PROSES KLINIK dan POMR

dr. Meddy Setiawan, SpPD Internal Medicine Department University of Muhammadiyah Malang

REFERENCES:

Harrisons Principles of Internal Medicine, 17th Edition Delph & Manning : Physical Diagnosis

Proses Klinik

Merupakan proses pengambilan keputusan pada penderita Mulai : pengumpulan data sampai kesimpulan Mulai : keluhan utama sampai Dx dan Tx Melibatkan interaksi dokter - penderita

DOCTOR PATIENTS RELATIONSHIP

environment
Doctor
Privacy Education Education Privacy personality

Patient

Culture Belief Belief

Religion Culture

Doctor

Religion

PROBLEM ANALYSIS

CULTURE

SOCIAL

PHYSIC

PATIENTS PROBLEMS

OTHERS

SPIRITUAL REALITIES

SCIENTIFIC PROBLEMS SOLVING APPROACH

S.P.S.A. PROBLEM IDENTIFICATION EVALUATION DATA COLLECTION CLINICAL PROCESS HEALTH PROBLEM FOLLOW-UP ANAMNESA/ P.D./ LAB. / MED-RECORD DATAS & ANALYSIS PRIORITY SETTING HYPOTHESIS FORMULATION HYPOTHESIS TESTING

IMPLEMENTATION

DATA ANALYSIS

IMPLEMENTATION INFORMATION

TREATMENT PRIORITY SETTING

DIAGNOSIS SYNTHESIS

PROBLEM SOLVING ALTERNATIVE

TREATMENT ALTERNATIVES

DIAGNOSIS PLANNING

Pendidikan dokter mengalami perubahan mendasar dalam kurun waktu 5 tahun : SPICES

Mengacu standart pendidikan profesi dan kompetensi Perubahan besar pada kurukulum KBK dengan pendekatan PBL

Student centered Problem based Integrated Community based Early exposure to clinic Structured

ROLES OF DOCTOR
Clinical expert Health advocate Manager Team player Scholar and teacher Professional

Skenario PREKLINIK

Arumi 28 th datang ke UGD dengan keluhan sesak nafas yang makin lama makin berat. Sesak telah dirasakan sejak 1 minggu yang lalu. Arumi adalah seorang ibu muda dengan kehamilan 8 bulan. Apa yang mungkin terjadi pada Arumi ?

Skenario KLINIK - POMR

Arumi 28 th datang ke UGD dengan keluhan sesak nafas yang makin lama makin berat. Sesak dirasakan sejak 1 minggu yang lalu. Arumi adalah ibu muda dengan kehamilan 8 bulan. Selain itu Arumi juga mengeluhkan sembab pada tungkai sejak 3 bulan yang lalu. Pemeriksaan fisik T 180/100 mmHg, N 110 x/mnt, RR 36 x/mnt dan kehamilan 36-37 minggu. Bunyi jantung dan gerak janin normal. Dari anamnesis diketahui bahwa tidak ada riwayat perdarahan ante partum dan tidak ada kelainan jantung. Berat badan Arumi meningkat 30 kg sejak hamil dan ditemukan edema pada seluruh tubuh. Apa yang mungkin terjadi pada Arumi ?

POMR (Problem Oriented Medical Record)

POMR :

Summary of data base (Ax, Physical Examination, Laboratory) Clue and cue PROBLEM LIST Initial diagnosis (differential diagnosis) Planing :

Diagnosis, Therapy Monitor, Education

Format POMR
SUMMARY of DATA BASE CLUE and CUE PROBLEM LIST INITIAL DX PLANNING

DIAGNO SIS

THERAPY

MONITOR ING

EDUCA TION

Identity : Chief complaint : Anamnese : Physical examination : Laboratory finding :

Pertanyaan :

Bagaimana Bagaimana Bagaimana Bagaimana Bagaimana Mo, Ed ?

mengumpulkan data ? membuat data grouping ? membuat problem ? membuat initial diagnosa ? membuat rencana Dx, Tx,

How do we collect the data ?

History taking Physical examination Additional examination :

Laboratory examination X ray examination Imaging ( USG, Doppler, etc )

Data Data-A Data-B Data-C Data-D Data-E Data-F Data-G Data-H Data-I Data-J

Problem Problem-1 Problem-2 Problem-3 Problem-4

Data Data Data Data

A, B, E and I D and H A, C and E F, G and J

Problem-1 Problem-2 Problem-3 Problem-4

Data grouping ( problem cue and clue )

Data grouping is based on the diagnostic criteria

To make the problem

Problem is synthesized from the data and based on diagnosis criteria Problem is fact not suspect Problem can be : a. Diagnosis ( if the data has fulfill the diagnosis criteria ) b. Syndromes ( if the data has not fulfill the diagnosis criteria, but fulfill the criteria of syndromes ) c. Sign or symptoms ( if the data has not fulfill the diagnosis criteria and the criteria of syndromes, but just only found as sign or symptom Problem must be numbered ( 1 , 2 , 3 etc )

Example

Female 36 yo (farmer), admitted with chief complain shortness of breath since 2 month ago come and go especially in activity. Productive cough with yellowish sputum. Fever noted 7 days acompained by decrease of appetite, bloating and nausea. She stayed in crowded area with 5 children

Phisical Examination

Look severe ill, CM, BMI 19 Kg/m2, BP 150/90 mmHg, Pulse 113 x/mnt, ireguler, RR 32 x/mnt, T 38,5 C Anemis, JVP = R+4 cmH20 (45) Rhonchi on middle of lung (right & left), Gallop rhytm Lever and spleen unpalpable Extremity within normal limit

Laboratory finding

Hb 9,8 gr/% Leucocyt 12.500 sel/UL Thrombocyt 200.000 sel/UL ESR 75 /hour Random Blood sugar 143 mg/dl Ureum 19 mg/dl Creatinin 1,0 mg/dl

SEMOGA BERMANFAAT.