MEDICAL RECORD

CREATED BY :

NI WAYAN LITA PERDANI

017

KEMENTERIAN KESEHATAN REPUBLIK INDONESIA

POLITEKNIK KESEHATAN DENPASAR
JURUSAN KEPERAWATAN
PRODI NERS
2021
 Sanjiwani Regional General Hospital,
Gianyar
Ciung Wanara Street No.2, Gianyar Regency Chart Summary

Ny. B
Home: (0361) 123456
Female DOB:
08/12/1997 130613 Ins: Commercial xxxxx

Patient Information
Name: Ny. B Home Phone: (0361)
123456
Address: Mulawarman Stress, Abianbase Office Phone:
village,
Gianyar Regency
Patient ID: 130613 Fax:
Birth Date: 08/12/1997 Status: Active
Gender: Female Marital Status: Married
Contact By: Phone Race: Bali
Soc Sec No: Language: English
Resp Prov: MRN: MR-709-2013
Referred by: Emp. Status: Full-time
Email: Sens Chart: No
Home LOC: Sanjiwani Regional General External ID: MR-709-2013
Hospital, Gianyar

Problem
ASTHMA

Medications
ALBUTEROL BY NEBULIZER: 0.5 mL in saline.

Sanjiwani Regional General Hospital, July 01, 2021

Gianyar
Ciung Wanara Street No.2, Gianyar Regency Page 2
 (0361) 111222 Chart Summary

Directives
Allergies and Adverse Reactions (! = critical)
Services Due

07/01/2021 – Office Visit: F/u Asthma

Provider: Lita
Location of Care: Sanjiwani Regional General Hospital, Gianyar

OFFICE VISIT
History of Present Illness
Reason for visit: Inpatient
Chief Complaint: Wheezing, getting worse

History
Ineffective Airway Clearance
Cough: Yes
Wheezing: Yes
Dyspnea: Yes
Restless: Yes
Respiratory rate changes: Yes
Breathing pattern changes: Yes

Ineffective Breathing Pattern

Dyspnea: Yes
Use of accessory muscles for respiratory: Yes
Abnormal breathing pattern: Yes
Nostril breathing: Yes

Sanjiwani Regional General Hospital, July 01, 2021

Gianyar
Ciung Wanara Street No.2, Gianyar Regency Page 2
 (0361) 111222 Chart Summary

Review of Systems
General: say fatigue, malaise, fever, denies weight loss
Eyes: denies blurring, diplopia, irritation, discharge
Ear/Nose/Throat: denies ear pain or discharge, there is nasal obstruction or
discharge
Cardiovascular: enies chest pain, palpitations, paroxysmal nocturnal dyspnea,
orthopnea, edema
Respiratory: there is cough, wheezing, dyspnea.
Gastrointestinal: denies abdominal pain, dysphagia, nausea, vomiting, diarrhea,
constipation
Genitourinary: denies hematuria, frequency, urgency, dysuria, discharge,
impotence, incontinence
Musculoskeletal: denies back pain, joint swelling, joint stiffness, joint pain
Skin: denies rashes, itching, lumps, sores, lesions, color change
Neurologic: denies syncope, seizures, transient paralysis, weakness, paresthesias
Psychiatric: denies depression, anxiety, mental disturbance, difficulty sleeping,
suicidal ideation, hallucinations, paranoia
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
Wt: 55 lbs. T: 100.5 degF. T site: oral. P: 100/min. R: 40/min. BP: 120/70 mm
Hg.

Sanjiwani Regional General Hospital, July 01, 2021

 Gianyar
Ciung Wanara Street No.2, Gianyar Regency Page 2
(0361) 111222 Chart Summary

Physical Exam
Eyes: conjunctiva and lids normal, PERRLA, EOMI, fundi WNL
Ears: ears clear
Nose: swollen, reddened membranes with white mucus
Throat: throat clear
Respiratory: breathing at 40/min. Audible wheeze, with faint inspiratory and
moderate expiratory wheezing on auscultation
Cardiovascular: regular rate and rhythm, S1-S2, no murmur, rub or gallop, no
bruits, peripheral pulses normal and symmetric, no cyanosis, clubbing, edema or
varicosities
Skin: clear, good turgor, color WNL, no rashes, lesions, or ulcerations

Plan
Medications:
ORAL ALBUTEROL, 1 tsp (2 mg) every 6 h.
Slow but steady liquid intake tonight and tomorrow

Orders:
Monitor Blood Gas Analysis Values
Monitor Breathing Patterns and Additional Breath Sounds
Position the Patient in Semi-Fowler’s or Fowler’s Position
Education/Counselling

Sanjiwani Regional General Hospital, July 01, 2021

Gianyar
Ciung Wanara Street No.2, Gianyar Regency Page 2
(0361) 111222 Chart Summary

07/01/2021 – Lab Report: Blood Gas Analysis Values

Temperatur 100.5 degF -

Ph 7,198 7,350-7,450
PCO2 46,8 33-44 mmHg
PO2 135,4 71-104 mmHg
Calculated data - -
HCO3 act 22,6 21- 28 mmol/L
BE (ecf) -4,00 2,00- + 3,00 mmol/L
BE (B) -3.5 -2,4--+2,3mmol/L
02 sat 90% 94-98 %

Sanjiwani Regional General Hospital, July 01, 2021

Gianyar
Ciung Wanara Street No.2, Gianyar Regency Page 2
(0361) 111222 Chart Summary
Female DOB:
08/12/1997
130613 Ins: Commercial xxxxx

Date 07/01/2021
WEIGHT (lb) 55
TEMPERATURE (deg F) 100.5
TEMP SITE Oral
PULSE RATE (/min) 100
RESP RATE (/min) 40
BP SYSTOLIC (mm Hg) 120
BP DIASTOLIC (mm Hg) 70