MEDICAL RECORD

OLEH

Nama : I Ketut Suardika

No. Urut :4
Prodi/Kelas : Profesi NERS Kelas A

KEMENTERIAN KESEHATAN REPUBLIK INDONESIA

POLITEKNIK KESEHATAN DENPASAR
PROGRAM STUDI PROFESI NERS
TAHUN 2021
RSUD Karangasem  

Ngurah Rai Street No. 58, Karangasem City

Fax : (0363) 21470 Chart Summary

Mr. X

Home: 082-xxx-
xxx-xxx
Male DOB: 53730104xxxxxxx Ins: Commercial
03/04/1989 x xxxxx

                                                     

Patient Information

Name: Mr. X Home Phone: 082-

xxx-xxx-xxx

Address: Ulakan Street. No. 11, Office Phone: -

Karangasem City

Patient ID: 53730104xxxxxxxx Fax: -

Birth Date: 03/04/1989 Status: Active

Gender: Male Marital
Status: Married

Contact By: Phone Race: Asian

Soc Sec No: 543216789xxxx Language: Indonesia

n

Resp Prov: dr. Nyoman MRN: MR-123-45

Referred by: - Emp. Status: Full-

time

Email: - Sens Chart: No

Home LOC: RSUD Karangasem External ID: MR-
123-45

Problems
APPENDICITIS
Medications
Pantoprazole 1 x 40 milligrams
Ketorolac 2 x 1 ampoule
Directives
Allergies and Adverse Reactions (! = critical)
Services Due
IVFD RL 30 dpm

03/03/2021 - Office Visit:

Provider: dr. Nyoman
Location of Care: RSUD Karangasem

OFFICE VISIT
History of Present Illness 
Reason for visit: Appendicitis follow up 
Chief Complaint: Lower right stomach pain

History
Pain assessment 
P : Pain when moving
Q : Pain like being stabbed
R : Lower right abdomen
S : 7 (0-10)
T : Anytime

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: patient complains of abdominal pain
Eyes: symmetrical, no abnormalities
Ear/Nose/Throat: symmetrical, clear, no abnormalities
Cardiovascular: regular rate and rhythm, no murmur, rub or gallop, peripheral
pulses normal and symmetric, no cyanosis, clubbing, edema or varicosities
Gastrointestinal: right lower abdominal pain, pain like being stabbed
Genitourinary: denies hematuria, frequency, urgency, dysuria, discharge,
impotence, incontinence
Musculoskeletal: denies back pain, joint swelling, joint stiffness, joint pain
Skin: clear, good turgor.
Neurologic: denies syncope, seizures, transient paralysis, weakness, paresthesias
Psychiatric: anxiety
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 Karangasem March 11, 2021

Ngurah Rai Street No. 58, Karangasem City Page 2

Chart Summary
Fax : (0363) 21470

Ht: 163 cm. Wt: 55 kg. T: 36,0 degC. Tsite: axilary P: 70 bpm

Rhythm: regular R: 20 bpm BP: 120/70 mmHg
Physical Exam
General Appearance: well developed, well nourished, no acute distress
Eyes: symmetrical, no eyelid edema, anemic conjunctiva, not icteric sclera, pupil
isocor
Ears, Nose, Mouth, Throat: symmetrical, no deformity, moderate or normal
size, in the ear canal there is no bleeding or discharge.
Respiratory: clear to auscultation and percussion, respiratory effort normal
Cardiovascular: regular rate and rhythm, no murmur, rub or gallop, peripheral
pulses normal and symmetric, no cyanosis, clubbing, edema or varicosities
Skin: clear, good turgor.
Problems (including changes): acute pain
Impression: patient grimacing and anxious.
Home Vital Sign Monitoring:
Temperature : 36,5 degC, Blood Pressure : 120/80 mmHg

Plan
Medications:
Pantoprazole 1 x 40 milligrams
Ketorolac 2 x 1 ampoule
IVFD RL 30 dpm
Treatment: Ultrasound will be done.
Orders:
Lab test results
Education/Counseling (time): 10 minutes
Coordination of Care (time): 20 minutes
Follow-up/Return Visit: 5 days
Disposition: return to hospital

WeServeEveryone Clinic March 11, 2021

Ngurah Rai Street No. 58, Karangasem City Page 2

Chart Summary
Fax : (0363) 21470

11/03/2021 - Lab Report:

Lab Tests:
(1) Metabolic Panel(ML-03CHEM)

Hemoglobin 12.1 g/dl 14-16

Hematocrit 45.2 % 40-50

Leukocytes 11.700 /mm3 4.000-10.000

Platelets 178.000 /mm3 150.000-400.000

We Serve Everyone Hospital March 11, 2021

Ngurah Rai Street No. 58, Karangasem City Page 2

Chart Summary
Fax : (0363) 21470

Female  DOB: 03/04/1989                      53730104xxxxxxxx Ins: Commercial

xxxxx

  Date 03/18/2011

HEIGHT (in) 163

WEIGHT (lb) 55

TEMPERATURE
(deg C) 36,5

TEMP SITE Axilla

PULSE RATE (/min) 70

PULSE RHYTHM  

RESP RATE (/min) 20

BP SYSTOLIC (mm
Hg) 120

BP DIASTOLIC
(mm Hg) 70

CHOLESTEROL
(mg/dL)  

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