Desta Asherti Putri

15010005
• Identifying Data
Name : Mr. A
Age : 60 th
Gender : Male
Marital Status : Married
Address : Indragiri Hilir
• Identifying Data
Mr. A is a 60-year-old teacher, He lives with
his wife and child

 Source :
Mr. A provides his own history and is reliable
and accurate

 Chief Complaint:
headache beat since 3 days ago.
 History of Present Illness
Patients, who have a history of 3 years of
hypertension, patients often experience
headache, dizziness, and sometimes difficulty
sleeping. patients like to consume oily food
and pasient to drink coffee 2 cups per day.
Symptom vs sign : HR : 170/150mmHg
T : 37,5C
R : 23 x/i
pulse : 90 x/i
Past Medical History
Patients suffering from hypertension 3 years
ago and had been brought to the hospital due
to fall from headache
o Allergies : none
o Childhood illnesses : fever and chiken pox
 Family History
◦ Father - 40 years old; accidental death;
hypertension
◦ Mother - 80 years old; diabetes
◦ Sister - 27 years old; accidental death ; childbirth
◦ 3 daugherts ( 35 , 30 , and 20 years old ) ; alive and
well
 Social History
◦ Smoking – None
◦ Alcohol – None
◦ Recreational drugs - none
◦ Caffeine - two cups of coffee or tea daily
◦ Diet – not control diet - often consume coconut milk and
fatty foods
◦ Exercise - none
 Patient Profile and Social History
◦ Brief biographical narrative
 birth : 30 January 1958
 Education : College
 living situation : live in crowded area of the population
 occupational history : father melayu mother melayu
 life style - personal interests, travel : life style to eat
spicy, oily food and coffe
 Type of work : work as Teacher
◦ List
 health habits : everyday drinking coffee
 Diet : eating is not control
 Review of Systems
o General: No fever
o Head: She has A headaches or dizziness.
o Skin, Hair, Nail: She has had thinning of the
hair for 1 years. Here are no unusual nails or
skin changes .
o Eyes, Ears, Nose, Throat: She wears glasses
and has no spots before the eyes, She has
good hearing . She wears dentures.
 Control vital sign
 Therapeutic treatment/medication
 Patient education about hypertension and
terapy non farmakologi blood presure
 Follow up pasient