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Mrs.E 61 years old Female bambu duri, karawang House wife Islam Married Sundanese Elementary School
Autoanamnese
Main
complaint : right foot feel hot,pain,itchy,swelling and poignant since one week ago
complaint : blurred vision,
Additional
Patient
came to IGD RSUD karawang complaint that she had feel hot,pain,itchy,swelling and poignant since one week ago at righ foot wound. Os got wounded since 2 weeks ago, applied honey to her wound but didnt cured Dont know clearly what makes os get wounded at right foot
Os
Os
DM (+)
Hypertention (+)
Drugs (-)
General condition
Appreance : moderately ill Consciusness: compos mentis Weight Height BMI : 48 kg : 154 cm : 20,23
nutrition
Head
Normochepaly, black hair, good distribution Anemic conjungtiva -/-, Icteric sclera -/-
Eyes Ears
Nose
Mouth
Red lip (+) dry (-) Tongue (N). Arcus faring (N). Tonsil (N). Posterior Pharyng (N)
Neck
Lymph node: enlargement (-), tenderness (-) Thyroid: enlargement (-), tenderness (-) JVP: 5+1 cmH2O
LUNG
Inspection
: Symmetrical Palpation : Equal vocal resonance Percussion : Sonor in both lungs Auscultation : Vesicular breath sound in both lung,ronchi (-/-),wheezing (-/-)
THORAX
INSPECTION
PERCUTION
AUSCULTATION
ABDOMEN Inspection : flat, symmetric, caput medusa (-), smiling umbilicus (-)
Palpation : Tenderness (+) Epigastrium pain (-) Distension (-) no liver and spleen enlargement Percussion : Tympanic 4 kuadran abdomen
Auscultation : bowel sound (+) 4 times/min , arterial bruit (-), venous hum (-)
Warm
acral
+ +
+ +
Ulcus
at right foot MTP II,III,IV,V Dried ulcus at left foot ITP III
Oedem
-
Hematology
Hb leukocyte trombocyte Ht Diff count Blood chemistry Random blood glucose ureum creatinin
value
9,5 23.700 284.000 29 0/0/0/86/11/2
Normal value
12-17 G% 5.000-10.000 ul 150-450 ribu 37-48% 0-1/1-3/2-6/4070/20-40/2-8 80-140 mg/dl 10-45 mg/dl 0,4-1,5 mg/dl
Blood chemistry
Random blood glucose
value
289 mg/dl
symptom hot,pain,itchy,swelling and poignant since one week ago at righ foot wound Dont know clearly what makes os get wounded at right foot always feels hungry,thirsty, and often urinate at night Os also have wound at left foot since 2 months ago Os also complaint that she had blurred vision since 1 years ago Have DM since 2 years ago, uncontrolled DM in family history
sign Blood pressure :160/90 Ulcus at right foot MTP II,III,IV,V since 1 week ago Dried ulcus at left foot ITP III 2 months ago
Lab Random blood glucose 1-12-2012 : 277 mg/dl Random blood glucose 2-12-2012 : 289 mg/dl
ULCUS
Ulcus
DVT
Buerger
Nacl
0,9% 20 dpm Ceftriaxone vial 1x2gr Rantin amp 2x1 Ondansentron amp 3x1 Insulin 3x12 unit OMZ 1x1 Pamol 3x1
Bed
Pinprick
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