January

24th, 2015

Doctor in charge: dr. Nani Zaitun, Sp. PD

MORNING REPORT

GROUP 4
Firstyaprilly Wahyuningtyas
Aulia Rahmah
Mahdi Aldha Mahashin
Ramadhan Wibowo
Devi Rahma Yulianti
Ahmad Rezqy Fadhillah

PATIENTS IDENTITY
Name
Sex
:
Age
:
Occupation
:
Address
Hospitalized since

: Mrs. Isnawati
Female
42 yo
Farmer
: Panamas
: January 20th, 2015

SUMMARY OF DATA BASE

Mrs.I/ 42 yo /Female (Autoanamnesis)
Chief Complaint : Unilatelar leg edema (dextra).

Patient has unilateral leg oedeme for fifteen days. Patient was
hospitalized at RSUD DR.H.Soemarno Sosroadmodjo Kuala Kapuas 1
week ago. The patients oedema was on her whole leg and persistant.
Patient also felt pain. the pain appeared insidious and occurred with
oedeme simultaneously. The pain was intermittent, pulsated and
worsen by activity. Patient was barely sleep, stand and walk because
of pain. Patient felt nausea, vomit and gastric pain because of
anorexia. Patient lost her weight around 5 kg. Patients allergic history
was unknown.
History of Past illness: Dyslipidaemia
History of Family illness: Hypertension (father)

PHYSICAL EXAMINATION
General appearance

Looked moderately ill, Conscious, GCS : 4 5 6

H: 144 cm W: 55 kg IMT = 26 (Grade I Obesity)

Vital Signs

BP=110/80 mmH;PR=76 bpm regular, strong;RR=24 Tpm; T=37,20C axilla

Head

Pale conjunctiva (-/-), Jaundice sclera (-/-), Edema palpebral (-/-), Diplopia (-),
discharge (-/-), exophthalmus (-/-), lid retraction (-/-), lid lag (-/-)

Neck

Lymphatic node swelling (-), struma (-), bruit thyroid (-)

Chest Heart

Inspection : ictus invisible

Palpation : palpable in MCS ICS V
Right margin : Right : ICS 5 L.Ster (D).
Auscultation : S1 > S2 single, murmur (-) gallop (-)
Inspection : Symmetric, barrel chest (-)
Palpation : FV symmetric
Percussion :
Auscultation :
S | S
V |V
S | S
V |V
D | D
- |Wheezing (-), Rhonchi (-)
Inferior margin : D = ICS5
S = ICS6

Lung

Abdomen

Percussion:
D | D |D
D | D |D
D | D |D

Tenderness:
- |- |- |- |- |- |-

Extremities

Superior D & S : Edema (-/-), Pain (-/-), Weakness (-/-), tremor (+/-)
Inferior D & S : Edema (+/-), Pain (+/-), Weakness (-/-), tremor (-/-)
Unilateral Edema (D=27,5 cm ; S=21,5 cm), Homans sign (+)

CLINICAL
APPEARAN
CE

LABORATORY FINDINGS
JANUARY 19 TH 2015

Examinati
on

Valu
e

Referred
Value

Unit

Examinatio
n

Value

Referred
Value

Unit

Hb

11,5

12,00-16,00

g/dl

GDS

102

<200

mg/dL

leukosit

11,8

4,0-10,5

th/ul

Kolesterol

169

150-220

mg/ dL

eritrosit

3,63

3,90-5,50

million/ul

SGOT

31

0-46

U/I

hematokrit

33,4

37,00-47,00

Vol%

SGPT

24

0-45

U/I

Trombosit

279

150-450

th/ul

Albumin

3,4

3,5-5,5

Gr/dl

RDW-CV

14,6

11,5-14,7

Ureum

14

10-50

Mg/dL

MCV

92,2

80,0-97,0

Creatinin

0,9

0,6-1,2

Mg/dL

MCH

31,6

27,0-32,0

pg

MCHC

34,4

32,0-38,0

Gran%

68,0

50,0-70,0

Limfosit%

23,6

25,0-40,0

MID%

8,4

4,0-11,0

Gran#

8,00

2,50-7,00

th/ul

Limfosit#

2,8

1,25-4,0

Th/uI

MID#

Th/uI

Problem list
Female, 42 yo
1. Unilateral leg
edema
1.1 DVT

1.2 Filariasis

Data Support
Ax:
Edema of whole
leg
Unilateral Edema
Pain
Difficult to move
and walk.
Px:
Local Tenderness
Edema of whole
leg
Unilateral Edema
(D=27,5 cm ;
S=21,5 cm)
Non varicose vena
dilatation
Homans sign (+)
Wells Scoring = 4
Unilateral leg
edema
Pain
Abdominal pain
regio epigastric
debility
lose weight

Planning
Diagnosis
USG
doppler
Clotting
time
CTVenograph

Planning
therapy
Confirm
Diagnosis
Inj Ketorolac
3x10mg

vital sign
observation
Edema
observation

Education

Elevati
on the
leg
Use
elastic
stockin
g

Microfilaria
examinatio
n

Monitor

Confirm
diagnosis
Inj
Ketorolac
3x10mg

Vital sign
Edema
observation

Use
elastic
stocking

Problem list
2. Dyspepsia
2.1 gastritis erosiva
2.2 Gastric ulcer (?)

3. History of Dyslipidaemia

Data Support

Planning
Diagnosis

Ax:
Nausea and
vomit e.c.
anorexia

OMD

Ax : History of
past illness

Laboratory
test : lipid
profile

Planning
therapy

Monitor

Education

IVFD NaCl
Inj Ranitidin 2x
50mg

diet
observation
urine output

Adequate
Diet

Confirm
diagnosis

Lipid profile

Avoid fatty
foods

Thank you