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0 0MEDICAL
0 1 RECORD
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Date of Visit : 17-April-2016 Time : 10:25

Student’s name and NIM : Vickry Adzkary Ghufron (14/366007/KU/17238)

Doctor’s name :
PATIENT IDENTITY :

Name : Mss. J
Sex : Female
Birth of Date : 24-June-1971
Husband Name : Mrs. G
Address : DI, Yogyakarta TP B
Blood Group :B
Number of Children :2

ANAMNESIS :

 Control of Diabetes Mellitus

 RPK : Hypertension
 No allergy, do not smoke/drinking alcohol, admits not frequently eat
food products with high amount of purin (e.g jeroan, spinach, long bean,
etc). Has a descendant with diabetes

PHYSICAL EXAMINATION :


Blood pressure : 140/95mmHg

Respiratory rate: 18 times/minute

Pulse rate: 75 times/minute

Body Weight: 60 cm

Body Height: 155 cm

No lymph node enlargement, no icteric sclera, no pale conjunctiva, face
expression is normal with no discomfort or pain expression can be
seen, patient is fully concious
LABORATORY TEST AND OTHER SUPPORTING TESTS :

 Blood urate level: 7,4 mg/dL (N: 4,2-6 mg/dL)

 Blood glucose level: 207 mg/dL (N: 75-113 mg/dL)
 Blood cholestrol level: 186 mg/dL (N: 156-233 mg/dL)
 No. :
Name : Mss. J Age 45
Address: DI, Yogyakarta Pakualaman
0 0 0 1 8 0

DIAGNOSIS :

Working Diagnosis
 Type 2 Diabetes Mellitus 2

Differential Diagnosis
 Type 2 Diabetes Mellitus : Diabetes mellitus type 1, Diabetic
ketoacidosis, Glucose Intolerance

TREATMENT AND MANAGEMENT PLAN

 Type 2 Diabetes Mellitus : Diabetes mellitus type 1, Diabetic

ketoacidosis, Glucose Intolerance

EDUCATION FOR PATIENT :

 For type 2 diabetes mellitus, do not cure by yourselves, avoid high

cholesterol food and lipid-contain food
 For stasis dermatitis use loose-fitting cotton clothing and elevate legs
above the heart, avoid the wet condition