DUTY REPORT (WARD)

12th NOVEMBER 2014

GP on Duty
PPDS on Duty
COASS

Farrah

ON

: Dr Ana
: Dr. Rezky
DUTY : Deputri

and

PATIENTS RECAPITULATION

3Rd Floor : 2 patients (Diabetic ulcer+

4th Floor : 3 patients (Hepatoma, CNF,
Neck Tumor)
5th Floor : 3 patients (Anemia, Anemia +
Melena)
6th Floor : 1 Patient (hypoglicemia)

PATIENTS IDENTITY

Name
DOB
Age
Gender
Occupation

: Mrs. Y
: 12-06-2014
: 58 years
: Female
: Housewife

Medical Record no. : 076438

Date of admission
: 12th November 2014

ANAMNESIS

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

History of present illness:

Patients present with fever since 3 days continuously. and came abruptly. No
differences of fever during morning and evening. Fever drops if the patient
takes the medication like paracetamol but fever may rise again. Complaints
of fever is not accompanied by rash on hands and feets, nausea, vomiting,
joint pain, and patients do not travel frequently to endemic malaria region.
Patient complain 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.
patients 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.
patients 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

:
:
:
:

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

blood(-), hyperemic

Mouth
Neck
Skin

pharynx (-), calm T1-T1

: dry lips, ketone breath odor(+)

: 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

PHYSICAL EXAMINATION

Abdomen
Inspection
: distended, (-) caput medussae, (-) mass
Auscultation
: normal bowel sound
Palpation
: tenderness (-),CVA(-), hepatomegaly and
splenomegaly (-)
Percussion
: tympanic sound

Extremities

warm acral, CR <2min, muscle strength

5|5
5|5
PEDIS Classification:
Perfusion
Extent
Depth
below dermis)
Infection

: 2 (80/140=0.57)
: 3x3x1 cm
: 2 (deep ulcer,
: 4 (infection with

GFR : 69,15 mL/min

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

pH
pCO2
pO2
HCO3
BE
Sat O2

7.40
5
25.0
*
47.9
*
15.8
*
-7.3*
84.6
*

12

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

ECG

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

nterval normal , QRS duration complex normal, no ST changes

RONTGEN OF PEDIS

1. phalang deformity of the proximal digiti pedis 1 left,

maybe one of osteomyelitis
2. 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. Rontgen pedis : phalang deformity of the proximal digiti

pedis 1 left, maybe one of osteomyelitis
2. pedis soft tissue thickening of the left with the formation
of gas gangrene

LIST OF PROBLEMS

1.

Diabetic Ulcer

2.

DAK

3. Hypertension Stage 2
4. Leukositosis
5.

Acute on CKD

6.

Anemia

ULCER DIABETICUM EC TYPE

Based on:
2 DIABETES
MELLITUS
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

1.

Anamnesis : history of
DM, 3P (+), fever (stress
metabolic)
Exam : temp : 380C, 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 :
Rehidrasi

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

DKA

22

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

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

JNC 7

27

PROGNOSIS

Quo ad Vitam
: dubia ad bonam
Quo ad functionam: dubia ad malam
Quo ad sanactionam : dubia ad bonam

THANK YOU