Summary of Database

Mrs. Z/55 yo/ward 28 bed 17

Autoanamnesa and heteroanamnesa with her husband
Chief Complaint:
general weakness
History of Present Illness:
Patient suffers from general weakness since these last 2 weeks. She was so weak nothing
more she can do but to lay down in her bed. Blood transfusion were given when she was hospitalized at
Pasuruan for 15 days. She sufferes from diarrhea since 20 days ago, with waste and residual presents, not
less than 8 times a day, with the volume around 100 cc each. There is no blood present, but greenish
mucous. She also feels pain whenever she defecates, intermittenly. Fever also presents intermittenly but
not so high since 15 days ago. Nausea and vomiting also occurs these last 15 days, but the frequency has
decreased since a week ago. There is also pain whenever she swallows anything since 4 months ago that
limited her to eat much.
She has undergone an operation at her right cheek 5 months ago because of abscess. Since
then, she felt the difficulty to open the mouth and to swallow. She had ever fallen and broken her right
shoulder at August 2017, and still feels the pain until now and has limitation of moving her right upper
shoulder because of pain. Her urinating has decreased since these last 2 weeks, with a darker yellow color
of urine. Hypertension and type 2 Diabetes mellitus history were unknown.
 Summary of Database
Past Medical History:
broken right shoulder at August 2017
right cheek abscess operation at March 2018
Family History:
-
Social History:
she is a housewife with 2 daughter
Review of System:
fever (+)