MORNING REPORTDepartment of Internal MedicineChristian
University of IndonesiaOctober 9nd 2014 TEAM 4
Mr. K (56 yo)
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Subjective DataName: Mr. KAddress: JakartaTC: thursday/9nd
October 2014CC: edema in palpebra, foot and hand
Anamnesis
Main symptom : edema palpebra, foot and handAdditional symptom :
-
56 years old male patient came to hospital with complaint of
edema in palpebra, foot and hand since three month before
admission. The complaint came suddenly and continously. The symptom
felt worse for two days.Patient has no history of hypertension, but
he has diabetes mellitus since three years ago and he got a
treatment with metformin. The patient told that he has go to the
hospital and the diagnose was kidney disease.
Past Medical History and Treatment the patient consume
medication for kidney since 4 years ago.
Family History(denied)
Social History Smoke(-), Alcohol (-)
Objective DataLOC: E4V5M6 ; ComposmentisAppearance: moderate
illBP: 140/100 mmHgPR : 96 x/min (adequate,regular)RR : 24
x/minTemp: 360CEYE: anemic conjungtiva -/- ; ict -/-THORAX:
HeartIns: IC not visiblePal: IC palpablePer: RHB ICS IV lin.
sternal dext, LHB ICS V lin. Midclavicula sinAusc: S1 single, S2
single, regular, murmur (-) gallop (-)
PULMOInsp: Static and dynamic symmetricPal: VF right and left
symmetricPerc: Sonor symmetric Ausc: BBS Brochial, Rhonci -/-,
Wheezing -/-ABDOMENInsp: Stomach looks flat Ausc: Bowel sound (+)
5x/minutesPal: undulation (-) Perc: shifting dulnes (-)BACKPerc:
CVA (+)
