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PROSES KLINIKdan POMR
dr. Meddy Setiawan, SpPD
Internal Medicine DepartmentUniversity o M!"ammadiya"
Malan#
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RE$EREN%ES&RE$EREN%ES&
Harrison’s Principles of
Internal Medicine, 17th Edition
Delph & Manning :
Physical Diagnosis
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Proses Klinik Merpakan proses penga!"ilan
keptsan pada penderita
Mlai : peng!plan data sa!paikesi!plan
Mlai : kelhan ta!a sa!pai D#
dan $# Meli"atkan interaksi dokter %
penderita
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DO%'OR P('IEN'SDO%'OR P('IEN'S
REL('IONS)IPREL('IONS)IP
Patient
Doctor
Doctor
environment
%!lt!re
*elie
Reli#ion
Ed!cation
Privacy
%!lt!re
Reli#ion
*elie
Ed!cation
Privacy
personality
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PRO*LEM (N(L+SISPRO*LEM (N(L+SIS
P$IE'$’( P)*+EM(
-.$.)E
*$HE)(
(PI)I$.)EI$IE(
PH/(I-
(*-I
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S%IEN'I$I% PRO*LEMS SOLIN-S%IEN'I$I% PRO*LEMS SOLIN-
(PPRO(%)(PPRO(%)S.P.S.A.
PROBLEM IDENTIFICATION
EVALUATION DATA COLLECTION
IMPLEMENTATION DATA ANALYSIS
PRIORITY SETTING HYPOTHESIS
FORMULATION
PROBLEM SOLVING HYPOTHESIS
ALTERNATIVE TESTING
CLINICAL PROCESS
HEALTH PROBLEM
FOLLOW-UP ANAMNESA/ P.D./
LAB. / MED-RECORD
IMPLEMENTATION DATAS &
INFORMATION
ANALYSIS
TREATMENT DIAGNOSIS
PRIORITY SETTING SYNTHESIS
TREATMENT DIAGNOSIS
ALTERNATIVES PLANNING
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Pendidikan dokter !engala!i per"ahan!endasar dala! krn 0akt tahn :(PI-E( (tdent centered Pro"le! "ased
Integrated -o!!nity "ased Early e#posre to clinic (trctred
Mengac standart pendidikan profesi danko!petensi Per"ahan "esar pada krkl! 2 K+K
dengan pendekatan P+
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ROLES O$ DO%'OR
-linical e#pert
Health ad3ocate
Manager $ea! player
(cholar and teacher
Professional
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(kenario P)EKI'IK r!i 45 th datang ke .6D
dengan kelhan sesak nafas yang
!akin la!a !akin "erat (esaktelah dirasakan se8ak 1 !inggyang lal r!i adalah seorang
i" !da dengan keha!ilan 5"lan pa yang !ngkin ter8adipada r!i 9
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(kenario KI'IK % P*M) r!i 45 th datang ke .6D dengan kelhan sesaknafas yang !akin la!a !akin "erat (esak dirasakanse8ak 1 !ingg yang lal r!i adalah i" !dadengan keha!ilan 5 "lan (elain it r!i 8ga
!engelhkan se!"a" pada tngkai se8ak "lan yanglal Pe!eriksaan ;sik $ 15
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POMR?Pro"le! *riented Medical
)ecord@
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P*M) : (!!ary of data "ase ?#, Physical
E#a!ination, a"oratory@
-le and ce P)*+EM I($ Initial diagnosis ?diferential diagnosis@
Planing : Diagnosis, $herapy Monitor, Edcation
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Aor!at P*M)SUMMARYof
DATA BASE
CLUEandCUE
PROBLEMLIST
INITIALDX
PLANNING
DIAGNO
SIS
THERAPY MONITOR
ING
EDUCA
TION
Identity :
Chief
o!"#aint :
Ana!ne$e :
Phy$ia#e%a!ination
:
La&o'ato'yfindin( :
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Pertanyaan : +agai!ana !eng!plkan data 9
+agai!ana !e!"at data groping 9
+agai!ana !e!"at Bpro"le!C 9
+agai!ana !e!"at initialdiagnosa 9
+agai!ana !e!"at rencana D#, $#,Mo, Ed 9
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History taking
Physical e#a!ination dditional e#a!ination :
a"oratory e#a!ination
2 ray e#a!ination I!aging ? .(6, Doppler, etc @
)ow do we collect t"e
data
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Data Pro/lem
Data%
Data%+
Data%-
Data%D
Data%E
Data%A
Data%6Data%H
Data%I
Data%
Pro"le!%1
Pro"le!%4
Pro"le!%
Pro"le!%F
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Data , +, E and I Pro"le!%1
Data D and H Pro"le!%4 Data , - and E Pro"le!%
Data A, 6 and Pro"le!%F
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Data groping is "ased on the
diagnostic criteria
Data #ro!pin# 0 pro/lem c!e and
cl!e 1
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Pro"le! is synthesiGed fro! the data and "ased ondiagnosis criteria
Pro"le! is fact not sspect Pro"le! can "e :
a. Dia#nosis ? if the data has fl;ll the diagnosiscriteria @
/. Syndromes ? if the data has not fl;ll the
diagnosis criteria, "t fl;ll the criteria ofsyndro!es @
c. Si#n or symptoms ? if the data has not fl;ll thediagnosis criteria and the criteria of syndro!es,"t 8st only fond as sign or sy!pto!
Pro"le! !st "e n!"ered ? 1 , 4 , etc @
'o ma2e t"e pro/lem
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E3ample
Ae!ale > yo ?far!er@, ad!itted 0ithchief co!plain shortness of "reathsince 4 !onth ago co!e and go
especially in acti3ity Prodcti3ecogh 0ith yello0ish spt! Ae3ernoted 7 days aco!pained "y decrease
of appetite, "loating and nasea (hestayed in cro0ded area 0ith children
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P"isical E3amination
ook se3ere ill, -M, +MI 1 Kg=!4,+P 1
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La/oratory 4ndin#
H" ,5 gr=
ecocyt 14
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SEMO-(*ERM(N$(('5555