grup 5

1.Aldo dinasti rusdian 1914201034

2.Febi rama fadhila 1914201035
3.Anita nabila putri 1914201045
4.Widya ananda putri 1914201053
5.Refina herawaty 1914201067
 Medical record
1. A.PATIENT IDENTIFICATION
2. Name : TN.W
3. Age : 68 years old
4. gender : male
5. Address : housing cendana-bangil pasuruan
6. Medical record : 04.95.32
7. Reg no : 5372896
8. Period of hospitalized : 09-12 december 2018
9. Name of hospital : HCU Melati room bangil pasuruan .
10.Main complaint: angina pectoris
 MEDICAL HISTORY
Current Nursing History
1) Chief complaint: Right chest pain
2) History of current illness:
The patient complains of chest pain at home on 08-12-2018 patient then given massage oil
and scraped but it still hurts then the patient was brought to the ER Bangil Hospital on 09-
12-09 2018 at 21.00 then the patient was observed a few hours ago the patient transferred
to dahlia inpatient room at 22.30 but his condition continues to decline and requires special
care then the patient moved again to HCU jasmine room on 12-12-2018 pokul 13.00.
During the assessment in the HCU room, the patient said that the patient had chest pain to
the right.
P: Narrowing or blockage of blood flow to the heart
Q: The pain is stabbing, the breath feels musty or heavy
R: Right chest pain S: 7
T : Disappearing
Previous Nursing History
Past medical history:
1) Diseases that have been suffered:
The patient said he had diabetes and cholesterol 1.5 years, the patient has never had surgery, no
allergies.
Family Health History
1) Diseases that have been suffered by family members: The patient said that his family
members had the disease chronic, heart disease
2) Home and community environment: The patient said the home environment was clean
and well ventilated enough
3) Behaviors that affect health: The patient said that in his youth he often smoked, and quit
smoked around the age of 40.
Fluid and nutritional status
On food, fluid and nutritional status, appetite was found enough, eating patterns before
illness 3x1/2 servings of patients on a special cholesterol diet, when sick 3x1/2 portion added
milk, drink more or less water 700cc/day, dietary restrictions are foods that are high in fat and
sugar,the diet menu is vegetables, fruits and milk, another complaint is nausea and cough
 Physical examination
General Circumstances:
Composmetis K/u: General condition is weak and the face is grinning

Vital Signs :
On signs ± vital signs found, blood pressure: 140/60 mmHg, temperature: 36.5 oC
(Measurement location: Axila), Pulse: 62 x/min (counting location: Radalis), Respiration:
24 x/min
THANKS
YOU