MORNING REPORT MORNING REPORT Thursday, November 5th 2009

PHYSICIAN INCHARGE:

IA : dr. Didin Retno, dr HidayatIB : dr. Fajar, dr Utama Budi. II : dr Lia III : Dr Sri Sunarti, SpPD

MODERATOR : dr , SpPD KPTI

NEW IN PATIENTMr. / yo/ W

1.

1.1

1.2

2.

2.1

2.2

3.

3.1

3.2

4.

4.1

4.2

Summary of Data BaseSummary of Data BaseMrs. Isponiati/ 67 y.o/ W24B

Chief complain: Wound in her leg•Patient suffered from wound in her leg since 2 days before admitted. Her right leg got injury when she was in a trip. Previously there were small bulae in her right leg since 1 week ago but there wasn’t complain. And it was getting bigger when she got that wound.•Fever (high grade fever) since 1 day before admitted.

• Generalized weakness since 5 days ago and some times felt headache so she topped her medication by her self. She usually took glibenclamide 1 tablet daily in the morning.

• History of diabetes mellitus since 5 years ago but she didn’t routinely control.

Physical examinationPhysical examinationBP = 155 /70

mmHg

PR = 120 bpm RR = 24 tpm Tax : 40,1 0C

General appearance looked severely ill GCS E4V5M6

Head Anemic - Icteric -

Neck JVP R + 2 cm < 450

Thorax cor Invisible Palpable at Ictus ICS V MCL S,

RHM SL D

LHM as ictus

S1 S2 single, mur mur -

lung I:Simetric, P: SF D = S v v Rh - - Wh - -

v v - - - -

v v - - - -

Abdomen flat,BS + normal, Hepar unpalpable, liver span 8 cm. Spleen

unpalpable, troube space timpany. Shiffting dullnes -

Extermities Oedema (-) dry skin. Pedis sinistra: Crusta at digiti 1.

Pedis dextra : edema, bullae at dorsum

pedis and vulnus skizum at

digiti 2 and 3 about 0,5cm x

0,3cm.

Laboratory findingLaboratory findingLab Value Lab Value

Leukocyte 13.700 3500;10000/µL PPT K: 12,8 dtk

HB 11,1 11,0-16,5g/dl APTT K: 30,0 dtk

MCV 89 80-97H um3 Bil Total <1,10Mg/dl

MCH 29,9 26,5-33,5H pg Bil Direct < 0,25Mg/dl

PCV 33,1 35-50% Bil Inderect < 0,75Mg/dl

Trombo

cyte

159.000 150000-390000/

µL

Na 133 136-145Mmol / L

RBS 661 (<200)mg/dL K 4,5 3,5-5,0Mmol / L

Ureum 98,1 10-50mg/dL Cl 96 98-106Mmol / L

Creatinine 1,71 0,7-1,5mg/dL SGOT 11-41U/L

Albumine 2,65 3,5-5,5g/dl SGPT 10-41U/L

LDH 210-425 U/l SG 1,025-1,029

Urinalysis

SG =1.015 PH = 5,0 Keton=2

+

Leucocyte 1+ Crystal -

Glucose = Protein= 4+ Ery= 5+

Ery >100 /hpf Leuco 2-3 /hpf

BLOOD GAS ANALISIS

pH : 7,436

pCO2 : 28,8 mmHg

pO2 : 128,8 mmHg

HCO3 : 19,1 mmol/L

O2 sat : 98,6 %

BE : -2,5 mmol/L

Chest X rayChest X ray

CXR :AP position, KV enough, symetric, trachea in the midlle, bone and soft tissue Normal, Phrenico costalis angle on Right and Left sharp, Hemidiaphragm D and S dome shape, lung D& Lung S clear, Cor site, size, shape normal CTR 50 %Conclusion : Normal CXR

ECG

• Sinus Rhytm, HR 112 x/mnt

• PR Interval :0,12”

• QRS Interval : 0,08”

• QT Interval : 0,4”

• Frontal axis : Normal

• Horisontal axis: Normal

• Conclussion : Sinus Tachicardi

CUE AND

CLUE

PL IDx PDx PLANNING THERAPY PMo

Female/ 67 yo

RBG: 661

PH: 7,436

Anion gap:

22,4

HCO3: 19,1

Osmolalitas:

322,9

Ketonuria: 4+

PR: 120 bpm

PP: 24tpm

Tax: 40,5C

Dry skin

1.

Hiperglycemia

Crisis

1.1HHS O2 3-4 l/minIVFD Nacl 0,9%1L initially and then 1 L/h depending on state of hydration•Regular insulin 0,15 units/kg as iv bolus •Regular insulin infus 0,1IU/kg bw/hour in 500cc Nacl 0,9% (50 unit in 500cc NaCl 50 drop/min microdrip)•Cek serum glucose hourly. If serum glucose does not fall by at least 50mg/dl in first hour, then double insuline dose hourly glucose falls at a steady hourly rate of 50-70mh/dl

CUE AND CLUE PL IDx PDx PLANNING

THERAPY

PMo

•Cek electrolyte, BUN, creatine and glucose 2-4h untilStable

•Target insuline 250-300mg/dL and plasma osmolality is < 315 mOsm/kg

•Chage Nacl 0,9% to 5%Dextrose with 0,45% Nacl

•Reguler insulin 0,05-0,1 iu/kgbw/hour(25 unit in 500cc NaCl 25 drop/min microdrip)

•If 110-140mg/dL give intermediate insuline 10 unit SC & Regular insuline 4-4-4 unit SC

• than than stop drip insulin after 2 hour

CUE AND CLUE PL IDx PDx PLANNING

THERAPY

PMo

Female/ 67 yo

•History of DM

for 5 years

•RBG: 661

mg/dl

•There were

wound in her

legs

Female/ 67 yo

Ureum: 98,1

Creatinine:

1,71

BUN/Creat:

26,8

2. DM type 2

normoweight

Poorly control

3. Azotemia

Pre renal

3.1 Due to

dehidration

As above

Rehidration 1L/h

RBG

Ureum creat

CUE AND CLUE PL IDx PDx PLANNING THERAPY PMo

Female/ 67 yo

• Wound in her left

leg since 1 week

•Bulllae in her right

leg

•New wound in her

digiti 2 & 3 pedis

dextra

•Healing wound in

her left leg

Female/ 67 yo

•Wound in her legs

•Fever

•PR:120 bpm

•RR: 24 tpm

•Tax: 40,5C

•Leokocyte: 13.700

4. Diabetic

Foot

wagner II

5. Sepsis 5.1

Due to

dabetic

foot

Wound culture and sensitivity test

Blood culture and sensitivity test

•Ceftriaxone 2x1 gram iv•Clocacillin 3x500mg

•As above

Thank youThank you