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POMR (Problem Oriented Medical Record)
Name : Ny. SAge :55 tahun
DATA BASECLUE AND CUE PROBLEM
LIST INITIAL DXPLANNING
DIAGNOSIS THERAPY MONITORING EDUCATION
Ny. S, 55 tahunChief complain : sakitkepalaAnamne!e :
• RPS"
-pasien mengeluh sakitkepala sejak kemarin,sempat pingsan selama 5menit.
-mual (+), muntah (+)sebanyak 6x, nyeri perut(-), nafsu makanmenurun.
-emam (+)
-batuk(-),sesak(-), nyeri!a!a (-)
-"#$ lan%ar !an n&rmal
-ti!ak bisa "#" sejakkemarin
RPD" '(+), (-)Ph#!ical e$aminaion :%e!a&a'an " %&mp&smentis
%U " lemah
:*5 mm'g
N : 6 xmnt /egular
// : 01xmnt /eguler
: 23, 4
-$ ai%! ----, pupil is&k&r ( !e7iasi tra%hea(-), struma(-), $8" !bn, 9; flatTho'a$ thorax: simetris,ves/ves,rh -/-, wh -/-
A)&omen soefl,
meteorismus (+), ! (+)
Ny.S, 55 th- hepalgia- '
-nausea- 7&mit-nafsu makanmenurun-<ebris-kalium serum 2
*. 'ipertensistage *
0. hip&kalemi
*.hipertensi stage* !enganhip&kalemia
- -S%an- =8-
- >< #ssering511%% l&a!ing
- *1? *511
kalhari- >nj. /aniti!in 0x*- Nife!ipin 2x5mg- $ 1 mm&l
*x* p&
- ital sign (8S,";, //, ;, t)
- $eluhan- =8
- enjelaskan!iagn&sis,pemeriksaan!an terapi pa!akeluarga
- ;asien!iharuskanistirahat
- ;asien!ianjurkanuntuk ,makanyang banyak.
-
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normal,"/# tt$
o E$'emia!" '$*
e!ema (--)
o La)o'ao'# fin&in+ "
-'emat&krit 2,2-'b **,-= 0256-leuk&sit .611-tr&mb&sit *3.111-S8@ *-S8; *5-bilirubin !ire%t 1,06-bilirubin t&tal 1,5-alkali f&sfatase *2*-%l&ri!a serum *15-kalium serum 2-natrium serum *23-serum %reatinin 1,-Area 0-uri% a%i! 0-%h&lester&l **5-' 2,2- 6,-8 6-8# *20
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