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

Headache

History 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.Patient

Vomiting (-),Otorhoe (-),Rhinorhoe (-)

PHYSICAL EXAMINATION

Generalis Status

Mental Status: Composmentis (GCS E4V5M6); inadequate in communicationCondition Appearance : Moderate illness

Vital Sign:

Pulse: 80 x/minutes, regular

Blood Pressure: 110/60 mmHg

Respiratory Rate: 20 x/minutes, thoraco-abdominal

Temperature: 37,0oC, axial

Head:

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

Thorax

inspection : Shape:N,

Chest Movement: Symetris

Contusion (-)

palpation :Fremitus R/L=N/N

Percution :Sonor

Auscultation:vesiculer

Abdomen

inspection : flat

palpation : Mass (-)

Percution : tympani

Auscultation: intestine sound (+/N)

Genital

Unexamination

Extremity

Upper : 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:

Prognose

Ad bonam