MORNING REPORT

Thursday, 3rd December 2015

COASS IN CHARGE:

Mariska Sayyida Ummah

Puspita Widyasari

Consultant : dr.Didi C, SpPD

 Patient came to ER suffered from pain at left foot
finger. The pain was continuously for 2 weeks. The wound
was known since 1 month before admission. At first, the
wound seems like blister, then its colour become black red.
The patient took sugar to her wound in order to heal the
wound. But, the wound worsen and he came to the doctor.
Then the doctor give powder medicine but the wound not
recovery. And the doctor reffered the patient to RSSA.
She also had nausea since 4 months ago, but worsen
with vomiting in 2 days before admission, that make her
decrease of appetite.
She had history of DM since 3 years ago. She
consume metformin and glimepirid unrountinely.
SUMMARY OF DATA BASE

SOCIAL HISTORY:
She is pecel seller. She Had 5 children

FAMILY HISTORY: There was no history of DM and HT in his family.

 Physical Examination
Looked normoweight, BW : 62 kgs Height : 150 cm
General Appearance: looked moderately ill
BMI :
GCS: 456 BP : 120/80 mmHg HR : 110 bpm regular strong RR : 22 tpm Tax : 37C

Head Anemic conjunctiva (+) icteric sclerae (-)

Neck JVP: R +2 cm H2O, in 30 position Lymphonode enlargement -

Wall Chest expansion symmetric

Ictus invisible, palpable at 2 cm lateral ICS V MCL S Trill: - Heaves: -

Heart RHM ~ SL D LHM ~ ictus
Chest S1 and S2 single, no murmur

Stem Fremitus D=S S S v v Rh - - Wh - -

Lung SS vv - - - -
SS vv - - - -

Abdomen flat, Traubes space tympani, shifting dullness (-), epigastrial tenderness (+), soft

Warm, edema -/- Warm, edema -/- , motoric 5/5, sensoris N/N , sensorik +/+ ,
+/+ 5/5 / +/+
R.Foot Sinistra : Pulsation (+) at A. tibialis Anterior & A. Poplitea, Extend : wound 2cm, Depth : base subcutan,
Extremities
Infection : redness (-), warmth (-), edema (-), gangren (-), necrotic (+), Sensation : , pain (+)
ABI S 0.93 ABI D 1
 LABORATORY RESULTS (December 2nd 2015)
Laboratory Result Normal Value Laboratory Result Normal Value
Hb 14.60 13,4 17,7 Natrium 132 136 145
g/dL mmol/L
Leucocyte 12.960 4.300- Kalium 5.68 3,5 5,0
10.300/L mmol/L
Hematocrit 46.8% 40 47 % Chloride 109 98 106
mmol/L
Thrombocyte 359.000 142.000- RBS 190 < 200 mg/dL
424.000/L
MCV 92.70 80 93 fL Ureum 94.70 16,6 48,5
mg/dL
MCH 28.90 27 31 pg Creatinine 1.61 < 1,2 mg/dL
MCHC 31.20 32 36 g/dL
Differential 1.4/0.3/72.3/ 0-4/0-1/51-
count 21.2/4.8 67/25-33/2-5 %

SGOT 32 0-40 U/L Albumin 3,72 3,5-5,5

SGPT 37 0-41 U/L 3,4-7,0 mg/dL

 URINALYSIS
Lab Value Lab Value
Urinalysis 10 x
SG Epithelial negatif
Cylinder negatif
6.0
PH
Hyaline negatif
negatif
Glucose
Granular negatif
trace
Protein
Keton
Bilirubin 40 x
Urobilinogen Erythrocyte 33.6
Nitrit positif - Eumorfik positif
Leucocyte 1+ - Dismorfik
Blood 3+ Leukocyte 12.7
Crystal
Bacteria 744,4 X 10.3
 Laboratory Findings
BGA With no oxygen Value
suplementation

pH 7.42 7,35 7,45

PCO2 24.2 35 45 mmHg

PO2 98.1 80 100 mmHg

True O2

HCO3 16.0 21 28 mmol/L

Base Excess -8.6 (-3) (+3)

O2 Saturation 985 > 95 %
Conclusion : Asidosis metabolic fully compensated alkalosis respiratoric
CXR (2nd December2015)
 CXR
AP position, asymmetric, less KV, less inspiration
Soft tissue and bone normal
Trachea in the middle
Hemidiaphragm right and left are dome shaped
Costophrenical angle right and left are sharp
Lung: normal bronchovascular pattern
Cor : site normal, size CTR: 65%, apex embedded
Aorta : Calsificatio +, dilatation -, elongation -
Conclusion: Cardiomegaly, Aortasclerosis
 Pedis AP/Lateral
December, 2nd 2015
Alignment: Good
Bone: fracture (-), litic lesion in distal metatarsal digiti
I-II
Joint: dislocation (-)
Soft tissue: Looks subluctation metatarsophalangeal,
Gas gangrene (-)
Conclusion: soft tissue Defect in digiti II pedis
and soft tissue swelling cruris S
ECG (March, 26th 2015)
 ECG INTERPRETATION
Sinus tachycardia , heart rate 105 bpm
Heart Rate : 105 bpm
Frontal axis : normal
Horisontal axis : clockwise rotation
PR interval : 0,12 s
QRS complex : 0,08 s
QT interval : 0,32 s
Sinus Tachcardia with HR 105 bpm
 CUE AND Problem List Initial Planning Planning Planning
CLUE Diagnosis Diagnosis Therapy Monitoring
FeMale/ 69 yo/W29 1. Septic 1.1 Diabetic USG DOPLLER Bed rest Subjective
Ax : Vital Sign
Wound at the left Condition Foot PEDIS IVFD Nacl 0.95
grade 3 IDSA Blood Culture 20 tpm Wound healing
foot
DM since 3 years ago Leucocyte
Moderate and Infus
PE :
HR : 110 bpm infection sensitivity Ciprofloxacine 2
RR: 22 tpm test x 200 mg iv PEdu:
Wound at Digiti 2 1.2 UTI Inf Hygiene
pedis Sinistra, pus +,
Urine culture Metronidazole 3 Feet protection
necrotic
Lab. : and x 500mg Disease
WBC: 12.960/l sensitivity Underlying disease
Neutrophil count : Treatment
72.3% test Prognosis
Rontgen Pedis
AP/Lateral :
Soft tissue swelling
with susp.
Osteomyelitis

Urinlisa :
Nitrit +
Leucocyte 12.7
 CUE AND Problem List Initial Planning Planning Planning
CLUE Diagnosis Diagnosis Therapy Monitoring
FeMale/ 69 yo/W29 2. Diabetic USG DOPLLER Bed rest Subjective
Ax : Metabolic Controlled
Foot PEDIS Blood CUlture DM diet 1700
Vital Sign
Wound at the left
grade 3 IDSA kcal/day, extra Wound healing
foot
DM since 3 years ago protein FBG
Moderate Microbiological 2hPPBG
PE : infection controlled
Wound
Inf Ciprofloxacine 2 x
Wound at Digiti 2 200 mg
pedis Sinistra, pus +, Inj. Metronidazole PEdu:
necrotic 3x500 mg intravena Hygiene
Lab. : Mechanical Feet protection
WBC: 12.960/l controlled Disease
Neutrophil count : Temporary shoes, Underlying disease
72.3% craddle insholes,
crutches
Treatment
Rontgen Pedis Prognosis
AP/Lateral :
Educational control
Soft tissue swelling Hygiene, foot
with susp. protection,
Osteomyelitis management
diabetic foot
Vascular controlled
ABI score
Ancle pressure, toe
pressure
ASA 1x80 mg
Simvastatin 1x20mg

Wound controlled
Wound toilet and
Debridement
Dressing
Consult to Thoraco
cardiovascular
surgery department
 CUE AND Problem List Initial Planning Planning Planning
CLUE Diagnosis Diagnosis Therapy Monitoring
FeMale/ 69 3. Diabetes Renal DM diet Monitoring:
yo/W29 mellitus type 1700 kcal/day, Vital sign
Ax: 2 low salt Complaint
Wound on the
normoweight sodium diet < FBG
left foot
History of DM poorly 2 gr/day 2hPPBG
since 3 years controlled protein 1.00- target organ
ago unroutinely 1.20 damage
control gr/BW/day RBS
Lab : IVFD Nacl
RBG 190 mg/dL 0.9% 20 tpm Education:
Inj Compliance to
intermediate therapy
acting insulin Disease
0-0-8iu sc Underlying
disease
Treatment
Prognosis
 CUE AND Problem List Initial Planning Planning Planning
CLUE Diagnosis Diagnosis Therapy Monitoring
FeMale/ 69 yo/W29 4. Azotemia pre 4.1 Diabetic - Treat Monitoring:
Ax: renal nephropat underlying Vital sign
Has DM since 3 years hy disease Complaint
ago 4.2 Septic Renal DM diet Wound healing
PE :
BP : 120/80 mmHg condition 1700 kcal/day, Ur Cr
PR : 86 bpm low salt GD1/GD2
RR : 20 tpm sodium diet <
Lab:
Hb : 14.60 g/dL 2 gr/day, Education:
Ureum : 94.70 protein 1.00- Hygiene
Creatinine : 1.61 1.20 Feet protection
BUN/Cr: 27
gr/BW/day
IV plug
Xray Pedis AP/Lat
Soft tissue swelling
with susp.
Osteomyeliti
CUE AND CLUE Problem Initial Planning Planning Planning
List Diagnosis Diagnosis Therapy Monitoring
FeMale/ 69 5. 5.1 Diabetic Gastric Inj. Monitoring:
yo/W29 Dyspep gastropares emptying Metoclopra Subjective
sia is test mid 3x10 Vital sign
Ax:
syndro Endoscopy mg/day
Nausea since 4
me 5.2 Gastritis USG Education:
months ago and intravenous
erosive abdomen Avoid acidic
worsen with (pro renata) food
vomitting since 2 5.3 Peptic Peroral :
days before ulcer Omeprazole
admission disease 2x20 mg
History of DM
tablet
since 3 years ago
unroutinely
control

PE:
Epigastric
tenderness (+)
Thank You