Professional Documents
Culture Documents
By :
Muhammad Sidiq, MD
Supervisor :
M. Diana Rahim, MD
Name: Mrs. AT
Age : 18 years old
Gender : Female
Medical Record Number: 171365
Admission Date : October,01 2021
Time : 00.30
GP : Eva, MD
HISTORY TAKING
The patient came to the emergency departement at Guntur Hospital with chief complain Nause and
vomiting since 4 days before, oftenly she just vomited fluid likes saliva or small amount of food. She
took medication which she got from clinic, but she forgot kind of medication for relieving her complaint.
Unfortunatly the medication didn’t relieve her complain. When she came to ER, she feel nausea and
vomitin, stomachache, especially part of upper middle, and she felt weak and loss appetite also.
Sometimes she got uncomfartable when she breath because his illness.
Fever, chest pain, diarrhea, bleeding, black stool was denied by patient
HISTORY TAKING
Head : normochepal
Eyes : Anemic Conjungtiva -/-, Icteric Sclera - / -,
Extremities :
Warm, Edema (-), CRT < 2 second
– Immunology :
• Rapid antigen Covid-19 : Negative
DIAGNOSE
• Gastritis akut
MANAGEMENT