Patient Details

Title : …………… First name(s) : m.aldy heliam tedry Surname : Helian

Gender: [+ ] F [ ] M Marital Status :….……
DOB : 4TH JUNY 1996 Country of origin: mataram Occupation : STUDEN
Address : mataram
Tel : (Home) …………… (Work) …………… (Mobile) 085339195288
Next of kin : KETUT (EMET) Relationship to patient : FATHER
Tel : (Home) …………… (Mobile) 085339195288
Allergies : NOTHING ……………
 CONVERSATION

Nama : Muhammad Isa Ansori

Kelas : 2a semeseter 3

N: hello sir
P : helo too
N: excusme My name is m.isa amsori you can call me agus and I’m nurse in this
hospital, I’d like to check your personal details, if that’s ok?
P : oke sir
N: can you tell me your full name?
P : my name is m.aldy helian tedri
N: can you spell it ?
P : m.-a.-h.-t-d-r-y
N : h-e-l-i-a-n that is right ?
P : yes, that is right
N : and what I call you ?
P : helian is fine
N : oke mr. helian , where are you from?
P : I’m from west nusa tenggara exactly sesela village
N : ok and what is your date of birth mr. agus ?
P : 4th of june,1996
N : is that 4th of june 1996?
P : that’s right.
N : and what is your job mr. aan ?
p : I’m study at medical polytechnic of Mataram.
N : okay , what’s your marital status and who is your next of kin, to contact in
emergency?
P : I’m single and my fathers name is, huzai he is my next of kin . his mobile number is
085337087653
N : thank you, do you have any allergis?
P : no , nothing
N: so where does it hurt Mr. helian?
P : in my stomach, it’s really painful sometimes
N: where exactly?
P : here, in right side of my stomach
N: oke. Can you describe the pain?
P : it’s feels like a stabbing pain
N: when it start?
P : on sunday
N: Oke tell me when do you feel the pain most?
P : I don’t know
N: all the time?
P : I think the pain just felt when I walked
N: I see how long does it last, this pain?
P : 4 minuts
N: oke. So mr. helian from 0-10 pain scale. 1-3 is mild pain, 4-6 is moderate pain, 7-10 is
severe pain. So What scale of pain do you feel?
p: I think is moderate pain when I walked
N : are there any other complaint, mr helian?
P : no nurse, only my stomach it’s a stabbing pain
N : have you ever experienced pain like this before?
P : never nurse
N : okay, I’ll be back to check your blood preasure and your thermomethers, I’ll excuse
first. Good morning
P : thank you nurse. Good morning too
N: Assalamu'alaikum mr.hamzan
p: waalaikumsallam ners aan😘😘

1) ABOUT VITAL SIGN

N : “ Hello good morning, how are you today?”
P : “ Oh good moning nurse, I’m not feeling well today”
N : “ Can you tell about your problem of condition?”
P : “ Oh es nurse. I have a problem with stomach”
N : “ Okay, thimorning I will checking vital sign to check your condition”
P : “ Yes nurse please check it”
N : “ Firstly, I will check your themperature and pulse. Please put the thermometer
in your axilla and wait for five minute. And then can you give your right hand to
check your pulse.”
P : “ Yes I can. How about the result nurse?”
N : “ Your themperature is 360 C and your pulse is 86 x / minute and then I will
check your blood pressure.”
P : “ Okay sure”
N : “ Can you raise your sleeves.”
P : “ Yes I can, wait please.”
N : “ Can you hold your arms with cuff, just relax it will just be a bit tight around
your arm.”
P : “ Okay”
N : “ That’s 100/70.”
P : “Ok. Thank you nurse.”
N : “Your welcome” assalamualaikum