Nurse : Good morning sir, may I know your name? Mr. S : My name is Mr. S Nurse : How old are you? Mr. S : 25 years old Nurse : Are you married? Mr. S : Yes I am Nurse : may i know your religion? Mr. S : of course, I am Islam Nurse : what is your last education? Mr. S : I only graduated from senior high school Nurse : Where do you live? Mr. S : I live in Surabaya. Nurse : Do you have hereditary diseases? Mr S : I have no history of hereditary diseases, both my family and wife. In my family there are also no family members who suffer from physical disability or mental illness. Nurse : what is the main complaint that you felt at this time? Mr. S : My head feels dizzy, my throat and body feel weak and sometimes it feels a little tight. My body feels weak often and sometimes feels sleepy during the day. I have also been hospitalized several times because of shortness of breath. There were about 5 blood bags donated to me for 5 times in the hospital for a period of 4 years, namely 2015 to 2019. There were 10 times hospitalization at the Panti Rapih Hospital. I often feel shortness of breath during excessive activity. I also felt my head hurt with a 5-7 pain scale. Nurse : Can you tell me what history of illness you have suffered? Mr. S : I often suffer from coughing for a long time and my head is often dizzy and the body feels weak, after being examined it turns out that the doctor said I had anemia. Nurse : Can you tell me how you care for your health? Mr. S : If I feel sick, I go to the health center or to the hospital. I always maintain health with lots of rest and control if I feel unwell. But for five months I was often sick, coughing and phlegm, and shortness of breath and dizziness. Nurse : what are your eating and drinking habits at home? Mr. S : I eat 3 times a day. At home I usually eat rice, vegetables, sometimes meat and crackers. But lately he eats a little and his appetite decreases. I drink about 4-5 glasses of water and sometimes drink tea. Nurse : how do you sleep at home? Mr. S : I usually sleep at night from 7:30 a.m. to 4:00 a.m. and do morning prayers. I sometimes wake up at night but I can sleep again until morning. I often rest and take time to sleep during the day. Nurse : well, now i will start a physical examination to you. Do you agree? Mr. S : Oke. Nurse : (The nurse checks the patient) Your blood pressure is 130/70 mmHg, Pulse rate: 78x/minute, Respiratory: 20x /minute, Temperature: 36,8º C, TB: 155 cm and BB: 42 kg. Sorry, I will check your head, clean the scalp and hair, gray hair. In the neck there are no enlarged neck lymph nodes. For thorax, your chest shape is symmetrical, there is no chest wall retraction, vesicular lung sounds, the heart does not experience enlargement, normal heart sounds. For abdomen, there is no ascites, no tenderness, good skin turgor. For Extremities: No swelling and cyanosis, clean nails and toes. Now I will evaluate your five senses. Do you agree? Mr. S : Oke, im agree. Nurse : Now I will evaluate your five senses. Do you agree? Mr. S : yes, Im agree. Nurse : First I will check your Vision (Eyes), Your eyeball is symmetrical, there are no abnormalities. But your conjugation is anemic, your sclera is not jaundiced, your pupil reflexes are normal. For your hearing (ear) examination, the ear shape is symmetrical, there is no cerumen, there is no hearing loss. For tasting functions, some teeth are dated only the lower canines, the tongue is clean, the sensation is sweet, salty, bitter, normal. For your sensation, skin turgor is good, you can still feel the sensation of pain, good touch sensation, good temperature sensation. For Smell (Nose): Nostrils look symmetrical, not secret, Konka Normal.
