POMR (Problem Oriented Medical Record)

CUE AND CLUE PL IDx PDx PTx PMo&Ed

Mrs. K/63 yo/ward 28 bed 39 5. Type 2 DIabetes Non Pharmacology : PMO
Mellitus - bed rest s,VS,
Subjective : - DM diet 1700 kcal/day FPG/2hPPG
-T2DM since 20 years, never
took any medicine Pharmacology : P.ed
-general weakness - OAD wait for FPG/2hPPG educate
about T2DM
Objective
look moderate ill

Laboratory :
RBS: 98 mg/dl
 POMR (Problem Oriented Medical Record)
CUE AND CLUE PL IDx PDx PTx PMo&Ed
Mrs. K/63 yo/ward 28 bed 39 6. CKD st 5 6.1 HTN -renal biopsy Non Pharmacology : PMO
6.2 DKD - bed rest s,VS, Ur/Cr
Subjective : - avoid nephrotoxic drugs
-renal failure (+) 3 months ago - renal diet 1700 kcal/day, low P.ed
-T2DM since 20 years ago salt 2g/day, protein 0,6-0,8 low salt dt,
-HT since 20 years ago kgBW/day limit water
intake
Objective Pharmacology :
look moderate ill GCS 456 -
BP 130/80 mmHg

Laboratory :
Ur/Cr: 109,9/3,27
Hb: 11
 POMR (Problem Oriented Medical Record)
CUE AND CLUE PL IDx PDx PTx PMo&Ed
Mrs. K/63 yo/ward 28 bed 39 7. Mild 7.1 decrease of Non Pharmacology : PMO
hyperkalemia renal excretion - bed rest s,VS, SE
Subjective :
-general weakness Pharmacology : P.ed
-Ca polystyrene sulfonate 3x5 education
Objective grams about patient
look moderate ill GCS 456 disease

Laboratory :
Kalium: 5,28
Non B non C hepatitis NAFLD

Ascites
Cirrhosis Hepatis

Hyperkalemia
CKD stage 5

Hypertension stage 2 T2DM