Morning Report Medical Consultation

Friday, June 29 2017

Co assistance incharge

Desra Aufar Alwafi

Moderator :
dr. Iqbal Lahmadi Sp.PD
 Summary of Database
Male/ 64 y.o

Chief complaint : leg pain

– patients feel pain in the right foot after being
pierced nails 10 days before entering the hospital,
the legs are getting swollen.
– patient consultation from surgery department to
interna department.
 Past Medical History
• HT (-)
• DM (+)
• patients taking insulin for 8 months, with a
dose of 16 IU novorapid and 16 IU levemir.
 Physical examination
BP = 120/70 mmHg PR : 115 bpm. RR = 20 tpm, T ax 37,10C

General appearance looked moderately ill GCS 456

Head wnl wnl

Neck wnl

Thorax Wnl
Heart

Lung Simetric, SF D = S SS v v Rh - - Wh - -
SS bv bv - - - -
SS bv bv - - - -

Abdomen Convex, Soefl.

Extremities edema in both lower extremity -/-, swollen, vulnus punctum pedis dextra
ECG
 Interpretation
• Sinus tachycardi, regular
• HR 120 bpm
• Axis :
– Frontal axis : normal
– Horizontal axis : normal
• PR interval : 0,20 ms
• QRS complex : 0,08 ms
• QT interval : 0,35 ms

Conclusion : sinus tachycardi with HR 120 BPM

CXR
 Interpretation
• PA position, symmetric
• Soft tissue and bone normal
• Trachea in the middle
• ICS D/S normal
• Hemithorax : Left and right costophrenicocostalis angle are
sharp, doom shape diaphragma
• Heart : site normal, Size 47%, shape normal
• Lung : Hillus normal, increasing of bronkovascular pattern

Concl: CXR in normal range

 LABORATORY FINDING
Value Lab Value

Leukocyte 15,800 3500-10000/µL SGOT 10 11-41 U/L

Eritrosyte 5,69 3,50-5,50 g/dl SGPT 11 10-41 U/L

Haemoglobin 14.2 11,0-16,5g/dl

Trombocyte 445.000 150000-390000/µL

Hematocrite 48,7 35,0-55,0 %

GDS 374 100-180 mg/dl

Ureum 52 10-50g/dL
Creatinin 1,56 0,9-1,3 mg/dl
perioperative cardiovascular

• Light-medium
 Assesment
• 1. Gangrene pedis dextra
• 2. Diabetes Melitus T2
 Planning

• IVFD NS 20tpm
• Ceftriaxone 2x1gr IV
• Metronidazole 1x500mg IV
• Levemir 18 IU SC
• Fasting Blood Glucose check
 Present conditions
• Symtoms : GCS 4E5M6V
• BP : 120/80 mmHg
• HR : 80 tpm
• RR : 20tpm
• Fasting blood glucose :
THANK YOU 