Академический Документы
Профессиональный Документы
Культура Документы
Physician in charge
June, Diane, Alvin
Moderator
dr. Dikara WS, Sp.PD
Patient Identity
Name : Mrs. N
Sex : female
Age : 59 y.o
Religion : Islam
Tribe : Banjar
Nation : Indonesia
Address : JL Kuripan, Banjarmasin
Occupation :-
Date of Hospitalization : August 25st 2017 at 13.00 pm
Autoanamnesis
Chief complained : Nausea
Autoanamnesis:
Patient complained of nausea and vomiting
since 1 week before hospitalized. Abdominal
pain at epigastric regio. The patient also
complained of faint because she didnt feel to eat.
The patient has a wound at her right and left legs
since 2 years ago, but hadnt treated well. The
patient had went to local govererment clinic but
refused to be treated at hospital. One week
before hospitalized, her thumb of right legs and
her left toes had been biten by mouse and get
some wound, and there are discharge at her toes.
Autoanamnesis
vomitting tik 3. Chronic
Px Fisik: nor diasease
Pale conjungtiva (+) mokr
Abdominal pain (+) omik
Lab: 2. Anor
Hb : 9,2 eksia
MCV : 77,4 geria
MCHC : 27,1 tri
at 11 am, neurologist was visite and he already to inform
about patient condition, and the reason why the condition of
patient getting worst is aspiration