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EMERGENCY

ROOM REPORT
TH
13 JANUARY
2016

GP on duty:
dr. Gerald & dr.
Indri
Co-Ass on duty:
Sabilla & Oki

PATIENT RECAPITULATION
1.
2.
3.
4.
5.
6.
7.

Mr. S Kolik Abdomen e.c GERD, CHF, HT


Mr. S Insect Bite
Mrs. IL Kolik Abdomen e.c Acute Gastritis
Mr. S DM, HT, CKD, Severe Anemia
Mr. RH DM, CKD, Severe Anemia
Mr. AS Diabetic foot, DM type 2
Mrs. UM Ensephalopati Hepatikum e.c Cirrhosis
hepatis, hepatitis C, hypoalbumin

PATIENTS IDENTITY

Name
:
Sex
:
Age
:
Occupation
Religion
:
Status
:
Address
:
Med. Record

AS
Male
46 Years Old
: Employee
Islam
Married
Ksatrian, East Jakarta
: 367382

ANAMNESIS
Autoanamnesis and
Alloanamnesis on 13th January
2016 at 10.30 P.M.
Chief Complaint
Wounds on sole of right foot and
left toe for 7 days.

History of Present Illness


The pastient came to the ER with wound
on his feet for 7 days. It is located on the
sole of right foot and left foot toe. His feet
were swollen at the first time and pus was
oozing from the wound after several days.
The wound is now dark reddish-black and
he feels pain at the wound site.
He said that he had gone to a clinic to treat
his wound. The wound already treated well
and he has given medication from the
clinic. He said that the medicine was
antibiotic but the patient didnt know what

He mentioned that he already has DM type 2 for 2


years. He also reported that he had been
hospitilized at the hospital at 2013 because of his
high blood sugar level. His DM is poorly controlled.
He mentioned that he urine a lot at night, eat so
much food because he felt hungry all the time, and
he always felt thirsty. He didnt control his meal.
He also mentioned that he had hypertension for
several years (approximately for 3 years).
He has taken Metformin, Amlodipin, Captopril for his
disease but he didnt take it routinely. He said that
he controlled to the doctor rarely.
Nausea (-), Vomit (-), Fever (-), chest pain (-),
shortness of breath (-), yellowish eyes or skin (-),
weight loss (-).

Past Medical History


Hypertension (+) for 3 years. Poorly
controlled.
DM type 2 (+), for 2 years. Classic
symptoms were exist (polyuri,
polidipsia and polyphagia). Poorly
controlled.
Heart Disease (-), Lung Disease (-),
Allergy (-), Jaundice (-).

Family History
No known family member with same
complaint.
Social History
Tobacco or Alcohol uses (-)

PHYSICAL EXAM
General State : Moderatel illness
Consciousness : Compos Mentis

Vital Signs
Blood Pressure: 130/70
Pulse : 104 x/mnt
Respiratory Rate : 18 x/mnt
Temperature : 36.8oC
Body Weight : 68 kg
Body Height : 168 cm
BMI : 24,1 (Normoweight)

Head : Normocephal
Eye
: Anemic Conjuctiva (-/-),
Icteric Sclera (-/-)
Ear
: Normotia, Dischare (-)
Nose : Septum Deviation (-),
Discharge (-/-)
Throat : Dry mucous (-), Tonsil T1-T1,
Hyperemic Pharynx (-)
Neck : JVP 5-2 cmH2O, Nodes
Enlargement (-)

Thorax : Normochest
Pulmo : VBS (+/+), Rales (-/-), Wheezing
(-/-)
Cor : Regular 1st and 2nd heart sounds,
murmur (-), gallop (-)
Abdomen : Distended (-), normal bowel
sound, tenderness (-), Liver and Spleen
enlargement (-), tymphanic percussion
sound
Extremities : Warm, CRT <2 sec, edema (-),
cyanosis (-).
Right foot: Ulcer (+) on sole, pus (+), blood
(-), tenderness (+), reddish-black color
Left foot: Ulcer (+) on ring finger, pus (+),

PEDIS SCORE
P : 1st degree , there is no involvement of
peripheral arterial surrounding the wound.
E : Right foot : 3 x 3 cm
Left foot: 1 x 0.5 cm
D : 1st degree, superficial ulcer.
I : 2nd degree, infection on the skin and subcutan
tissue without involvement any depper tissue. Ex:
swollen and tenderness at the wound site.
S : 1st degree, no loss sensibility.

LABORATORY DATA
Haematology Test (14th January 2016)

Hb
Ht
RBC

Results
15.7
43
5.3

WBC

10.370

PLT

186.000

Normal Value
13-18 g/dl
40-52 %
4.3 6.0
million/ul
4.800
10.800/ul
150.000450.000/ul

Clinical Chemistry Test (14 th


January 2016)
Ureum
Creatinin
Blood Glucose
Na

Results
23
0.6
453
135

4.0

Cl

100

Aseton

Normal Value
20-50 mg/dl
0.5-1.5 mg/dl
<140 mg/dl
135-147
mmol/L
3.5 5.0
mmol/L
95 105
mmol/L
-

RESUME
A 46 y.O man presented with wounds on
his sole of right foot and toe on his left foot
for 7 days. It was swollen at first time and
pus oozed from the wound. The color of the
wound was reddish-black and he felt pain
from the wound site.
He diagnosed with DM type 2 for 2 years
and Hypertension for 3 years. Both
diseases are poorly controlled with
Metformin, Captopril and Amlodipin.

Vital signs: BP: 130/70 mmHg, HR: 108


bpm, RR: 18 bpm, Temp: 36.8oC. Physical
examination revealed within normal
condition, but there were ulcer, Pus (+),
blood (-), dark reddish-black color on his
feet.
Haematology test shows within normal
condition.
Clinical chemistry test shows high blood
glucose and it contains aseton on his blood.

PROBLEM LIST

Diabetic foot ulcer


Diabetic Ketosis
Type 2 DM
Hypertension

Diabetic Ketosis
The patient presents without nausea and vomit.
He was diagnosed with DM type 2 since 2 years
ago, poorly controlled. Classic symptoms were
exist (polyuria, polydipsia, polypaghi).
Lab test revealed hyperglicemia and ketosis.
Diagnostic plan : Therapeutic plan : Insulin, control blood sugar

Type 2 DM
Based on his past medical history
that he was diagnosed with DM type
2 since 2 years ago. The classic
symptoms were still exist
(polyphagia, polydipsi, polyuri).
Lab test revealed that hes
hyperglicemia.
Diagnostic plan: HbA1C, lipid profile,
daily blood sugar level
Therapeutic plan: Metformin 3 x 500
mg, Insulin

Diabetic feet ulcer


Based on patients complaint that he
has dark reddish-black wound on his
feet. Its located on his sole of right
foot and his left ring fingers feet.
Pus (+), blood (-), pain (+)
Diagnostic plan: wound Gram stain
and culture
Theurapeutic plan: wound care by
debridement, ceftriaxone IV 2 gr
q24hr, metronidazole IV 500 mg q8hr

Hypertension
Based on his past medical history
that he has hypertension since 3
years ago and poorly controlled.
From PE revealed that the BP within
normal condition.
Diagnostic Plan: EKG, kidney function
test, liver function test
Therapeutic plan: Amlodipin 3 x 5
mg, captopril 1 x 25 mg

PROGNOSIS
Quo ad Vitam : Dubia ad Bonam
Quo ad functionam : Dubia ad
Malam
Quo ad sanationam : Dubia ad
Bonam