Mr. R/ 61 years old/W.

27
1. UTI
2. Lung Infection
2.1 Pneumoniae CAP
2.2 Lung TB

3. LUTS + Gross hematuria

3.1 BPH
3.2 Ca prostat
3.3 rupture uretra

4. Schizophrenia
5. Azotemia
5.1 Renal
5.2 Pre renal

Summary of Data Base

Mr. R/ 61 years old/W. 27
HISTORY TAKING

: anamnesa with patient and his son

CHIEF COMPLAINT : pain urination

HISTORY OF PRESENT ILLNESS
Patient suffered from pain when passing urine since 1 month before admission,
intermittenly, without fever and blood but patient said sometimes with pus when the first
passing urine. He just felt pain in gland penis. Pain when passing urine worsened since 3
days ago. Patient felt difficult to pass urin. Because of that condition, his familly admitted
him to lawang hospital and he went hospitalized for 1 day. He never felt anyanganyangan before.
Patient complained about cough since 1 year ago, productive cough with greenish
color sputum, but without blood. Patient never consumes drug for 6 months. Sometimes
he felt shortness of breath when he walks around 1 km. He just need 1 pillow when he
slept and never woke up at night because of shortness of breath. Patient never had fever
nor decreasing of body weight.
Since 1 month ago patient cant control his emotion, he also got angry easily without
any reason and sometimes steals neighbors plants. He never had hypertension nor
diabates mellitus.

Familly history : no history of same illness in his family

Social history :
married once, work as cow seller , has 2 children, routine
consumes traditional potion. Routine consumes alcohol like Topi
Miring.

PHYSICAL EXAMINATION
General Appearance: moderatelly ill

Looked overweight

GCS: 4.5.6

BP: 120/70 mmHg

PR: 90 bpm

Head

anemic conjunctiva -, icteric sclerae -, lnn enlargment (-)

Neck

JVP R+2 cm H2O, lymphnode enlargement -/-

Chest

Wall

Symmetric

Heart

Ictus invisible, palpable at ICS VI cm MCL S

RHM ~ SL D
LHM ~ ictus
S1 and S2 single, murmur(-)
Stem Fremitus D=S

Lung
Abdomen

RR: 20 tpm

Trill: -

Tax : 36 0C

Heaves: -

Sonor Sonor bv bv Rh + +
Sonor Sonor bv bv
+ +
Sonor Sonor v v
--

Wh - ---

soefl, bowel sound normal, tenderness -, liver span 8 cm, Traubes space tympany,
shifting dullness -,

Extremities

Warm, edema -/- , refleks patologis (-) parese - - motoric ( 5 5), sensoric (N)
+/+
-55

RT

Spinter ani (+) N, mucosa smooth, sulcus medianus hard to evaluate, mass (-),blood (-)

Lab

Value

Lab

Value

Leukocyte

30.150

3.500-10.000/L

Natrium

130

136-145 mmol / L

Haemoglobine
MCV

15.70
94.80

11,0-16,5 g/dl
80-97

Kalium

4.03

3,5-5,0 mmol / L

MCH

30.40

26,5-33,5

Chlorida

107

98-106 mmol / L

PCV

48.90%

35-50%

RBS

141

< 200 mg/dL

Trombocyte

195.000

146.000-424.000/L

SGOT

23

11-41U/L

Eo/Ba/Neu/Ly/Mo

1.1/0.1/87.9/7.
9/3.0

0-4/0-1/51-67/2533/2-5

SGPT

32

10-41U/L

Ureum

57.50

10-50 mg/dL

Albumin

3.12

3.5-5.5 g/dL
2.5-3.5 g/dL

Creatinine

1.34

0,7-1,5 mg/dL

PSA

7.9

<4.0

Bun creatinin 20.05

ratio

URINALISI
S

Hasil

Kontrol

Urinalisis

Hasil

Kontrol

10 X
kekeruhan
colour
pH
Serum
gravity

Clear
Yellow
5.5
1.025

Glucosa

Negative

Keton

Negative

Protein
Bilirubin
Urobilinog
en
Nitrit
Leucocyte

Epitel
Cillinder
4.8 8.0 - Hyalin

+
Negative
-

1.005 -Berbutir
1.030

Negatif

Negatif - other

40 X

2+

Negatif Eritrocyte

40-50

Negative

Negatif -Eumorfic

Negatif - Dismorfic

1+
Negative
2+

Negatif Leucocyte
Negatif Cristal

uncountab
le
-

Without 02Finding
supplementation
Laboratory

BGA
PH

7.33

7,35-7,45

PCO2

38.1

35-45

PO2

62.8

80-100 mmHg

Truly O2

mmHg

80 100

HCO3

20.1

21-28

mmHg

O2 saturation

90.0%

> 95 %

Base Excess

-6.0

-3 until +3

Hb

15.2

g/dL
0.5 2.2 mmol/L
0.5 1.1 mmol/L

Suhu

37.0

Conclusion

Acidosis
metabolic
partially
compensated

CHEST X RAY INTERPRETATION

AP position, asymmetry, enough KV, less inspiration

Trachea in the middle
Mediastinum normal
Soft tissue and bone normal
Hemidiaphragma dextra and sinistra are dome shape
Costophrenical angle dextra and sinistra are sharp
Pulmo: Bronchovesicular pattern increased, infiltrate in
upper and medial lung dextra and sinistra
COR: CTR: size 62%, cardiac waist (+), shape normal
Conclusion : pneumonia + looks cardiomegally

ELECTROCARDIOGRAPHY
INTERPRETATION
Sinus rhytm, heart rate 100 beats/minute
Frontal axis : normal
Horizontal axis : clock wise rotation
PR interval : 0,10 second
QRS interval : 0,08 second
QT interval : 0,36 second
Conclusion: sinus rhytm with HR 100 bpm +
clock wise rotation and low voltage

PROBLEM ORIENTED MEDICAL RECORD

Cue and Clue
Male/61 Yo/w.27
Pain when
passing urine
Worsened since 3
day before
admission
Sometimes with
pus
Pain in gland
penis when
passing urine
PE:
blood (+) from
insertion catheter
Leg edema (+)
Lab finding:
Leucocyte:
30.150/L
Ureum: 57.50
mg/dl
Creatinin: 1.34
mg/dl
Urinalysis:
Prot: 2+
Urobilinogen:1+
Leucocyte 2+
Blood 3+
Eritrocyte: 40-50
hpf
Leucocyte there

Problem List
1. Urinary tract
infection

Initial Diagnosis

Planning
Diagnosis
Urine culture
and sensitivity
Blood culture
and sensitivity

Planning Monitoring
and Education

Planning Therapy
Bed rest
Diet HCHP 1800 kcal
per day
Inj . Furosemid 3 x 20
mg (intravena)

Monitoring:
Subjective
Vital sign
UOP
Education:
Hygiene

Inf. Ciprofloxacin 2 x
200 mg (intravena)
Inj. Metoclopramide 3
x 10 mg (intravena)

PROBLEM ORIENTED MEDICAL RECORD

Cue and Clue
Male/61 Yo/w. 27
Cough since 1
years
Greenish sputum
Without blood
Sometimes felt
shortness of
breath
PE:
RR: 20 tpm
SaO2: 95%
without O2
Rhonki (+) in
upper and medial
lung dextra and
sinistra
Lab:
Neutrofil:87.9%
Port score:91 (risk
class III, may
need brief)
CXR : pneumonia

Problem List

Initial Diagnosis

2. Lung Infection 2.1 pneumonia

CAP
2.2 Lung TB

Planning
Planning Monitoring and
Planning Therapy
Diagnosis
Education
Sputum culture O2 2-4 lpm if
Monitoring:
and sensitivity needed
Subjective
Vital sign
AFB
Inj ceftriaxone 2 x
Education:
1 gr (intravena)
Cough etiquette
(skin test)
PO:
N-acetyl sistein 3
x 200 mg
Join care with
pulmonology
department from
ER

PROBLEM ORIENTED MEDICAL RECORD

Cue and Clue

Problem List

Male/61 Y0/w 27
3. LUTS+gross
Pain when
hematuria
passing urin
No history bloody
urine before
Difficult when
passing urine
Trauma (-)
alcoholism
PE:
Gross hematuria
blood (+) from
insertion catheter
Leg edema (+)
Lab finding:
Leucocyte:
30.150/L
Ureum: 57.50
mg/dl
Creatinin: 1.34
mg/dl
RT:Spinter ani (+) N,
mucosa smooth, sulcus
medianus hard to
evaluated, mass (-),blood
Urinalysis:
Prot: 2+
Urobilinogen:1+
Leucocyte 2+
Blood 3+
Eritrocyte: 40-50
hpf

Initial
Diagnosis

Planning
Diagnosis

3.1 BPH

USG urology

3.2 Ca prostat

PSA

3.3 rupture
uretra

Uretrografi
retrogard
CT scan pelvis

Planning
Therapy

Planning Monitoring
and Education

Consult to urology Monitoring:

department in ER: Subjective
Insert catheter to UOP
monitoring
And from catheter
Education:
UOP with initial
urine 500 cc and Hygiene
Stop consuming alcohol
clear

Confirm
diagnosed

PROBLEM ORIENTED MEDICAL RECORD

Cue and Clue
Male/61 Yo/w 27
cant controlled
his emotion since
1 month ago,
angry without a
reason
sometimes steals
neighboring
plants
alcoholism

Problem List
4. Schizophrenia

Initial Diagnosis

Planning
Diagnosis

Planning Monitoring and

Education
Plan consult to
Monitoring:
psychiatry
Subjective
department
Education:
Illness
PO:
Chlorpromazine 2 Family education
x 50mg
If needed
Planning Therapy

PROBLEM ORIENTED MEDICAL RECORD

Cue and Clue
Male/61 YO/w 27
Pain when
passing urine
Worsened since 3
day before
admission
Sometimes with
pus
Pain in gland
penis when
passing urine
Lab:
Ureum: 57.50
mg/dl
Creatinin: 1.34
mg/dl
BUN creatinin
ratio: 20.05

Problem List
5. Azotemia

Initial
Diagnosis
5.1 renal
5.1.1 dt retensio
urin
5.2 pre renal
5.2.1 UTI

Planning
Diagnosis

Planning Monitoring and

Education
IVFD NS 0.9% 20 Monitoring:
tpm
Subjective
Vital signs
Fluid balance
Ureum
negative 500 until Creatinin
1000 cc per 24
Education:
hour
Hygiene
Stop consuming alcohol
Planning Therapy

CONDITION THIS MORNING

GCS: 4 5 6
BP : 120/80mmHg
HR : 90 times per minute
RR : 22 times per minute
T : 37.3 0C

Thank You