B.

PATIENT PROFILE

Name of the Patient: Patient S

Age: 44 years old

Father name: Daddy H

Mother name: Mommy I

Spouse name: N

Address:1084 Tayabas Tondo Mla.

Chief Complaint: Non- healing wound left SHIN

Brief History: 2 weeks PTC (+) Erythematous papillus which she scratched then
progressed to 0.5x 0.3cm around given cloxacillin 500mg 1 tab qid, 1 weak PTC wound to
8cmx 4cm (+)foul odor due to persistence of system prompted consult to admission

ROS:
(-) weight loss (-) Abdominal pain

(-) Dysnia (-) colds

(+) Polyuria (+)polyuria

(-) Tea colored urine (-) weakness

Past Medical History:

(+) DM 24 years maintain euglovil 2x OD

Family History:
(+)DM (-) PTB

(+)HPN
C.PATIENT PHYSICAL EXAMINATION;
> Pupil 2-3mm ENTL, palpebral conguilan with ulcer

 Clear BS cm BLF. No allergic, at 5cm

UIGS,1m LL, no murmur

EXTREMITIES:

(+) necrotic well define erosion as the left anterior sides.

D.DIAGNOSIS;

DM ulcer left shin

 Hgb 123 110-130
Hct 0.369 L 0.37-0.45
Wbc 7.5 4.6-10
Segmenter 0.60 0.30-0.70
Lymph 0.325 0.20-0.40
Monocyte 0.072 0-0.07
MCV 87.3 80.9-99.9
MCH 29.1 21.0-31.0
MCHC 33.4 33.0-37
Blood morphology

Blood Chem

BUN 4.29 2.5-6.4

Cholesterol 4.42 3.5-5.7
Creatinine 29.08L 79.5-132.0
HDL 1.013L 1,00-155
LDL 2.91 0-636
Trigycirine 1.09 0.4-1.8
VLDL 0.5L 0.5-1.04

Electrolytes

Sodium 136.9 134-145

potassium 4.08 3.5-4.5