POMR POMR (PROBLEM ORIENTED MEDICAL RECORD) (PROBLEM ORIENTED MEDICAL RECORD) Presented By Presented By Group 2 Group 2 April 11 April 11 th th 2007 2007
Sep 25, 2015
POMR
(PROBLEM ORIENTED MEDICAL RECORD)
Presented By
Group 2
April 11th 2007
Anamnese
Identity:
- Name: Ms.Ernawati
- Age: 24 years old
- Job: university student
- Address: Jl.Antasari
Tribe: Bugis
Religion: Moslems
Chief Complaint
HeadacheHistory of illness
Patient have complain about headache when she got accident on the road at 04.00 pmShe rode motorcycle alone, and suddenly a motorcycle from behind hit her, and then she fell to the right side of the motorcycle.She wear a helmet, but when the accident happened, the helmet off.Which part of the head had injury?The explanation of headache? Headache at upperhead, type of headache? She was unconciousness when the accident happened until she arrived at Emergency Room. She also cant remember about how the accident happened and what next going on.PatientPHYSICAL EXAMINATION
Generalis Status
Mental Status: Composmentis (GCS E4V5M6); inadequate in communicationCondition Appearance : Moderate illnessVital Sign:
Pulse: 80 x/minutes, regular
Blood Pressure: 110/60 mmHg
Respiratory Rate: 20 x/minutes, thoraco-abdominal
Temperature: 37,0oC, axial
Abnormal with haematom at right temporoparietal, 10 cm, consistency soft, painfull tenderness, external haemorrhagic (-), wound (-), fluid level ???
Eye: pupil equal in size, Left=Right ? mm
light reflex R/L=N/N
Conjungtiva Anemia (-)
Eye Movement :R/L=N/N
Thoraxinspection : Shape:N,
Chest Movement: Symetris
Contusion (-)
palpation :Fremitus R/L=N/N
Percution :Sonor
Auscultation:vesiculer
inspection : flat
palpation : Mass (-)
Percution : tympani
Auscultation: intestine sound (+/N)
GenitalUnexamination
ExtremityUpper : laceration at third left finger,pain and limitation of movement
lower : laceration at 1/3 distal left cruris region, crepitation? (Look; feel n move???)
Working Diagnostic
Mild head Injury with
REQUIRED INVESTIGATION
Head CT Scan
Cervical x-ray lateral (swimmer position), AP-open mouth
Left third finger x-ray AP, lateral
Head CT Scan
Treatment
ABCs clearAdvicesOral medicationsSupportive :Ivfd RL: NaCl 1:3
Piracetam: 2x1 apr
Analgetic : 3x1 apr
Antibiotic:
Ad bonam