MORNING CASE REPORT

Duty on February 13th, 2017

PATIENT IDENTITY
Initial : INW
Sex : Male
Age : 51 years old
Religion : Hindu
Ethnic : Balinese
Marital Status : Married
Adress : Br. Kerta Buana Tianyar Barat
Kubu
Occupation : Employer
Time of Coming : 18.00
 ANAMNESIS
Chief Complaint:Wound at right calf
Patient came to the hospital with wound at right calf. The
wound occured since 1 week BATH. The wound is reddish,
swollen, and pain. At first the wound felt itchy and was
started to be swollen since the patient continuously rub it.
The wound is small in the beginning but now become larger.
Patient also complain fever which occurred since 1 day
ago.
 ANAMNESIS cont
He also complaint of tingling sensation on the sole since
4 months ago.
He has no complaints of sensory loss or blurred vision.
Vomit and nausea was denied
 Past History

Patient has history of DM since 15 years ago. He took

metformin and insulin, but he said that he took the
medicines irregulary
Patient has been diagnosed with DMDF 4 months ago which
has been debridement
Family History
Both parents have history of DM

Social Economy history

He works as an employer
He has the habit of consuming sweet foods and beverages
He has the habit of smoking approximately 1-2 daily
He denied the history of alcohol consumption
Physical Examination
Present status:
General condition : moderately ill
Consciousness : E4V5M6
BP : 120/80 mmHg
Pulse rate : 80 bpm
Resp. rate : 20 bpm
Axillary temp. : 36,7o C
Weight : 65 kg
Height : 160 cm
BMI : 23,87kg/m2
PHYSICAL EXAMINATION
General Status
Eye : anemic -/-, ikt -/-, pupillary reflexes +/+ isokor
ENT : Tonsil Normal, Pharing: no redness, gland swelling (-)
Neck : JVP PR +0 cm H2O
Thorax : symmetrical
Cor :I : ictus cordis unseen
Pal : ictus cordis palpable in MCL ICS 5
Per : UB : ICS II
RB : right PSL
LB : ICS 5 MCL sinistra
Aus: S1S2 Single Regular, Murmur(-)
Lung: I : Symetrical
Pa : VF N/N
Per : sonor on both lung
Aus : ves +/+, wh-/-, rh-/-
 Abdomen : I : Dist (-)
Aus : Bowel sound normal
Pal : Liver/spleen unpalpable,
balottment (-)
Per : Tympany(+), flank pain -/-
Extremeties : Warm + + Edema - -
+ + + -
Local status :
Location : cruris dextra
Look : oedema (+)
Feel: Warm (+), Tenderness (+)
Move: limited caused by pain
LABORATORIES
Complete Blood Count
Parameter Result Unit Reference Range
WBC 10,15 103/L 4,1 10,9
-Ne 7,02 69,1% 103/L 2,5 7,5
-Ly 2.16 21,23% 103/L 1,0 4,0
-Mo 0,77 7,58% 103/L 0,1 1,2
-Eo 0,16 1,56% 103/L 0,0 0,5
-Ba 0,05 0,53% 103/L 0,0 0,1
RBC 4,39 106/L 4,00 5,20
HGB 11,64 g/dL 12,00 16,00
HCT 37,17 % 36,0 46,0
MCV 84,66 fL 80,0 100,0
MCH 26,5 pg 26,0 34,0
MCHC 31,31 g/dL 31,0 36,0
PLT 184,9 103/L 150 440
LABORATORIES
Blood Chemistry Panel

Parameter Result Unit Remarks Reference Range

SGOT 9,3 U/L 11,00 33,00

SGPT 9,2 U/L 11,00 50,00

BUN 16,0 mg/dL 10,00 23,00

Creatinine 0,66 mg/dL 0,50 1,20

Random blood glucose 395 mg/dL H 70,00 140,00

Na 131 mmol/L 136-145

K 3,36 mmol 3,5-5,1

THORAX AP
- Cor: normal
- Costophrenic angle sharp at
both side
- Bronchovascular normal
- Consolidation (-)
- Conclusion : Normal CXR
 Ro cruris AP/Lat Dextra
Alignment : good
Bone trabeculation : Normal
Bone destruction (-)
Sclerotic in subchondral bone layer
(-)
Abnormal calcification (-)
Soft tissue swelling (-)

Conclusion:
Normal cruris
ASSESSMENT
- Diabetes Melitus Tipe 2
- Selulitis cruris
THERAPHY
Hospitalized
IVFD Nacl 0,9 % 20 dpm
Paracetamol 3 x 500 mg (IO)
Drip Rapid insulin 4 IU/jam with NS 0,9% until
BS 290 2 IU/jam with NS 0,9% until BS
200 1 IU/ jam with NS 0,9% BS 110-140
PLANNING DIAGNOSIS
Consult to surgery and dermatology department
MONITORING
Vital sign
Complaints
Blood Sugar @ hours
Thank you