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
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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