pulmo: BS vvv/vvv Rh ---/--- Wh ---/---
Enlargement of right lymphnodes region
(+) diameter 2 cm
Laboratorium finding
CBC 9.3/10,300/29.1/103000
DC 0/0.1/80.4/10.2/9.3
FNAB Colli
Granulomatous chronic lymphadenitis with
granular necrosis
2. Lymphadenopathy 2.1 Lymphadenitis TB
on OAT 4th month
- - PO OAT Hepar Regimen Lfx 1x500
mg + E1000 mg (postponed)
• Vital sign
• Clinical features
• Lab evaluation LFT,
RFT
• Sputum BTA at 5th
month
• CXR evaluation at
6th month
POMR
3. PPL IDX PDX PTX PMO
3. Mrs. O/63yo/11605451
Anamnesa
• History on OAT 4FDC for 2 months,
yellowish and vomiting, loss of body
weight (+)
Physical examination
GA: moderate GCS: 4x6
BP: 108/89 mmHg HR : 189 x/min
RR : 24 x/min Temp : 36,9⁰C
SpO2: 89% on RA
Pulmo: BS vvv/vvv Rh ---/--- Wh ---/---
Laboratorium finding
Pattimura Lab on 8/12/23
Bil TDI 13.13/10.18/2.95
OT/PT 60/25
3. Hyperbilirubinemia 3.1 Drug Induced Liver
Injury (Improved)
- - PO Curcuma 3x1 tab
- Switch OAT 4FDC to OAT Hepar
regimen
• Vital sign
• Clinical features
• Lab evaluation LFT
POMR
4. PPL IDX PDX PTX PMO
4. Mrs. O/63yo/11605451
Anamnesa
• Vomit since 1 months ago especially
after consumed OAT, nausea (+), loss of
body weight (+)
Physical examination
GA: moderate GCS: 4x6
BP: 108/89 mmHg HR : 189 x/min
RR : 24 x/min Temp : 36,9⁰C
SpO2: 89% on RA
Pulmo: BS vvv/vvv Rh ---/--- Wh ---/---
Abdomen soefl, BU (+)
Laboratorium finding
CBC 9.3/10,300/29.1/103000
DC 0/0.1/80.4/10.2/9.3
4. Vomiting 4. Dt OAT side effect - - IV Metoclopramide 3x10 mg
- IV Ranitidin 2x50 mg
• Vital sign
• Clinical features
POMR
5. PPL IDX PDX PTX PMO
5. Mrs. O/63yo/11605451
Anamnesa
• Difficult to communicate, immobilize
since 2019, history of CVA hemmoragic
in 2019 and 2021
Physical examination
GA: moderate GCS: 4x6
BP: 108/89 mmHg HR : 189 x/min
RR : 24 x/min Temp : 36,9⁰C
SpO2: 89% on RA
Pulmo: BS vvv/vvv Rh ---/--- Wh ---/---
Facial droop (+)
5.1 Dysarthria
5.2 Immobilization
5.1 dt history of CVA
hemmoragic 2nd attack
- - Medical rehabilitation • Vital sign
• Clinical features
POMR
6. PPL IDX PDX PTX PMO
6. Mrs. O/63yo/11605451
Physical examination
GA: moderate GCS: 4x6
BP: 108/89 mmHg HR : 189 x/min
RR : 24 x/min Temp : 36,9⁰C
SpO2: 89% on RA
Pulmo: BS vvv/vvv Rh ---/--- Wh ---/---
6. Controlled
Hypertension
6.1 Primary
Hypertension
6.2 Secondary
hypertension
- - PO Amlodipin 1x10 mg • Vital sign
• Clinical features
POMR
PPL IDX PDX PTX PMO
7. Mrs. O/63yo/11605451
Anamnesa
intermittent cough (+), sputum (+) since 4
months ago, immobile since 2019, Loss of
appetite (+), weight loss (+) 10 kg in 2
years.
Physical examination
GA: moderate GCS: 4x6
BP: 108/89 mmHg HR : 189 x/min
RR : 24 x/min Temp : 36,9⁰C
SpO2: 89% on RA
Pulmo: BS vvv/vvv Rh ---/--- Wh ---/---
Conjunctiva Anemis +/+
Laboratorium finding
CBC 9.3/10,300/29.1/103000
DC 0/0.1/80.4/10.2/9.3
7. Anemia NN 7.1 dt Chronic Disease
7.2 Low intake
- Blood smear - IVFD NS 0,9% 20 tpm
- Treat the underlying disease
• Vital sign
• Clinical features
7. PPL IDX PDX PTX PMO
8. Mrs. O/63yo/11605451
Physical examination
GA: moderate GCS: 4x6
BP: 108/89 mmHg HR : 189 x/min
RR : 24 x/min Temp : 36,9⁰C
SpO2: 89% on RA
Pulmo: BS vvv/vvv Rh ---/--- Wh ---/---
Laboratorium finding
Ur/Cr 107/5,26
8. AKI stage III 8.1 dt low intake
8.2 dt parenchymal
disease
- USG abdomen - IVFD Rehidration 500 cc
- Consult to Internal medicine Dept.
• Vital sign
• Clinical features
• UOP
• Ur/Cr
POMR
PPL IDX PDX PTX PMO
9. Mrs. O/63yo/11605451
Anamnesa
Myoma uteri when she was young
9. Gynaecologic tumor 9.1 Hystori of Myoma
Uteri
- - • Vital sign
• Clinical features
8. Patient’s Condition this Morning
S O A P
SOB (+), Cough (+),
Sputum (+)
‐ GA : Moderate Idx :
1. Clinically diagnosed Lung TB, TCM Unknown, HIV Unknown on
OAT 4th month
2. TB lymphadenitis on ATD 4th month
3. DILI (improved)
4. Vomiting with ATD side effects
5. History CVA Hemorrhagic 2nd attack
6. HT St. 1
7. Hystory Uterine myoma
8. Anemia
9. AKI St III dd ACKD
Pdx :
- Sputum TCM Tb gen Xpert
- PITC
PMo
- Lab Eval LFT 3 days
- UOP
PTx :
- O2 tappdown NK 5 lpm (~FiO2 needed 0.44)
- IVFD NS 0.9% : Futrolit 1:1 1000 cc / 24 hours
- IV Metoclopramide 3x10 mg
- IV Ranitidine 2x50 mg
- PO ATD Hepatic Regimen Levofloxacin 1x500mg + Ethambutol 1000 mg
(Postphoned)
- PO Vit B6 1x25 mg
- PO Curcuma 3x1
- PO Amlodipine 1x10 mg
- Consult to Internal medicine department regarding AKI
The patient admitted in RHCU Brantas bed 4
‐ GCS : 456
‐ BP : 116/66 mmHg
‐ HR : 84 bpm
‐ RR : 22 x/min
‐ Temp : 36,9 oC
‐ SpO2 : 99% on 5 lpm NC
Pulmo
‐ Insp ‐ Aus V V
Static D=S V V
Dynami
c
D=S V V
‐ Palp
SF
N N Rh - -
N N - -
N N - -
‐ Perc S S Wh - -
S S - -
S S - -
