MEDICAL RECORD

OLEH

Nama : I Putu Yoan Sugiantara

No. Urut : 26
Prodi/Kelas : Profesi NERS Kelas A

KEMENTERIAN KESEHATAN REPUBLIK INDONESIA

POLITEKNIK KESEHATAN DENPASAR
PROGRAM STUDI PROFESI NERS
TAHUN 2021
RSUD Wangaya  

Kartini Street No. 133, Dauh Puri Kaja,

Denpasar City
Fax : (0361) 222487 Chart Summary

Mr. Y

Home: 089-541-xxx-
xxx
Male DOB: 51710306xxxxxxx
03/06/1971 x Ins: Commercial xxxxx

                                                     

Patient Information

Name: Mr. Y Home Phone: 089-

541-xxx-xxx

Address: Gunung Agung Street. No. Office Phone: -

100, Denpasar City

Patient ID: 51710306xxxxxxxx Fax: -

Birth Date: 03/06/1971 Status: Active

Gender: Male Marital
Status: Married

Contact By: Phone Race: Asian

Soc Sec No: 987654321xxxx Language: Indonesia

n

Resp Prov: dr. Agus MRN: MR-135-79

Referred by: - Emp. Status: Full-

time

Email: - Sens Chart: No

Home LOC: RSUD Wangaya External ID: MR-
135-79

Problems
ANEMIA
Medications
MALTIRON 2 x 1 tablets
PAMOL 3 x 1 tablets

Directives
Allergies and Adverse Reactions (! = critical)
Services Due
IVFD NaCl 0,9% 20 dpm

03/03/2021 - Office Visit:

Provider: dr. Agus
Location of Care: RSUD Wangaya

OFFICE VISIT
History of Present Illness 
Reason for visit: Anemia follow up 
Chief Complaint: feeling limp and dizzy

History
Anemia Management 
Weak : yes
Tired : yes
Sluggish : yes
Limp : yes
Fatigue : yes

Sympathomimetic Symptoms 
Diaphoresis: no
Agitation: no
Tremor: no
Palpitations: no
Insomnia: no
Neuroglycopenic Symptoms 
Confusion: no
Lethargy: no
Somnolence: no
Amnesia: no
Stupor: no
Seizures: no
Review of Systems
General: fatigue, malaise,
Eyes: denies blurring, diplopia, irritation, discharge
Ear/Nose/Throat: denies ear pain or discharge, nasal obstruction or discharge,
sore throat
Cardiovascular: denies chest pain, palpitations, paroxysmal nocturnal dyspnea,
orthopnea, edema Respiratory: denies coughing, wheezing, dyspnea, hemoptysis
Gastrointestinal: denies abdominal pain, dysphagia, nausea, vomiting, diarrhea,
constipation
Genitourinary: denies hematuria, frequency, urgency, dysuria, discharge,
impotence, incontinence
Musculoskeletal: denies back pain, joint swelling, joint stiffness, joint pain
Skin: denies rashes, itching, lumps, sores, lesions, color change
Neurologic: denies syncope, seizures, transient paralysis, weakness, paresthesias
Psychiatric: denies depression, anxiety, mental disturbance, difficulty sleeping,
suicidal ideation, hallucinations, paranoia
Endocrine: denies polyuria, polydipsia, polyphagia, weight change, heat or cold
intolerance
Heme/Lymphatic: denies easy or excessive bruising, history of blood
transfusions, anemia, bleeding disorders, adenopathy, chills, sweats
Allergic/Immunologic: denies urticaria, hay fever, frequent UTIs; denies HIV
high risk behaviors
Vital Signs

RSUD Wangaya March 03,

2021

Kartini Street No. 133, Dauh Puri Kaja, Page 2

Denpasar City Chart
Summary
Fax : (0361) 222487
Ht: 170 cm. Wt: 60 kg. T: 36,2 degC. Tsite: axilary P: 70 bpm
Rhythm: regular R: 16 bpm BP: 100/60 mmHg
Physical Exam
General Appearance: well developed, well nourished, no acute distress
Eyes: conjunctiva and lids normal, PERRLA, EOMI, fundi WNL
Ears, Nose, Mouth, Throat: TM clear, nares clear, oral exam WNL
Respiratory: clear to auscultation and percussion, respiratory effort normal
Cardiovascular: regular rate and rhythm, S1-S2, no murmur, rub or gallop, no
bruits, peripheral pulses normal and symmetric, no cyanosis, clubbing, edema or
varicosities
Skin: clear, bad turgor, dry skin
Problems (including changes): Blood pressure is lower..
Impression: anemia

Home Vital Sign Monitoring:

Temperature : 36,3 degC, Blood Pressure : 105/74 mmHg

Plan
Medications:
MALTIRON 2 x 1 tablets
PAMOL 3 x 1 tablets
Blood Transfusion 1 kolf : 250 cc
IVFD NaCl 0,9% 20 dpm

Treatment: Will have a complete blood test at next visit, will have a diet high in
iron.

Orders:
UA
Anemia Panel
Education/Counseling (time): 5 minutes
Coordination of Care (time): 20 minutes
Follow-up/Return Visit: 1 day
Disposition: return to hospital

RSUD Wangaya March 03,

2021

Kartini Street No. 133, Dauh Puri Kaja, Denpasar Page3

Chart
City Summary
Fax : (0361) 222487

03/03/2021 - Lab Report: Complete Blood test: dr. Agus

Tests:

Hemoglobine 7,8 11,7-15,5

Leukosit 10,1 3,6-11

Hematokrit 39 35-47

Eritrosit 3,3 3,8-5,2

Trombosit 229 150-440

MCV 87 80-100

MCH 30 26-34

MCHC 34 32-36

DIFFCOUNT

Eusinofil 0 1-3

Basofil 0 0-1

Netrofil 80 50-70

Limfosit 13 25-40

Monosit 7 2-8

LED

1 hours 115 <15

2 hous 30 <15

ELEKTROLIT

Natrium 140,8 135.0-142

Kalium 4,4 3,5-5,0

Klorida 105,7 95,0-110

Cholesterol 118,0 150-200

Trigliserida 80 70-140

Uric acid 8 <6,8

 
RSUD Wangaya March 03,
2021

Kartini Street No. 133, Dauh Puri Kaja, Denpasar Page 4

City Chart
Summary
Fax : (0361) 222487

Male  DOB: 03/06/1970      51710306xxxxxxxx                

 

  Date 03/03/2021

HEIGHT (cm) 170

WEIGHT (kg) 60

TEMPERATURE
(deg C) 36,2

TEMP SITE Axilary

PULSE RATE (/min) 70

PULSE RHYTHM regular 

RESP RATE (/min) 16

BP SYSTOLIC (mm
Hg) 100
BP DIASTOLIC
(mm Hg) 60

CHOLESTEROL
(mg/dL)  118,0

HDL (mg/dL)  -

LDL (mg/dL)  -

BG RANDOM
(mg/dL) -

CXR  -

EKG  -

PAP SMEAR  -

BREAST EXAM  -

MAMMOGRAM  -

HEMOCCULT -

FLU VAX  -

PNEUMOVAX  -

TD BOOSTER -

Foot Exam  -

Eye Exam Complete