HEALTH ASSESSMENT

A. Patient’s Profile
Name: Mrs.Mita
Age: 21 years old
Gender: Female
Address: Rangas
Place of birth: Majene
Date of birth: August 17, 1998
Occupation: College student
Nationality: Indonesia
Civil status: Single
Religion: Islam
Educational level: College Graduate
Chief Complaint: Urinate often at night
Diagnosis: CKD
Attending Physician: Dr.Smith
Date of admission: October 9, 2020 at 05:21 AM
Date Handled: October 10, 2020

B. PRESENT HEALTH HISTORY

At 9:00 in the morning, before entering, while the patient was sitting, he experienced it
Chest pain and shortness of breath. He assesses pain 4/10 and thinks of the pain which takes
a 1-minute duration which occurs every minute. Patients often urinate at night, urinate about 3-
4 times a night. the closest. Patients who get urinary tract infections, so patients can be given
antibiotics consisting of ampicillin. After a few days, the symptoms of the patient's disease are
getting worse than before.
The patient's family decided to take the patient to the downtown assembly hospital.
Arriving at the hospital, the patient performs a laboratory examination by taking the patient's
urine as a sample in the urinalysis test, sometime later, the laboratory results in obtaining the
patient's urine containing abnormal albumin protein. So the sufferer is diagnosed with acute
chronic kidney disease.
C. PAST HEALTH HISTORY
 Patients have suffered from diabetes. Approximately 14 years, had asthma from young
who appeared at the age of 9 years. Patients have a history of hypertension for 7 years, as well
as having a stroke for 1 year, but have recovered. Patients have been admitted to the hospital
6 times.

D. FAMILY HEALTH HISTORY

according to the patient, his illness had never happened to his family members.
However, according to the patient, his father is a sufferer of diabetes mellitus. while the
patient's mother had experienced hypertension for approximately 1 year. And there are 2
siblings of patients who suffer from diabetes mellitus.

MUH.NUR RAHMAN HADI

MITA ASRIDA

TERJEMAHANNYA
R.SEKARANG
Pada jam 9:00 pagi, sebelum masuk, ketika pasien sedang duduk, dia mengalaminya
Nyeri dada dan sesak napas. Dia menilai rasa sakit 4/10 dan memikirkan rasa sakit yang
membutuhkan durasi 1 menit yang terjadi setiap menit. Pasien sering buang air kecil di malam hari,
buang air kecil sekitar 3-4 kali semalam. terdekat. Pasien yang mendapat infeksi saluran kemih,
sehingga pasien dapat diberikan antibiotik yang terdiri dari ampisilin. Setelah beberapa hari, gejala
penyakit pasien semakin memburuk dari sebelumnya.
Keluarga pasien memutuskan untuk membawa pasien ke rumah sakit perakitan di pusat kota.
Sesampainya di rumah sakit, pasien melakukan pemeriksaan laboratorium dengan mengambil urin
pasien sebagai sampel dalam tes urinalisis, beberapa waktu kemudian, hasil laboratorium dalam
mendapatkan urin pasien yang mengandung protein albumin abnormal. Jadi penderitanya didiagnosis
menderita penyakit ginjal kronis akut.

R. TERDAHULU

Pasien telah menderita DM Kurang lebih 14 tahun,mengalami asma sudah dari muda yang muncul
pada saat umur 9 tahun.Pasien mempunyai riwayat hipertensi selama 7 tahun,serta sampai mengalami
stroke selama 1 tahun,tetapi sudah sembuh.Pasien sudah 6 kali masuk rumah sakit.

R.KELUARGA
menurut pasien, penyakitnya tidak pernah terjadi pada anggota keluarganya. Namun, menurut pasien,
ayahnya adalah penderita diabetes mellitus. sedangkan ibu pasien pernah mengalami hipertensi
selama kurang lebih 1 tahun. Dan ada 2 saudara kandung pasien yang menderita diabetes mellitus.