Nama : Bayu Tri Gharis (22102176)

Satria Pradana (22102216)

Kelas : 22D (Keperawatan)
TM 6 : Dialog Medical Record

Nurse : good morning, how can I help you?

Theresia: good morning nurse, my mother is sick nurse
Nurse : ok, please sit down, if I may know what’s your mother name?
Theresia: mrs.natalia
Nurse : how old is your mother?
Theresia: 43 years old
Nurse : what does your mother do?
Theresia: bisnis woman
Nurse : what is your mother’s marital status?
Theresia: my mother’s divorced with my father
Nurse : it’s nice to know what you mom complained about?
Theresia:mother feels nausea,vomiting, diarrhea, excess thirst, headache,
dizziness, visual disturbance, and palpitation.
Nurse : are there any other complaints besides that?
Theresia: mom has anorexia for the past 3 to 4 months
Nurse : does your mom have any allergies?
Theresia: yes, my mother had allergies-sulfa (rash/hives)
Nurse : is there a history or iliness in his family
Theresia: there’s father has diabetes and mother has hypertension
Nurse : does your mother have advanced a dult iliness?
Theresia: we have diabetes millitus and hypertension
Nurse : does your motherever smake or drink alcohol?
Theresia: she didn’t smoke but drink a cocktail ot two on the weekend
Nurse : doeshe take other drugs?
Theresia: yeah, he’s on a lot of antidepressants
Nurse : does he exercise?
Theresia: no, he never played any sports
Nurse : what about daily activities?
Theresia: she wakes up at 5, makes breakfast and lunch, naps in the afternoon,
makes dinner, and she and her daughter clean up together
Nurse : ok thank you
Theresia: you’re welcome
MEDICAL RECORD OF THE PATIENT
Data Subjektive:
 IDENTIFYING DATA:
Name : Mrs.Natalia
Age : 43 years old
Gender : Female
Occupation : Bisnis woman
Marital status : Widow/Divarce
 SOURCE/RELIABILITY:
Ms.theresia gave miss natalia mother’s history and was reliable and
accurate
 CHIEF COMPLAINT:
mom has anorexia for the past 3 to 4 months
 HISTORY OF PRESENT ILLNESS:
mother feels nausea,vomiting, diarrhea, excess thirst, headache, dizziness,
visual disturbance, and palpitation.
 PAST MEDICAL HISTORY:
Childhood smallpox
Adult diabetes mellitus
 FAMILY HISTORY:
father has diabetes
mother has hypertension
 PATIEN’S PROFILE:
bisnis woman
she wakes up at 5, makes breakfast and lunch, naps in the afternoon,
makes dinner, and she and her daughter clean up together.
 REVIEW SYSTEMS:
Eyes : she wears glasses and has a visual difficulty, inflammation or eye
pain, double vision, or tearing.
Ear : she has good hearing and no tinnitus or aural discharge.
Tooth : she has in her teeth.
Throat : she gest a little hoarse sometimes.