Scribd Logo
Upload

Welcome to Scribd!

  • Patient Social Identity: Medical Record

    Uploaded by

    Jihan Fazza Royhana
    7 views2 pages
    This medical record is for a 57-year-old married male named Mr. A, who presented to the hospital with abdominal pain on January 29, 2023. His vital signs showed elevated blood pressure of 170/100 mmHg and pulse of 101 beats/minute. He reported a burning pain in his abdomen at a level of 5 out of 10 that was worse with activity. His past medical history included an appendectomy 2 years ago. On physical examination, his head, eyes, nose, mouth and neck were examined and found to be normal except for elevated blood pressure.

    Original Description:

    Original Title

    Untitled

    Copyright

    © © All Rights Reserved

    Available Formats

    DOCX, PDF, TXT or read online from Scribd

    Did you find this document useful?

    Is this content inappropriate?

    Report this Document
    This medical record is for a 57-year-old married male named Mr. A, who presented to the hospital with abdominal pain on January 29, 2023. His vital signs showed elevated blood pressure of 170/100 mmHg and pulse of 101 beats/minute. He reported a burning pain in his abdomen at a level of 5 out of 10 that was worse with activity. His past medical history included an appendectomy 2 years ago. On physical examination, his head, eyes, nose, mouth and neck were examined and found to be normal except for elevated blood pressure.

    Copyright:

    © All Rights Reserved
    Download as DOCX, PDF, TXT or read online from Scribd
    Flag for inappropriate content
    Download as docx, pdf, or txt
    7 views2 pages

    Patient Social Identity: Medical Record

    Uploaded by

    Jihan Fazza Royhana
    This medical record is for a 57-year-old married male named Mr. A, who presented to the hospital with abdominal pain on January 29, 2023. His vital signs showed elevated blood pressure of 170/100 mmHg and pulse of 101 beats/minute. He reported a burning pain in his abdomen at a level of 5 out of 10 that was worse with activity. His past medical history included an appendectomy 2 years ago. On physical examination, his head, eyes, nose, mouth and neck were examined and found to be normal except for elevated blood pressure.

    Copyright:

    © All Rights Reserved
    Download as DOCX, PDF, TXT or read online from Scribd
    Flag for inappropriate content
    Download as docx, pdf, or txt
    of 2

    NAMA : Jihan Fazza Royhana

    NIM : 011211011

    Medical Record
    Patient social identity
    Name : Mr. A
    Date of birth : June 21, 1966
    Gender : Male
    Occupation : freelance workers
    Islam
    Address : Sumurup 15/4 Asinan Bawen Kab. Semarang
    Education : High School
    Status : Married
    Date of Entrance to RS : 29/01/2023
    Identity of the person in charge
    Responsible Name : Ny. J
    Relationship with Patients : Wife
    Address : Sumurup 15/4 Asinan Bawen Kab. Semarang
    Job : Housewife
    Main complaint: abdominal pain
    Vital sign:
    Blood pressure : 170/100mmHg
    Pulse : 101x/minute
    Breathing : 20x/minute
    Temperature : 36.5C
    Spo2 : 99%
    History of Allergy: Nothing
    Pain screening
    Does the patient feel pain? (No) (yes)
    If, yes Movers: During Activities
    Quality: like burning
    Area: Abdominal
    Scale: 5
    Time: lost arising
    Previous history
    The patient has no derivative disease from the family. The patient said that he had an
    appendix operation 2 years ago at the hospital. A
    Physical examination
    1. Head
    Face symmetrical (+)
    black hair
    Clean scalp
    normal head circumference
    Defotmity (-)
    tenderness (-)
    2. Eyes
    Conjunctiva (-)
    Symmetrical (+)
    Tenderness (-)
    3. Nose
    Air Expenditure Flow (+)
    Deformity
    Tenderness (-)
    Tap pain (-)
    4. Mouth
    Mucosa (+)
    Tenderness (-)
    5. Neck
    Jugular vein (+)
    Krotis pulse (+)
    Lymph node> 10mm

    You might also like