PROBLEM ORIENTED MEDICAL RECORD

Problem List and

Cue and Clue Planning
Initial Diagnosis
Identity: P2/ Mr. MA/ 17 yo Emergency : - Planning Diagnosis:
- - Colonoscopy
Primary survey : - Biopsy (waiting for the result)
Circulation: warm, Airway: patent Breathing: spontan
Secondary survey : Urgency Planning Treatment
Chief complaint : Bloody Stool 1. Hematoschezia - -Bed Rest
- Bloody stool since 1 day before reffered to RSSA, 2 times, the color of 2.1. Related to No. 2 - Soft Diet 1700 kcal/day
the blood was reddish, at about ½ - 1 glass of water per each. - IVFD NS : Aminofluid 2:1,
- Abdominal pain since 5 months ago, intermittently. The pain was like 1500 cc/day
Non Urgency - IV Ondansetron 3x4 mg
being stabbed at all area of his abdomen, especially at upper area of his 2. Decreased of Body Weight + - IV Omeprazole 1x40 mg
stomach. He was brought to hospital and performed operation with the Hematoschezia + Intra Abdominal Mass - IV Asam Tranexamat 3x500
indication of susp appendicitis perforation with peritonitis and mg
abdominal mass, he also got abdominal biopsy at that time. Post Biopsy
1.1. Inflammatory Bowel Disease - PO Paracetamol 3x500 mg
- Decreased of body weight at about 30 kg in the last 5 months. - Confirmed the diagnosis
- Nausea accompanied with vomiting, intermittently in the last 5 1.1. Chron’s Disease
months. He also complaint about decreased of appetite (only ate 1-2 1.2. Colitis Ulcerative Planning Monitoring:
spoons per day). 3. Hypochromic Microcytic Anemia - GI bleeding, Nausea +
- History of malignancy at his family was denied. 3.1. Acute Blood Loss concomittant Vomiting, VAS, VS, CBC +
- Treatment from previous hospital : IV Ceftriaxone 2x1 gram, IV with Iron Deficiency OT/ PT + SE (waiting for the
Tranexamic acid 3x500mg, IV Pantoprazole 1x40 mg, IV Ketorolac 2x30 3.2. Chronic Disease result)
mg, IV Ondansetron 3x4 mg. 4. Nausea + Vomiting
4.1. Related to No 1
Objective: GA: Looked moderately Ill, GCS: 4-5-6; BP: 110/75 mmHg; PR: 4.2. Peptic Ulcer Disease
120 bpm, regular, RR: 21 tpm; Tax: 36,2 C; SaO2: 97 %- Room Air; Karnofsky
Score : 80-90 %; VAS : 5/10 with provocation at Regio Abdomen; Daldiyono
Score : 2 (No sign of dehydration)

H/N: Conjunctiva Anemis (+)

Abdomen : Flat, Normal bowel sound, Liver span 8 cm, Traube’s space
tympani, Tenderness at post operation site, the scar was covered by
bandage
RT: Defecation (+), Blood (+), Mass (-)
 PROBLEM ORIENTED MEDICAL RECORD
Problem List and
Cue and Clue Planning
Initial Diagnosis
Laboratory Findings (06/10/2020) - -
Hb : 9,7 g/dL; WBC : 12480/uL; HCT : 31,6 %; PLT : 582000/uL; MCV : 74,9 fL; MCH : 23,1
pg; Diff : 1/0,2/ 82,5/10,3/6 %; ALC : 1290/uL; Ur/ Cr : 30/1 mg/dL; SE : Na/ K/ Cl :
136/3,8/94 mmol/L ; CEA : 1,7 ng/mL; CA 19-9 : 4,51; LDH : 331 U/L

RBS (16.00) : 91 mg/dL

ECG (06/10/2020) : Sinus Tachycardia HR 120 bpm

CXR (06/10/2020)
- Within Normal Limit

BOF / LLD (06/10/2020)

- No sign of opacity in urinary tract
- No sign of intestine distention