Friday, August 27th 2010

PHYSICIAN INCHARGE:
IA : dr. Nicholas dr. Meci
IB : dr. Eric, dr. Fajar
II : dr. Frenita
III : dr. Laksmi, SpPD
 Summary of Data Base
Male/ 55 yo/ W 24A

Chief Complain : wound at the 5th finger of the left foot

Patient had wound at the 5th finger of his left foot since a
week ago, after he, accidentally, hit a chair. Because he did
not feel pain, he just let the wound open without any
medication or treatment. But the wound was getting worse, it
became bigger and caused his left ankle swollen, and
became painful when being moved.

Patient had diabetes mellitus since 14 years ago. Until now,

she routinely took Glibenclamide 1 tablet twice a day.
He never checked his blood glucose, so he took the same
dose for 14 years.

He also had blurred vision since a year ago, but he never

looked for medical assistance.

Patient frequently got his feet injured but he did not feel pain,
even though the wounds were big and took a long time to
recover.

He had been working at a governmental institution until now.

He had never felt shortness of breath.
 Physical examination
BP = 130/80 mmHg PR = 80 bpm, RR = 18 tpm Tax : 36,4 C
strong, regular

General appearance looked moderately ill GCS 456; BW:80kg; BH:170cm; BMI:27,68
Head Anemic - Icteric -
Neck JVP R + 0 cm; 30
Thorax: Cor: Ictus invisible and palpable at 2cm lateral MCL ICS VI Sinistra
RHM SL Dextra
LHM ictus
S1, S2 regular, with no murmur

Lung: Symmetric, SF D = S, v v Rh - - Wh - -
vv -- --
vv -- --

Abdomen Flat, soft, liver span 10 cm, troube space tympani

Extremities Wound at 5th digit of the left foot

 Laboratory finding
Lab Value Lab Value

Leukocyte 13.400 3.500- Natrium 138 136-145 mmol / L

10.000/L
Haemoglobine 10,7 11,0-16,5 g/dl Kalium 4,7 3,5-5,0 mmol / L
PCV 31,9 35-50% Chlorida 102 98-106 mmol / L
Trombocyte 169.000 150.000- RBS 474-248
390.000/L
SGOT 27 11-41U/L Ureum 48,2 10-50 mg/dL
SGPT 25 10-41U/L Creatinine 0,85 0,7-1,5 mg/dL
Albumin 3,14 3,5-5,5 g/dL

Urinalysis

SG: 1.015 pH: 5 Protein: 3+ Glucose: 4+ Keton: 3+ Ery: 3+

Bacteria: + Nitrite: -
 ECG (27/08/2010)
Sinus rhythm, heart rate 90 bpm
Frontal Axis : Normal
Horizontal Axis : Normal
PR interval : 0,16
QRS complex : 0,08
QT interval : 0,36
Q pathologic at V1-V2
Conclusion : Sinus rhythm with OMI septal wall
 CXR (27/08/2010)
AP position, asymetric, less KV
Trachea in the middle
Soft tissue and bone thick
Right and left phrenico-costalis angle are sharp
Right and left hemidiaphragm are dome shape
Pulmo looks normal
Cor site and shape are normal, CTR: 63%
Conclusion:
Looks cardiomegaly
 Pedis Sinistra X-ray (27/08/2010)
No osteomyelitis

Conclusion: essentially normal pedis sinistra x-ray.

 CUE AND CLUE PL IDx PDx PTx PMo

Male/55 yo 1. Pus Wound treatment Subjec

Wound on the 5th Diabetic culture Metronidazole 3x500mg (iv) tive
digit of the left foot foot Clindamycin 3x300mg (po) Woun
for 1 week and getting Wagner d
worse grade 2

Male/55 yo 2.Hyperg 2.1.Diabetes Rehidration NS 0,9% 1L/1 hour Subjec

History of DM for 14 lycemic Mellitus type 2 NS 0,9% 20 dpm tive
years state overweight Insulatard 0-10iu (sc) FPG
Never routinely uncontrolled 2hPPB
check his blood G
glucose
BMI: 27,68
GDA: 474-248
 CUE AND CLUE PL IDx PDx PTx PMo

Male/55 yo 3.Heart 3.1.Diabetic Echocard Captopril 3x6,25mg Subjec

History of DM for 14 Failure cardiomyopathy iography tive
years stage B 3.2. BP
Never routinely Hypertensive HR
check his blood heart disease RR
glucose
BP: 130/80
BMI: 27,68
GDA: 474-248
Cardiomegaly

Male/55 yo 4.Hypoal 4.1.Renal loss Total High calories high protein diet Albumi
Albumin:3,14 bumine 4.2.due to protein/ n
mia chronic disease Albumin/
Globulin