Story taking

Kelompok 1

1. Axcel tri adi putra

2. Gelsi anggra monita

3. Mutia alesa

4. Piza unik sintasi

Ket:
N = nurse
K = klien

N : good morning ma'am before anything else,

i'd like to introduce myself first, i am shikhina maranga your student nurse for today and you are
K: i am mrs cherry aquino
N: all right and how would you like me to
K: call you just call me sherry
N: okay sherry so before we proceed i need you to verify some of your personal informations here your complete name
please,
K: cheri aquino and your age i am 49 years old
N: is this your address
K: yeah that's right
N; okay and are you married
K; i'm happily married to you
N; all right so before getting any further i'd like to
let you know that in order for me to help you today i need to ask you some
questions um particularly about your health andmedical background
and some of your personal circumstances will that be all right with you
K; all right
N; okay and your answers will be documented so that we will be able to
formulate the best care that will suit your need
K; fine
N; do you have any questions
K; no
N;okay, so let's get started so what brings you here today in the hospital
sherry
K; well i came here today i come here today because i am having a problem
with my severe coffee
N; okay, and how long has this cough beentherefore
K; i suppose it's been uh four to five days already
N; okay and have you got any other symptoms along with this cuff
K; yeah i had a verybad sore throat it's very itchy
N; okay and this sore throat has it been there the same amount of time as the cuff
K; yeah
N; okay and does your cough and sore throat get worse at any particular time of day
or night
K; yeah it's usually very uh disturbing every time i'm going to sleep
N; Okay and about your circle are you able to swallow it
K; yeah i can swallow but there is a slightpain every time i swallow some solid food
N; okay and can you drink
K; yeah i have no problems with liquid
N; okay so about the cup um can you describe it for me
K; well every time i cough i noticed that there is a presence of plant which is
yellowish in color and it's very sticky
N; all right is there any tinge of blood in thesputon
K; i haven't noticed
N; all right so on the scale of one to ten ten being the worst and one being the least
how bad
is your cup
K; well i suppose it's seven to eight seven to eight
N; and do you feel any pain around your chest or your neck or anywhere else in your
body
K; yeah there's pain every time i coughand actually i had also slight difficulty in
breathing every time i cough i had also pain in my throat
N; okay and can you point exactly where the pain is
K; so every time i cough i have i feel some very slight pain here and also here
N; okay so the pain is in the middle of your chest and also here in your throat
K; yeah
N; okay does this pain radiate anywhere else
K; no
N; okay so it's pretty localized
K; yeah
N; okay and can you describe the pain is it like throbbing stabbing or squeezing perhaps
or anything
K; well it's like squeezing
N; okay so on the scale of 1 to 10 , 10 being the worst one being the least how bad
is the pain that you
K; feel well since it's very um variable pain so it's just three to four
N; okay and have you taken any meds to alleviate the pain or the cup or the sore throat
K; yeah two days ago i went to the pharmacy and i bought uh carb resistant soil milks it
was 500 milligrams and also i bought along with it [Music] strep seals that's a lozenge
and to relieve my sore from
N; okay and how how many days have you been taking this medicines
K; i think it's alreadY Two days okay two to three days
N; okay and have you ever been admitted in the hospital before for any
health problems
K; well i have never been admitted to the hospital because of illness or disease but i have
been admitted at the time when i gave birth
N; okay so you don't have any other illness like diabetes heart problems or asthma like that
K; no
N; okay and i suppose you also don't have any maintenance medications
K; no
N; all right and um how about allergies are you allergic to anything like food or pets well i
K; am i have some allergy particularly on nuts like peanuts and cashews and also i am i have also
some i got some reactions every time i eat trips i've also noticed that every time i play with
my dog i i always knees so i think i have an allergy to my throat
N; okay and do you know if you have any drug allergies
K; not i can remember
N; okay and um you told me a while ago that you are married and that you've got kids and
may i know how old are they now
K; my eldest is 23 years old and my youngest is 18 years old
N; all right and are you still having your menstrual period
K; no
N; okay and have you experienced any miscarriages
K; no
N; do you have any reproductive problems
K; well i only have menstrual cramps at the time i still have my period
N; okay all right let's proceed now for family history i'd like to elicit some information
about your family health background will that be all right with you no
K; it's okay
N; okay so do you know if there is any of your first degree relatives like your mom your dad
your siblings ever suffered from any jaundice
K; no
N; okay, was diagnosed to have an
K; asthma and she always had a severe attacks of asthma
N; okay and what about heart disease
K; i don't remember but my father was known to have a very high blood pressure but he he
doesn't have any heart problems or stroke
N; okay yeah anyone with diabetes
K; yeah my dad was diagnosed to have diabetes
N; okay any cancer at all
K; no
N; okay so aside from those that you'vementioned is there any other disease that has ever
affected your family
K; i don't remember him
N; okay and now um i'd like a little bit of information about your social backgroundif that's
okay with youand so if you don't mind me asking what is your occupation
K; well i am an entrepreneur and i usually work at home
N; okay that is very nice and are you happywith work
K; yes i do
N; all right and have you lately been exposed to people with um fever runny nose or stuff
K; well a week ago my husband had a cough and he is already pooped
N; okay and at home is everything all right no stressors
K; there's no stressor except for those
skills coming every month
N; okay and how about your friends how frequently you see them
K; well before the pandemic we always get Together once a month or twice but since
pandemic is here we can't do that anymore but we still had a connection through social
media
N; okay that's good to know that you're still in contact with them and can i ask you do you smoke
at all
K; yeah
N; and how many um cigarettes do you consume per day
K; i consume at least five sticks of cigarettes a day
N; okay and do you consider quitting smoking
K; yeah i consider to stop smoking because i realize that it's really bad for my health
N; well that's really nice to hear and if you ever decide to stop smoking you can just come by here
anytime and we have a team designated that can help
and assist you overcome smoking okAy and let's continue do you drink any alcohol
K; i don't drink alcohol but i drink wine once in a while during special occasions
N; and your diet what kind of food do you usually eat
K; well i have a garden in my backyard so i usually eat vegetables and also i like mixing it with
some pork and some like chicken also
N; okay and do you exercise
K; well i can't really exercise right now because lately i'm very busy
N; okay well i highly encourage you to do some exercise because exercising can improve your
immunity and also incorporate fruits in your diet okay anyways we're done with those
important data now i'd like to sum up everything that we've covered and if i get any error feel free to
correct me okay okay so you are mrs cherry aquino 49 years old and you came here in the
hospital due to severe coughing ichi sore throat and has a slight pain in the center of the chest
during coughing there is a slight difficulty in swallowing solid foods but not with liquids
breathing can sometimes be difficult because of the frequent coughing you're able to cuff out
flam which is yellowish in color and is sticky and to alleviate the situation you took carbosystem
solutes 500 milligrams three times a day for two to three days and some lozenges you don't have
any other illness but you're allergic to nuts shrimps and dogs which is a cat you have at home and
your father was diagnosed with diabetes at high blood pressure and your mom with asthma aside
from those there are no other disease to that has affected your family and that's it is there
anything you'd like to correct or clarify
K; no everything is correct
N; okay so we're almost done now i just have to take some of you some of your vital signs and i'd
like to listen to your lungs to hear any abnormal sounds is that okay
K; it's okay
N; okay thank you okay so now i'm going to take your vital signs your temperature your blood
pressure pulse rate and breathing rate and also center lungs for any abnormal sounds Okay so.
okay so here is the result of your vital Signs uh your temperature is 37 degrees Celsius your
pulse rate is 70 beats per minute your respiration rate is 16 breaths per minute and your blood
pressure is 120 over 80 millimeter mercury all right so now i'll have to listen to your lungs
breathe in and breathe out again breathe breathe out and one more time okay and again okay so i
hear um some wheezing sound in the lower part of your lungs okay the doctor's gonna be coming
in next i'll just have to give him the results of what i have just done and they'll come and visit
you and i'll be i'll see you after that okay. i'm back and the doctor just told me that he heard the
same thing that i've heard and so he gave me your prescriptions and your meds are as follows so
you've got amoxicillin augmenting 500 milligrams every eight hours for seven days to combat
the infection and mucosal bun ambroxol to loosen the mucous secretions and for your allergies
he prescribed you with antihistamine diabetes okay so you can go home now with your
prescription but the doctor wants you to come back after seven days for your follow-up checkup
K; okay thank you
N; okay so that would be all thank you i'll be back after seven days then i'll see you then
 
thankyou