MORNING

REPORT
02 2023
IDENTITY

● Name : Mrs. S
● Age : 72 years old
● Gender : Female
● RM No :-
● Emergency room admission date : September 28 2023
● Patient Type : Non Trauma
 ANAMNESIS

Main Complaint:
Both legs are swollen and painful

Illness:
Swollen, painful feet since 1 month. The patient also admitted that he had been hit by a cupboard so that his
leg was injured and had not healed in the past month. The patient feels pain when walking. Itching (-), fever
(-).

History of disease: DM (+), HT (+)

Medical history: Metformin, Amlodipin
Family History: -
Allergic history: egg and
PHYSICAL EXAMINATION

GENERALIST STATUS
KU : Baik
GCS : 456
SpO2 : 95% RA
TD : 149/87 mmHg
N : 72x/mnt
S : 36.5 C
RR : 20x/mnt
 PHYSICAL EXAMINATION

THORAX :
HEAD/NECK: Cor:
Inspection: ictus cordis invisible
Head: Palpation: ictus cordis palpable at ICS 5 MCL S
Head/neck: a/i/c/d -/-/-/- Percussion: D heart border at ICS 4 PSL D, heart
3mm/3mm isochor pupils, border S at ICS 5 MCL S
Auscultation: S1 S2 single, regular, murmur (-),
RCL +/+, RCTL +/+
gallop (-)

Neck : Pulmo:
Inspection: tracheal deviation (-) Inspection: normal chest wall shape, retraction (-)
Palpation: enlarged lymph nodes (-) Palpation: symmetrical D/S chest wall movement
Auscultation : Bruits (-) Percussion: sonor
Auscultation:
Ves + + Wh - - Rh - -
+ + - - - -
+ + - - - -
 PHYSICAL EXAMINATION

Abdomen Localis State:

Inspection : Flat, inflammation (-) scar (-)
eritem (-) Local status of the Cruris D region
Auscultation : BU (+) 12x/minute Inspection: Vulnus Laceratum measuring
Percussion : Timpany 7x1cm, hyperemia (+), minimal edema
Palpation : Palpation: tenderness (+)
Tenderness (-) superficial and deep Move : free ROM
---
--- Local status of the Cruris S region
--- Inspection: extensive hyperemia (+),
minimal edema
Extremity: Palpation: tenderness (+)
Dry red warm akral ++/++, CRT<2, edema - - / + Move : free ROM
+
 PHYSICAL
EXAMINATION
 PROBLEM LIST & PLANNING
Problem list PROBLEM LIST & Definitive Diagnosis Planning Diagnosis Planning Therapy

Anamnesis :
PLANNING
• Both legs are swollen and painful
-
-
DM
Susp. DVT
- Laboratorium (CBC,
Blood Chemical, D-
NS infusion 20tpm
IV Metronidazole
- Hypertension Dimer) 500mg
BP 149/87 mmHg - USG Doppler IV Metamizole Na 1gr
Treat wounds and
apply antibiotic
Past history: DM (+), HT (+) ointment
Metformin 2x500mg
Local status of the Cruris D region Amlodipine 10mg
Inspection: Vulnus Laceratum measuring
7x1cm, hyperemia (+), minimal edema
Palpation: tenderness (+)
Move : free ROM

Local status of the Cruris S region

Inspection: extensive hyperemia (+), minimal
edema
Palpation: tenderness (+)
Move : free ROM
LABORATORY EXAMINATION

Hematologi (28/09/2023)
HGB 12.2 L
RBC 4.29
HCT 34.7
WBC 7.38
PLT 189
Current glucose 108
D Dimer >5000
SGOT 19.8
SGPT 13.8
Ureum 34.6
Creatinin P 0.74
THANK YOU