DUTY REPORT (WARD)12th NOVEMBER 2014

GP on Duty : Dr AnaPPDS on Duty : Dr. RezkyCOASS ON DUTY : Deputri and Farrah

• 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)

PATIENT’S RECAPITULATION

Name : Mrs. Y

DOB : 12-06-2014

Age : 58 years

Gender : Female

Occupation : Housewife

Medical Record no. : 076438

Date of admission : 12th November 2014

PATIENT’S IDENTITY

Chief Complaint:Fever since 3 days before being admitted

Additional Complaint :

Pain on her left foot

ANAMNESIS

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

HabitPatient denies smoking history, alcohol consumption, and other

long term medication

History of medications:• Gludepatic 3 times per days

• Paracetamol if fever occur

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)

PHYSICIAL EXAMINATION

Head : normocephal

Hair : normal distribution, grey color

Face : symmetrical, deformity (-)

Eye : pale conjunctiva -/-, icteric conjunctiva -/-

ENT : normotia, rhinorrhea (-), otorrhea (-), blood(-), hyperemic pharynx (-), calm T1-T1

Mouth : dry lips, ketone breath odor(+)

Neck : JVP 5+2 cmH2O, Lymphadenopathy (-)

Skin : dry skin

PHYSICAL EXAMINATION

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PHYSICAL EXAMINATION

ThoraksPulmonary ExaminationsInspection : 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 fieldAuscultation : vesikuler+/+, there were no

rhonchi or wheezing

Cardiac ExaminationsInspection : invisible ictus cordisPalpation : impalpable ictus cordis Percussion

Right heart border : ICS V right sternal lineLeft heart border : ICS V left midclavicular

lineHeart waist : ICS III left sternal line

Auscultation : S1/S2 regular, gallop (-), murmur (-)

PHYSICAL EXAMINATION

AbdomenInspection : distended, (-) caput medussae, (-)

massAuscultation : normal bowel sound Palpation : tenderness (-),CVA(-),

hepatomegaly and splenomegaly (-)Percussion : tympanic sound

Extremities : warm acral, CR <2min, muscle strength 5|5

5|5PEDIS Classification:

Perfusion : 2 (80/140=0.57)

Extent : 3x3x1 cmDepth : 2 (deep

ulcer, below dermis)Infection : 4

(infection with systemic manifestation

Impaired Sensation : 2 (present)

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pHpCO2pO2HCO3BESat O2

7.40525.0*47.9*15.8*-7.3*84.6*

7.37-7.4533-44 mmHg71-104 mmHg22-29 mmol/L(-2)-394-98%

GFR : 69,15 mL/minOsmolality : 300,61 mOsm/LAnion Gap : 22,2 mEq/L

ECG

IMPRESSION: sinus rhythm, HR 88 bpm, normal axis, no pathologic Q wave, PR interval normal , QRS duration complex normal, no ST changes

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

RONTGEN OF PEDIS

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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 odorlessdiabetes 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: 132Ur/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

RESUME

1. Diabetic Ulcer2. DAK

3. Hypertension Stage 2

4. Leukositosis5. Acute on CKD

6. Anemia

LIST OF PROBLEMS

Based on:

Anamnesis: history of DM, uses of thight shoes, didn’t 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

ULCER DIABETICUM EC TYPE 2 DIABETES MELLITUS

• 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 :

1. Rehidrasi

2. Rapid Insulin 4 Unit/jam

DKA

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

ACUTE ON CKD

ANEMIA

DKA

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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

Based on:

Anamnesis: Patient denies hypertension.

PF: 160/100 mmHg

Diagnostic planning:

Thorax Rontgen

Non-Pharmacology Pharmacology

Low Sodium Diet Captopril 3 x 12,5 mg

Exercising nn

HYPERTENSION STAGE II

JNC 7

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Quo ad Vitam : dubia ad bonam

Quo ad functionam: dubia ad malam

Quo ad sanactionam : dubia ad bonam

PROGNOSIS

THANK YOU …