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SUPERVISOR
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PATIENTS IDENTITY
Name : Ms. D
Age : 46 years old
Sex : Female
Religion : Islam
Reg. Number : 781355
Address :Tamengundur Street
Polman
HISTORY TAKING
Chief complaint
Swelling in the lower limb right
Present illness history
Felt since 3 days after admission, the patient
complained of swelling in the lower limb right.
Swelling began to grow slowly, pain (+), bluish
toe (-), patient can still feel when touched.
Patient had a history of stroke one year ago and
weak on the left side of the body. History of
swelling in the lower limb did not exist. History
of the same disease in the family does not exist
HISTORY TAKING
Past medical history
Patient had a history of stroke one year
Chest
Inspection : Symmetrical left=right,
normochest
Palpation : Epigastric tenderness (-), massa (-),
vocal fremitus left = right
Percussion : Sonor
Auscultation : Breath Sound vesicular, Additional
Sound: Rh -/-, Wh -/-
PHYSICAL EXAMINATION
Heart
Inspection : Ictus cordis invisible
Palpation : Ictus cordis impalpable
Percussion : Deaf, impress size normal.
Border-right: right linea
parasternalis, Border-left: left linea
medioclavicularis
Auscultation : Heart sound S1,S2 neutral,
regular, noisy (-)
PHYSICAL EXAMINATION
Abdomen :
Inspection: Convex, in accordance breath motion
Auscultation: Peristaltic (+), normal sound
Palpation: tumor mass palpable mobile solid mass the
size of 5x5cm Liver and spleen are not palpable
Percussion: Timpani (+), Ascites (-)
Extremities :