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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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