MORNING CASE

REPORT
August 5th, 2014

By: Ayu Trisna Dewi, Widi Mas Gunanthi, Angga

Pradana, Bagus Anggaraditya, Prayoga Ariguna,
Rozan Fikri

PATIENT IDENTITY

Name
Gender
Age
Religion
Address
Status
ToA
No. MR

:
:
:
:
:
:
:
:

SA
Male
46 yo
Hindu
Pedungan, Denpasar
Married
August 5th 2014 / 14.30 WITA
14045957

ANAMNESIS
Chief Complaint: wound and swelling at left foot
Present History
Patient came to hospital with chief complaint wound and
swelling at his left foot since 1 week ago. The complaint
become worsen. The wound appeared when he use foot
reflexion tools.
He felt pain on his left right and the wound discharged
pus. He also feel numbness on his foot
He has no complaint of blurred vision
He has diabetes since 4 year ago and the diabetes was
uncontrolled.
History of nausea, vomiting, cough, dyspnea was denied

Past History
He has history of DM type 2 since 4 years ago.
He takes Glibenclamide and Metformin
Family History
His brother has history of diabetes
History of hypertension, heart disease, and kidney
disease was denied
Social History
Alcoholic and smoking was denied

PHYSICAL EXAMINATION

General app.
Consc.
GCS
BP
Pulse rate
Respi. Rate
Axillary temp.

: Moderately ill
: Compos mentis
: E4V5M6
: 160/100 mmHg
: 140x / minute
: 29x/ minute
: 38.5 C

Status Present
Eyes : anemis (-/-), icterus (-/-),pupil reflex (+/+) isochoric,
Oedem palpebrae (-/-)
ENT : Tonsil, Pharynx, tongue WNL
Neck : JVP + 0 cmH2O, gland enlargement (-)
Thorax
: symmetry
COR
Insp
: ictus cordis not visible
Palp
: ictus cordis not palpable
Perc
: UB : ICS II
LB : MCL S ICS V
RB : PSL D
Ausc : S1S2 single regular murmur (-)

PULMO
Insp
Palp
Perc
Ausc

: symmetrical
: tactile fremitus N/N
: sonor/sonor
: vesicular +/+ ; ronchi -/- ; wheezing -/-

Abdomen
Inspection
Auscultation
Percussion
Palpation

: distension (-)
: bowel sound (+) normal
: tympani
: hepar and spleen unpalpable,
tenderness (-)
Extremities : warm +/+
edeme -/+/+
-/-

LABORATORY EXAMINATION
Complete Blood Count
Parameter

Result

Unit

Normal Range

WBC

11,4

103L

4,10-11,00

Ne %

74,6

47,00-80,00

Lym%

15,4

13,00-40,00

Mo %

7,49

2,00-11,00

Eo %

1,40

0,00-5,00

Ba %

1,11

0,00-2,00

Ne#

11,4

x10^3/L

2,50-7,50

Ly#

1,77

x10^3/L

1,00-4,00

Mo#

0,857

x10^3/L

0,10-1,20

Eo#

0,160

x10^3/L

0,00-0,50

Ba#

0,125

x10^3/L

0,00-0,80

Remarks

High

Result

Unit

RBC

2,91

x10^6/L

4,50-5,90

HGB

6,76

g/dL

12,0-16,0

HCT

23,5

36,0-46,0

MCV

80,5

fL

80,0-100,0

MCH

23,2

pg

26,00-34,00

Low

MCHC

28,8

g/dL

31,00-36,00

Low

RDW

14,2

11,60-14,80

PLT

427

x10^3/L

140,0-440,00

MPV

5,74

fL

6,80-10,00

Parameter

Normal Range

Remarks

Low

Low

Blood Chemistry Panel

Parameter

Result

Unit

Reference
range

Remarks

Natrium

128

mmol/L

136145

Low

Kalium

4,3

mmol/L

3,50 5,10

Parameter

Result

Unit

SGOT

14

U/L

Reference
range
11- 27

SGPT

11

U/L

11-34

Albumin

1,8

mg/dL

3,4 4,8

BUN

16

mg/dL

8,00 23,00

Creatinin

1,3

mg/dL

0,50 0,90

High

Hb A1C

13,13

< 6,5

High

Remarks

Low

Blood Gas Analysis

Parameter

Result

Unit

pH

7,44

pCO2

45

mmHg

pO2

101

mmHg

BEecf

6,4

mmol/L

HCO3-

30,6

mmol/L

SO2c

98

TCO2

32

mmol/L

Remarks

Reference range
7,35-7,45
35,00-45,00

High

80,00-100,0
-2-2

High

22,00-26,00
95%-100%

High

24,00-30,00

Urinalysis
Parameter
Specific
gravity
pH
Leucocyte
Nitrite
Protein
(urine)
Glucose
(urine)
KET
Urobilinogen
Bilirubin
(urine)
ERY
Colour

Result

Unit

Normal Range
negative

Remarks

Low

Mg/dL

7,35 7,45
Negative
Negative
Negative

Mg/dL

Normal

Mg/dL
Mg/dL

Negative
Normal
Negative

1,015
5
Negative
Negative
150 (++
+)
1000 (4+)
15 (++)
Normal
Negative
25 (++)
p. Yellow

Leuco/uL

Ery/uL

Negative
P yellow
yellow

IMAGING
Thorax photo
Cor: shape and size WNL,
calsification of aortic knob
Pulmo: infiltrate ait left parahiler
and both paracardial
Pleural sinus: sharp
Both diaphragma are normal
Conclusion:
Aortosclerosis
Pneumonia

ASSESSMENT
Diabetes Melitus type 2
Diabetic foot grade III pedis with ketosis
and ketoalbuminemia
Hypertension stage II
CKD ec suspect DKD
Moderate anemia ec CKD

TREATMENT
Hospitalized
IVFD NaCl 0,9% 20 dpm
Drip insulin 4 U/h if BS > 250 2 U/h if BS 200-250
1 U/h if BS < 200
Fasting during insulin drip
Cefotaxime 3 x 1 gram (IV)
Metronidazole 3 x 500mg (IV)
Captopril 2 x 20 mg per oral
Paracetamol 3 x 500 mg per oral
Transfusi PRC until Hb = 9 gr/dL

PLANNING
Check BSN, Blood sugar 2hours post
prandial, lipid profile, blood culture
Consult to surgery for debridement
Monitoring vital sign and complaints
BS every hour and Na-K every 6 hours