Departement of internist

30 jULY 2013

Identity
Name Age Adress MRS : : : : Mrs. S 51 YO Majenang Kedungpring Lamongan. 29 juli 2013

Anamnesis
Chief complaint: right leg pain Present illnes: Patient complaining right leg pain and swelling since 4 days before hospital admission. 3 days ago, swelling got worse after right legs into hot water. Patients also complained of body heat since 3 days ago.And patient has know diabetic 3 days ago, and average of random blood sugar : 315 mg/dl. No headache, no nausea. The bowel habit and urinary habit within normal.

 History or pass illness : - HT (+),gout(+) History of family: History of sociality: - Smoke - Alcohol - Herbal Medicine -

 Physical examination: General status GCS : 456 Vital Sign: BP : 185/87 mmHg Pulse : 85/mnt Temp : 36,70C RR : 20/mnt Head/neck An -, ict-, cy-, dys-, JVP normal

Thorax Symmetric, retraction (-), sonor, ves/ves, rh -/-, wh -/murmur (-), gallop (-) Abdomen flat, Supple, hepar lien unpalpable, thimpany, bowel sound (+) N, Extremity Warm, dry, red, oedem +/-

Laboratory Findings
Diffcount : 0/0/76/20/4 Hematocrit : 30,7 Hemoglobin : 10,1 Leukosit : 11.900 Thrombocyte : 267.000 AST : 266 ALT : 261 Clorida serum : 100 Sodium : 129 Creatinin : 0,7 Urea : 17 RBS : 36

RADIOLOGY

Clue and Cue

Female, 51 yo right leg pain redness, swelling, and pain Diabetic history in Leukosit : 11.900 RBS : 36

Resume
Patient, Female 51 YO, with right leg pain, (redness, swelling, and pain). patient has know diabetic 3 days ago, and average of random blood sugar : 315 mg/dl Increase leukosit, RBS : 36 mg/dl,

Problem List - right leg pain - diabetic history in one year - redness, swelling, and pain - leukositosis - hypoglicemia

Initial Diagnosis cellulitis pedis dextra with hypoglicemia

Planning Diagnosis Complete bood count /3 days HbA1c RBS each day electrolite serum

Planning Therapy IVFD Asering 1500cc/24 hours Inj.D40% 2 fl inj. Ceftriaxone 2 x 1 gr Inj. Ranitidine 2 x 25 mg Consul internist

Monitoring
Vital signs Complaint Random Blood Sugar /days Elektrolit

Prognosis
Dubia ad bonam

Education
Explaine to the family about the disease of the family, about its theraphy and intervention will be done, and also about complication, diet, and prognosis diabetes melitus