Mrs.

Rositawati, 45 years old

UGD RS UKI Cawang
CC : Leg swelling Saturday, June 14
th
2014, 08.00 PM
Findings Assesment Therapy Planning
Patient came to UKI hospital with leg swelling about 3 day ago before
entering the hospital. Her leg sweliing if she have to stand for too long.
She has been treated in clinic and got Captopril 1 x 25 mg, but its not
work out. Patient also has been treated to the clinic with back of pain
after taking medication, and her leg become swelling. Two days ago, the
patient felt shortness of breath when walking away. The patient also had
hypertension and patients consume Captopril, but not controlled.
Nausea (-), vomiting (-), Defecation and urine good.
PHYSICAL EXAMINATION
Appearance : being sick, GCS E4V5M6
BP : 180/100mmHg
HR : 80x/min
RR : 26x/min, T : 36,6C
Eye hyperemic conjunctiva (-/-), Icteric sclera -/-
THT : normal
Mouth : normal
Neck : lymph nodes not enlarge, JVP : 5-2 cmH2O
Thorax
Ins : chest movement symmetric
Pal : vocal fremitus sound symmetric
Per : symmetric sonor sound
Aus : basic sound of breath vesicular, wheezing (-/-), ronchi (-/-)
Heart sound I & II regular, murmur (-), gallop (-)
Abdominal
Ins : looks flat
Aus : bowel sound (+), 4x/min
Per : no percution pain, timpani sound
Pal : no tenderness and defence muscular
Extremities
warm acral, CRT < 2 s, edema
LABORATORIUM
Hemoglobin : 11,9 g/dl, Haematocrit : 33,9 %
Leucocyte: 6,6 ribu/ul, Thrombocyte : 348.000 /ul
Blood ureum: 20 mg/dl, Creatinin : 0,93 mg/dl
GDS : 274 mg/dl
- Hypertension grade II
- DM type II
-Prohospitalized
-Diet : low fat and low in salt
-IVFD : I RL / 24 hours
-Mm/
Captopril 3 x 25 mg
Lasix 1 x 1 amp
OMZ 2x 40 mg
Metformine 3 x 500 mg

Laboratorium (Blood
H2TL, GDS,
Electrolyte)/day