DUTY REPORT (WARD)

12th NOVEMBER 2014

GP on Duty
PPDS on Duty

: Dr Ana
: Dr. Rezky
COASS ON DUTY : Deputri and Farrah

RECAPITULATION

3Rd Floor
4th Floor
5th Floor
6th Floor

: 2 patients (Diabetic ulcer)

: 3 patients (Hepatoma, CNF, Neck Tumor)
: 3 patients (Anemia, Anemia + Melena)
: 1 Patient (hypoglicemia)

PATIENTS IDENTITY

Name
DOB
Age
Gender
Occupation
Medical Record No.
Date of Admission

: Y
: 12-06-1954
: 58 years
: Female
: Housewife
: 076438
: 12th November 2014

ANAMNESIS

Chief Complaint:
Fever since 3 days before being admitted
Additional Complaint :
Pain on her left foot

History of Present Illness:

Patient complained of fever for 3 days continuously and came abruptly. No
differences of fever during morning and evening. Fever dropped when the patient took
the medication like paracetamol but the fever rose again. The fever was not
accompanied by rash on hands and feet, nausea, vomiting, and joint pain. The patient
did not travel frequently to endemic malaria regions.
Patient complained about pain on her left foot because of a wound since 7 days before
being admitted. Developed by uses of thight shoes in physical exercise. blister appear at
first but as the running times becomes purulent and stink. The patient also had a wound
in the tiptoe of index finger of foot from 3 weeks ago, that developed to dry wounds,
blackened and odorless. patient had a history of diabetes mellitus since 1 month ago
with symptoms of 3P (+), during regular consumption gludepatic oral medication.
controlled blood sugar levels,
patient recall well, the patient did not complain of blurred in both eyes. patient
admitted numbness in the feet since 1 month before being admitted.
Bowel and bladder had no complaints, shortness of breath and chest pain denied.
History of hypertension, heart disease, kidney disease, allergies and asthma denied

History of past illness:

The patient denied ever experienced the same thing

Trauma history denied

History of Allergy

No allergy, no drugs allergies

Family History:
History of diabetes, hypertension, heart disease, kidney disease, liver disease and lung
diseases, allergies and asthma denied

Habit
Patient denies smoking history, alcohol consumption, and other long term medication

History of medications:

Gludepatic 3 times per days

Paracetamol if fever occur

PHYSICIAL EXAMINATION

GENERAL EXAMINATION
General condition
: Looks moderately ill
Consciousness
: Compos Mentis
Blood pressure
: 160/100 mmHg
HR
: 100 times/minute
RR
: 20 times/minute
Body temperature
: 380 C
Body Weight
: 160 cm
Body Height
: 50 kg
Body Mass Index
: 19 kg/m2 (normoweight category)

PHYSICAL EXAMINATION

Head
Hair
Face
Eye
ENT
hyperemic

Mouth
Neck
Skin

: normocephal
: normal distribution, grey color
: symmetrical, deformity (-)
: pale conjunctiva -/-, icteric conjunctiva -/: normotia, rhinorrhea (-), otorrhea (-), blood(-),
pharynx (-), calm T1-T1

: dry lips, ketone breath odor(+), atrophy papil (-)

: JVP 5+2 cmH2O, Lymphadenopathy (-)
8
: dry skin

PHYSICAL EXAMINATION
Thoraks
Pulmonary Examinations
Inspection
: normochest, symmetrical chest movement on static and
dynamic. Spider naevi (-), ICS retraction (-)
Palpation
: symmetrical chest expansion, tactile fremitus, (-) mass, (-)
tenderness
Percussion
: sonor at both lung field
Auscultation
: vesikuler+/+, there were no rhonchi or wheezing
Cardiac Examinations
Inspection
: invisible ictus cordis
Palpation
: impalpable ictus cordis
Percussion
Right heart border : ICS V right sternal line
Left heart border : ICS V left midclavicular line
Heart waist
: ICS III left sternal line
Auscultation
: S1/S2 regular, gallop (-), murmur (-)

PHYSICAL EXAMINATION

Abdomen
Inspection
Auscultation
Palpation
Percussion

: distended, (-) caput medussae, (-) mass

: normal bowel sound
: tenderness (-),CVA(-), hepatomegaly and splenomegaly (-)
: tympanic sound

Extremities : warm acral, CR <2min, muscle strength 5|5

5|5
PEDIS Classification:
Perfusion
Extent
Depth
Infection

: 2 (80/140=0.57)
: 3x3x1 cm
: 2 (deep ulcer, below dermis)
: 4 (infection with systemic
manifestation
Impaired Sensation : 2 (present)

GFR : 69,15 mL/min

Osmolality : 300,61 mOsm/L
Anion Gap : 22,2 mEq/L

pH
pCO2
pO2
HCO3
BE
Sat O2

7.405
25.0*
47.9*
15.8*
-7.3*
84.6*

7.37-7.45
33-44 mmHg
71-104 mmHg
22-29 mmol/L
(-2)-3
94-98%

12

ECG

IMPRESSION: sinus rhythm, HR 88 bpm, normal axis, no pathologic Q wave,

PR interval normal , QRS duration complex normal, no ST changes

RONTGEN OF PEDIS

1.
2.

phalang deformity of the proximal digiti pedis 1 left, maybe one of

osteomyelitis
pedis soft tissue thickening of the left with the formation of gas gangrene

14

RESUME

Patient, woman, 58 years old, with chief complain fever since 3 days before being
admitted. Pain on left foot (+),blister evolved to stink odor and purrulent wound, since
7 days before admitted, a wound in the tiptoe of index finger of foot from 3 weeks ago,
that developed to dry wounds, blackened and odorless
diabetes mellitus(+) since 1 month ago with symptoms of 3P (+), during regular
consumption gludepatic oral medication. controlled blood sugar levels,
Physical examination : BP: 160/100, dry mucous of lips, ketone breath odor (+),
extremities : PEDIS score
Lab. Findings : Hb 9,5, leukosit :17040, RBG:439, Na: 132
Ur/Cr: 23/0.7, GFR (69,15)

1.
2.

Rontgen pedis : phalang deformity of the proximal digiti pedis 1 left,

maybe one of osteomyelitis
pedis soft tissue thickening of the left with the formation of gas gangrene

LIST OF PROBLEMS

1.

Diabetic Ulcer

2.

DAK

3.
4.

Hypertension Stage 2
Leukositosis

5.

Acute on CKD

6.

Anemia

ULCER DIABETICUM EC TYPE 2

DIABETES MELLITUS

Based on:

Anamnesis: history of DM, uses of thight shoes, didnt feel the blister, then becomes purulent dan
stink. Numbness on feet (phisical sign : PEDIS : ), RBG : 439, ABPI :
Diagnostic planning:

HbA1C

RBG

Angiography

Bactery cultur

Tx:
Non Pharmacology:

1.

Vascular control : consult to orthopaedics (angioplasty)

2.

Wound control : dressing bandages everyday

3.

Pressure control : uses of right shoes, minimize the pressure

4.

Education control

Pharmacology:
1.

Metabolic control : blood glucose on regulated insulin or oral hipoglicemic drugs

2.

Infection control : Ceftriaxone 1xII gram

DKA

Anamnesis : history of DM, 3P

(+), fever (stress metabolic)
Exam : temp : 38 0C, keton breath
odor, dry lips, dry skin, Extremity
: diabetics ulcer (cause of
infection),
Lab: rbg :439, Na :132, aseton (+),
osmolality : 300,61, pH normal,
HCO3 15,8
DD : HHS
Treatment :
1. Rehidrasi
2. Rapid Insulin 4 Unit/jam

DKA

20

HYPERTENSION STAGE II

Based on:
Anamnesis: Patient denies hypertension.
PF: 160/100 mmHg
Diagnostic planning:
Thorax Rontgen

Non-Pharmacology

Low Sodium Diet

Exercising

Pharmacology

Captopril 3 x 12,5 mg
nn

LEUKOSITOSIS

Anamnesis : Fever, site of wound on the feet

Lab finding : leukosit : 17040
Further examination : diff count

ACUTE ON CKD

Anamnesis :
Bladder had no complain, risk factor (DM & Hypertension)
Lab. Findings :
Ur/Cr: 23/0.7 (GFR 69,15) (II)
DD : AKI
Further examination : urinalysis

ANEMIA

Anamnesis : no complain
Physical exam : no abnormalities
Lab findings : Hb : 9,5
MCV/MCH/MCHC : no abnormalities
Impress : anemia normocyte, normochrom, can occur in anemia e.c chronic
illness, deficiency iron, and thallasemia
Further examination : peripheral blood smear

DM Diet :
Ideal weight = 90% x (TB-100) x 1 kg
= 90% x (160-100) x 1 kg
= 54 kg
For woman, calorie needs 25 cal/weight 1350 calorie
Age 58 years old - 5%
Light activity +10%
So, we can give 1417,5 kal/day for this patient, with :
Carbohydrate (65%) 921 cal
Lipid (20%) 283,5 cal
Protein (15%) 212 cal

JNC 7

28

PROGNOSIS

Quo ad Vitam
Quo ad functionam
Quo ad sanactionam

: dubia ad bonam
: dubia ad malam
: dubia ad bonam

THANK YOU