POMR

PPL IDX PDX PTX PMO

1. Mrs. Tyas Kristianingsih/ 38 yo/ 11590902 1. Respiratory failure 1. RF Type 1 - - The patient refuses ICU treatment and • Vital sign
signs the Terminal IEC and DNR form • Clinical features
Anamnesa from Anesthesiology Dept • Lab evaluation
• SOB (+) worsening since 2 days ago - O2 on HFNC flow 60lpm FiO2 70% (fio2
• History of diagnosed with Lung Tumor (+) needed 0,8)
since 3 weeks ago

Physical examination
GA : moderate GCS: 456
BP: 109/81 mmHg RR: 35-49
HR: 121 T : 36 'C
SpO2: 85% RA - 99% on 15 lpm NRBM 
99% on HFNC 60 lpm FiO2 70%
Pulmo BS vvvdecreased/vvv Rh ---/---Wh ---/---

Lab RSSA (16/10/23):

BGA 7,46/32,4/69,2/23,4/-0,6/95,4 on 15
NRBM
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2. Mrs. Tyas Kristianingsih/ 38 yo/ 11590902 2. Lung tumor 2.1 Lung tumor D - TTNA awaiting PA results - Cemotherapy or TKI wait for Cancer Cell • Vital sign
T4N3M1C st IVB PS 1 on 23/10/23 result • Clinical features
Anamnesa Meta Hepar, Meta • CXR evaluation
- SOB (+) since 2 months ago, DOE (+), PND Vertebrae L2, meta
(+), Cough (+) since 4 month ago, whitish contralateral lung, Kx
sputum (+), history of bloody cough (+) hemoptysis, cancer pain,
- History of smoking : passive smoker +- 30 bilateral pleural effusion
years

Physical examination
SpO2: 85% RA - 99% on 15 lpm NRBM 
99% on HFNC 60 lpm FiO2 70%
Pulmo BS vvvdecreased/vvv Rh ---/---Wh ---/---

CXR RSSA 16/10/23

Multiple nodules at both lungs

CT Scan Thorax + Contrast RSSA

03/10/2023
- Bilateral multiple pulmonary nodules and
bilateral multiple pleural nodules are suspected
to be a metastatic process
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3. Mrs. Tyas Kristianingsih/ 38 yo/ 11590902 3. Chronic pain 3.1 Cancer pain vas 4/10 - - PO Paracetamol 4x500 mg • Vital sign
on Tx - PO Codeine 3x10mg • Clinical features
Anamnesa - Durogesic patch 12.5 mcg/3 days
• Chest pain (+) since 4 months ago
• History of diagnosed with Lung Tumor (+)
since 3 weeks ago

Physical examination
VAS 4/10

CXR RSSA 16/10/23

Multiple nodules at both lungs

CT Scan Thorax + Contrast RSSA

03/10/2023
- Bilateral multiple pulmonary nodules and
bilateral multiple pleural nodules are suspected
to be a metastatic process
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PPL IDX PDX PTX PMO

4. Mrs. Tyas Kristianingsih/ 38 yo/ 11590902 4. Acute lung infection 4.1 Obstructive pneumonia - Sputum gram culture - O2 on hfnc flow 60lpm FiO2 70% (fio2 • Vital sign
DST needed 0,8) • Clinical features
Anamnesa - IVFD NS: Futrolit 2:1 1500cc/24 hours • Lab evaluation
• SOB (+) worsening since 2 days ago - IV Levofloxacin 1x750mg • CXR evaluation
• Cough (+), whitish sputum (+), history of
bloody cough (+)
• History of diagnosed with Lung Tumor (+)
since 3 weeks ago

Physical examination
GA : moderate GCS: 456
BP: 109/81 mmHg RR: 35-49
HR: 121 T : 36 'C
SpO2: 85% RA - 99% on 15 lpm NRBM 
99% on HFNC 60 lpm FiO2 70%
Pulmo BS vvvdecreased/vvv Rh ---/---Wh ---/---

CXR
Multiple nodules with surrounding infiltrates in
bilateral lungs
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5. Mrs. Tyas Kristianingsih/ 38 yo/ 11590902 5. Pleural effusion 5.1 Minimal bilateral pleural - Pro marker thorax - Pro Thoracentesis if the marker (+) • Vital sign
effusion ultrasound scheduled for (uultrasound in the emergency room, the • Clinical features
Anamnesa 23/10/23 results are minimal)
SOB (+) since 2 months ago worsening for 2
days, DOE (+) PND (+)

Physical examination
RR: 35-49
HR: 121
Pulmo BS vvvdecreased/vvv Rh ---/--- Wh
---/---

CXR RSSA 16/10/23

Costophrenicus angel D et S : Blunt
Conclusion : bilateral pleural effusion

CT Scan Thorax + Contrast RSSA

03/10/2023
- Right pleural effusion
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6. Mrs. Tyas Kristianingsih/ 38 yo/ 11590902 6. Metastatic bone disease 6.1 dt Lung tumor D - - PO Paracetamol 4x500 mg • Vital sign
T4N3M1C st IVB PS 1 - PO Codeine 3x10mg • Clinical features
Anamnesa Meta Hepar, Meta - Durogesic patch 12.5 mcg/3 days
• Low back pain (+) since 4 months ago Vertebrae L2, meta
• History of diagnosed with Lung Tumor (+) contralateral lung, Kx
since 3 weeks ago hemoptysis, cancer pain,
bilateral pleural effusion
Physical examination
VAS 4/10

CT Scan Thorax + Contrast RSSA

03/10/2023
- Osteolitic lesion at L2
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7. Mrs. Tyas Kristianingsih/ 38 yo/ 11590902 7. Obstructive renal 7.1 Left moderate - Abdominal ultrasound - Consult to Urology Dept • Vital sign
disease hydroureteronephrosis scheduled for 23/10/23 • Clinical features
Anamnesa
• Low back pain (+) since 4 months ago

Physical examination
VAS 4/10

CT Scan Thorax + Contrast RSSA

03/10/2023
- Moderate hydroureteronephrosis
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PPL IDX PDX PTX PMO

8. Mrs. Tyas Kristianingsih/ 38 yo/ 11590902 8. Moderate 8.1 dt low intake - - Vip Albumin 3x2 caps • Vital sign
hypoalbuminemia 8.2 hypercatabolic state - High protein diet • Clinical features
Anamnesa • Lab evaluation
• Decreased appetite (+)
• SOB (+) since 2 months ago
• Cough (+) for 4 month ago
• History of diagnosed with Lung Tumor (+)
since 3 weeks ago

Lab RSSA (16/10/23):

Albumin 2,52