MEDICAL RECORD

UPTD PANTI SOCIAL

Identity
Name Mrs. S
Age 70 years
Gender Female
Religion Islam
last education No school
Previous work Household assistant.
Address before the orphanage Jl. Pemuda 4 Samarinda.
The date of admission to the orphanage 28 May 2011
Assessment date 5 April 2021
Room 3
Person in charge Indah
Responsible work Caregiver

Employment history
Current employment status. Does not work.
Previous work. Household assistant.
Sources of income and adequacy of needs. Government Assistance.

Source / support system

Doctor √
Nurse √
Hospital / Puskesmas / Clinic. √
Home health services. -
Others, please specify. Caregiver

Current Health Status

General health status for the past year. Gout Artritis and Hypertension.
General health status for the past 5 years. Hypertension
Major health complaints. Knee joint pain and dizziness.
Knowledge about management of health Taking medication.
problems.
The degree of overall functioning relative to
medical problems and medical diagnoses.

Drugs
Drug name and dosage. Allupurinol 100 mg.
How / when to use. 1x a day
The intrusive doctor. Do not know
Prescription date

Immunization Status
Tetanus, Diphtheria Has never been.
Influenza Has never been.
Pneumoni Has never been.
Allergy No allergies.
Drugs Allupurinol 100 mg.
Food There are no specific food
 allergies.
Substance contact. Never have direct contact with
people with infectious diseases.
Environmental factors. The client's environment is free
from sufferers of immune system
diseases.

Nutrition
Diet, restrictions on eating and drinking. According to giving
History of weight gain / loss. There is a decrease of about 6 kg.
Food consumption patterns. 2 times a day independently.
Problems that identify problems. Nothing
Habit Using sambal.

Past health status

Childhood illness. Fever and flu.
Serious / chronic illness. Hypertension and Gout Artritis.
Trauma Nothing
Hospital treatment. Nothing
Operation Nothing

Physical examination
General Yes Not
1. Fatigue √
2. Change in appetite. √
3. Fever √
4. Night sweats. √
5. Trouble sleeping. √
6. Frequent colds, infections. √
7. Self-assessment of health status. √
8. Ability to perform AKS. √
Integument Yes Not
1. Pruritus √
2. Pigmentation changes. √
3. Texture changes. √
4. Frequent bruising. √
5. Hair changes. √
6. Nail changes. √
7. Long exposure to the sun. √
8. Healing patterns of lesions, bruises. √
Hemapoetic Yes Not
1. Abnormal bleeding / bruising. √
2. Swollen lymph nodes. √
3. Anemia √
4. History of blood transfusions. √
Head Yes Not
1. Headache √
2. Trauma means in the past. √
3. Dizzy √
4. Itchy scalp. √
Eye Yes Not
1. Vision changes. √
2. Eye glasses / contact lenses. √
3. Pain √
4. Excess tears. √
5. Swelling around the eyes. √
6. Escape √
7. Phobia photos. √
Ear Yes Not
1. Hearing changes. √
2. Tinnitus √
3. Vertigo √
4. Hearing sensitivity. √
5. Prosthesis tools. √
6. History of infection. √
7. The most recent inspection date. √
8. Ear care habits. √
9. Impact on AKS appearance. √
Nose Yes Not
1. Rinorea √
2. Discharge √
3. Epistaxis √
4. Obstruction √
5. Snoring √
6. Pain in the sinuses. √
7. Allergy √
10. History of infection. √
11. Self-assessment on olfactory abilities. √
Mouth and Throat Yes Not
1. Sore throat. √
2. Ulcers / lesions √
3. Hoarse √
4. Change in voice. √
5. Difficulty swallowing √
6. Prosthesis tools. √
7. History of infection. √
8. The most recent dental check-up date. √
9. Tooth brushing pattern. √
10. Problems and habits of cleaning dentures. √
Neck Yes Not
1. Stiffness √
2. Pain / tenderness. √
3. Lump / Mass. √
4. Movement limitations. √
Breast Yes Not
1. Lump / Mass √
2. Pain / tenderness √
3. Swollen √
4. Discharge from the nipple. √
5. Changes in the nipple. √
6. The pattern of breast self-examination was dated and the √
results of the most recent mammography.
Breathing Yes Not
1. Cough √
2. Out of breath √
3. Heopteses √
4. Sputum √
5. Wheezing √
6. Asthma / Respiratory allergies. √
Cardiovascular Yes Not
1. Chest pain / discomfort. √
2. Palpitations √
3. Out of breath. √
4. Diapnea on activity. √
5. Paroximal nocturic dipsnea. √
6. Orthopnea √
7. Murmur √
8. Edema √
9. Varicose veins √
10. Lame legs. √
11. Parasthesia √
12. Change in foot color. √
Gastrointestinal Yes Not
1. Dysphagia √
2. Can't digest. √
3. Heartburn. √
4. Nauseous vomit √
5. Hematemesis √
6. Change in appetite. √
7. Activity intolerance. √
8. Ulcers √
9. Pain √
10. Jaundice √
11. Lump / mass √
12. Changes in bowel habits. √
13. Diarrhea √
14. Constipation √
15. Melena √
16. Haemorrhoids √
17. Rectal bleeding. √
18. The usual defecation pattern. √
Urinal Yes Not
1. Dysuria √
2. Dripping √
3. Doubtful √
4. Encouragement √
5. Hematuria √
6. Polyuria √
7. Oliguria √
8. Nocturia √
9. Incontinence √
10. Pain when urinating. √
11. Stone √
12. Infection √
Genitalia Yes Not
Female Reproductive Genito
1. Lesions √
2. Discharge √
3. Post-intercourse bleeding. √
4. Pelvic pain √
5. Sexually transmitted diseases. √
6. Infection √
7. Sexual activity problems. √
Musculoskletal Yes Not
1. Joint pain. √
2. Stiffness √
3. Swelling of the joints. √
4. Deformity √
5. Spasms √
6. Cramps √
7. Muscle weakness. √
8. Walking problems. √
9. Back pain. √
10. Prosthesis √
11. Exercise / exercise habits. √
12. Impact on AKS appearance. √
Nerves Yes Not
1. Headache. √
2. Seizures √
3. Heart attack. √
4. Paralysis √
5. Paresis √
6. Coordination problems. √
7. Tic / tremor / spasm. √
8. Parastesis √
9. Head injury. √
10. Memory problems. √
Endocrine Yes Not
1. Heat intolerant. √
2. Cold intolerant. √
3. Goiter √
4. Skin pigmentation / texture. √
5. Hair changes. √
6. Polyphagia √
7. Polidipsi √
8. Polyuria √
Samarinda, 5 April 2021
NURSE

Nurul Hidayah