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G P O N D U TY : D R. I KE D A N D R . I ND RI

C O A S S O N D U T Y : D A N I & N I T A

DUTY REPORT

16thDecember 2015

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PATIENT RECAPITULATION

Outpatient ! Patient"

Inpatient 2 Patient"

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PATIENT#$ IDENTITY

Name %r"& D

A'e (5 )ear" *+,

Re+i'i*n %*"+em

%arita+ $tatu" %arrie,Occupati*n -*n*rer R$PAD

A,,re"" .+& P& %enta/ai Perum ( $

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ANA%NE$I$

Aut*anamne"i" *n 2n,December 2015

Chie C*mp+aint 3e4er 5 ,a)" pri*r t* a,mi""i*n

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CURRENT ILLNE$$

The patient ema+e (5 )ear" *+, /a" a,mitte, in the'enera+ /ar, /ith e4er 5 ,a)" pri*r t* a,mi""i*n& Thepatient ep+ain" that the e4er i" intermittent& $he a+"* ee+"that ,urin' the ni'ht her temperature i" hi'her /hen

c*mpare, t* ,urin' the ,a)& The patient cann*t reca++ an)act*r that impr*4e" *r /*r"en" her e4er& The patient ha"n*t c*n"ume an) me,icati*n )et& In a,,iti*n t* the e4erthe patient c*mp+ain" * nau"ea an, 4*mitin' 5 ,a)" pri*r

t* a,mi""i*n& The patient ha" 4*mite, m*re than 5 time"e4er "ince it "tarte,& The patient c+aim" that "he 4*mit" upt* 172 '+a"" * /ater each time& The c*ntent" * the 4*mit i"**, an, /ater&

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CURRENT ILLNE$$

The patient a+"* c*mp+ain" * +**"e "t**+" 5 ,a)" pri*rt* a,mi""i*n& The patient ha" ,eecate, m*re than 5time" each time mea"urin' ab*ut 172 '+a""e" * /ater&The "t**+ /a" m*re +i8ui, than u"ua+ an, c*ntaine,"*+i, aeca+ matter a" /e++ a" /ater& The patientpre"ence * b+**, in the "t**+& +ac9 "t**+" :;

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PA$T ILLNE$$

-)perten"i*n :;