DUTY REPORT

31ST May 2015

GP on duty:
dr. Gerald
Dr. Karen Pandhika
Co-Assistant on duty:
Susasti Hasanah and Melissa Trixiana

PATIENT RECAPITULATION

PATIENTS IDENTITY
Name
: Mrs. TR
Sex
: Female
Age
: 60 years old
Job
: Housewife
Religion
: Moslem
Marital Status : Married
Race
: Sundanese
Address
: Cimanggis, Depok

Anamnesis
Chief complain:
Patient came with swollen big toe 7
days prior to admission

HISTORY OF PRESENT
ILLNESS
Patientcamewithachiefcomplaintswollenatherrightbig
toe7dayspriortoadmission.
Atthebeginning,patienthadcallousonherleftbigtoe,then
patienttriedtodiminishitbyerodingitbyherselfuntilthen
patientrealizeithasbecameanulcusbutshefeltnopainon
theulcus.
The pedis also started to swollen and red as soon after the
ulcusformed,anditcausedpainonthepedis.
Theulcusproducedyellowishfluidthatsmelly.
Sometimespatientgotfebris
Decreaseoftheappetitefor7dayspriortoadmission

Past Illness

DM (+)
HT (-)
Stroke (-)
Heart disease (+)
Jaundice (-)
Kidney Disease (-)
Gallstone (-)

History of Family Illness

DM (-)
HT (-)
Stroke (-)
Heart disease (-)
Jaundice(-)
Kidney Disease (-)
Similar complaint with patient(-)

History of Socio-Habits
The patient neither smokes, drinks alcohol, nor
uses any forbidden drug.
She could not eat and drink well, he is only eat
2-3 spoon/day

Allergic History
No allergic history

Physical Examination
General State :Mildly sick
Consciousness :Fully alert
Vital Signs
Blood Pressure :129/55 mmHg
Heart rate
:92 bpm (regular)
Respiratory Rate :20 times/minute
Temperature :37 oC
Body Weight
:52kg
Body Height
:153cm
BMI
:22 (Normoweight)

General Examination
Head

: Normocephal

Eye : anemic conjunctiva (-/-), icteric sclera (-/-)

Ears : discharge (-)
Nose : septum deviation (-), discharge (-)
Mouth

: coated tongue (-), hyperemic pharynx (-), normal

T1-T1,

pale mouth mucosa (-), dried mucosa (-)

Neck : JVP 5 2 cmH2O, lymph nodes enlargement (-)

 Thorax: symmetric, intercostals retraction (-)

COR

Inspection: Ictus cordis (-)

Palpation: heave (-), lift (-), thrill (-)
Percussion:
Right border: ICS V, linea parasternal dekstra
Left border : ICS V, linea midclavicularis
sinistra
Heart waist: ICS III, linea parasternal sinistra
Auscultation : regular 1st and 2nd heart sound,

PULMO
Inspection : chest within normal shape, symmetries on static and dynamic state
Palpation : tactile vocal fremitus both lungs were symmetries, chest expansion
symmetries
Percussion : resonant both lungs
Auscultation : vesicular breathing sounds, rales (-/-), wheezing (-/-)

Abdomen : flat, not distended, timpani, no enlargement of liver

& spleen
Extremities : an ulcus seen on digiti I pedis sinistra, warm,
hyperemic (+), pain by pressure (+)

LABORATORY RESULTS
Examination

Result

Normal lab

Hb

10,8

13 - 18 g/dl

Ht

30

40 52 %

Erythrocyte

3,7

4.3 - 6.0 mil /ul

Leukocyte

13620

4800 - 10800/ul

Thrombocyte

319.000

150000 - 400000/ul

MCV

82

80 96 fL

MCH

29

27 - 32 pg

MCHC

36

32 36 g/dL

Routine Hematology:

Examination

Result

Normal lab

Ureum

39

20 - 50 mg/dl

Creatinin

1,1

0.5 1.5 mg/dl

Random Blood Glucose

372

< 140 mg/dl

Sodium

139

135 147 mmol/L

Potassium

3,9

3.5 5.0 mmol/L

Chloride

105

95 105 mmol/L

Blood Gas Analysis:

pH
pCO2
pO2
Bikarbonat (HCO3)
Kelebihan Basa (BE)
Saturasi O2

7,402
29,6
97,6
18,6
-4,7
97,7

7,37 7,45
33 44 mmHg
71 104 mmHg
22 29 mmHg
(-2) 3 mmol/L
94 98 %

Clinical Chemistry:

ECG

Resume
Patient came with a chief complaint swollen at her
rightbigtoe7dayspriortoadmission.
At the beginning, patient had callous on her left big
toe, then patient tried to diminish it by eroding it by
herselfuntilthenpatientrealizeithasbecameanulcus
butshefeltnopainontheulcus.
Thepedisalsostartedtoswollenandredassoonafter
theulcusformed,anditcausedpainonthepedis.
Theulcusproducedyellowishfluidthatsmelly.
Sometimespatientgotfebris
Decreaseoftheappetitefor7dayspriortoadmission

 PE an ulcus on digiti I pedis sinistra with

swollen pedis and hyperemic
Lab
Hb 10,8 (decreased)
Ht 30 (decreased)
Eritrosit 3,7 (decreased)
Leukosit 13.620 (increased)
Blood gas analysis: pH 7,402 ; pCO2 29,6 () ;
HCO3 18,6 ()