MORNING REPORT

Thursday, July 14th 2014

Co-Ass in Charge:

1. Romi
2. Devi Anggraeni

MODERATOR : dr. Atma G, Sp.PD-KGH

 Summary of Data Base
Mrs. Carmiasih/49 yo/ W. 29
Anamnesis: heteroanamnesis (patient’s husband)
Chief complaint: decrease of consciousness
Patient suffered from decrease of consciousness gradualy since 1
days before admission. First, she was looked more quietly and
then became hard to be communicated.
Patient also had decrease of appetite, she ate 2-3 time a day, a
half of her regular portion. She sometime had nausea without
vomiting. She said that her stomach felt very full even though with
out eating. Patient also had low grade fever since 1 week ago, the
fever often happen in the night and it was not accompanied with
shivering but she did not took any medicine to relief the fever.
 Patient suffered from wound at her right foot since3 month, the
wound may caused by her habit to walk around the neighborhood
with out using sandals. The wound at first was reddish, but the
treatment was late to be given because she always concealed her
illness. But then the family knew about the wound because it
produced pus, blood and bad odor and her leg color change to
darken.
18 days before admission, she was hospitalized at RSUD lawang
because of the wound. She underwent surgery to remove the
infection in her wound without amputation procedure because the
patient refuse it. At lawang she got insulin medication, 3 x 8 iu sc 15
minutes before ate and 8 iu sc at 22.00.
Social history: married, 7 child. She was a house maid, she had
been diagnosed with diabetes type 2 since 9 years ago, she routine
consume glibenclamide 2 x mg but she never controlled. Her blood
glucose ever reach 600 mg/dl.
Family History:
• Family history about hypertension and
diabetes were unknown.
 Physical Examination

General appearance : looked severely ill GCS 224-113

BP arm: 70/50 – PR (ER): 110 bpm, become 88 strong, RR : 20--16 tpm Tax : 36.6 0C
100/60 mmHg regular
Leg: hard to evaluate
Head Anemic (+) , icteric (-), meningeal sign (-)
Light reflexes +/+ , pupil isocor 3mm/3mm
Neck JVP R+ 0 cm H2O, 30 degree
Lymph node engargement (-)
Thorax : Cor Ictus invisible and palpable at ICS V MCL sinistra
Chesst: makula LHM ~ ictus, heart waist + RHM: SL D
hyperpigmentation, S1, S2 single with no murmur
polycyclis, induration at
the edge lesion,
itchy,scaly
Pulmo Symmetric, SF D = S, Rh - - Wh - -
- - --
- - --
Abdomen Rounded, Slightly distended, bowel sound N, liver span 8 cm, traube’s space
tymphani
Extremities Warm acrals,
Pulsation at A. Tibialis Posterior (D) unpalpable, Extent: all area of pedis Depth:
until ligament , Infection: darken(+), warmth (+), pus (+), necrotic tissues (+)
Blood (+). Leg Swelling (+)/(+)
 Laboratory finding
Lab Value Lab Value

Leukocyte 11.060 4.700-11.300/µL Natrium 130 136-145 mmol / L

Haemoglobine 9.20 11,4-15,1 g/dl Kalium 3.34 3,5-5,0 mmol / L

MCV 84.50 80-93 fL

MCH 26.40 27-31 pg Chlorida 112 98-106 mmol / L

PCV 29.50 38-42% RBS 205-188- < 200 mg/dL
213-202-
242

Trombocyte 473.000 142.000- SGOT 26 11-41U/L

424.000/µL

Eo/Ba/Neu/Ly/M 0.1/0.4/83. 0-4/0-1/51- SGPT 22 10-41U/L

o 9/8.9/6.7 67/25-33/2-5

Ureum 31.90 16.6-48.5 mg/dL TLC 984

Creatinine 1.02 < 1.2 mg/dL PPT 15.10 11.5-11.8 detik

Calsium 6.8 7.6-11.0 mg/dL INR 1.31 0.8-1.30
Phospor 5.1 2.7-4.5 mg/dL APTT 32.20 27.4-28.6 detik
Albumin 1.34 3.5-5.5 g/dL
 Value Value
10 X
Kekeruhan Cloudy Epitel 5.9 ≤1
Color Yellow Cylinder -
pH 5.5 4.8 – 8.0 - Hialin - ≤2
Berat Jenis 1.015 1.005–1.030 -Granule - Negative
Glucose - Negatif - Lain-lain -
Protein Trace Negatif 40 X
Keton - Negatif Erythrocyte 5.0 ≤3
Bilirubin - Negatif - Eumorfi -
k
Urobilinoge - Negatif - Dismorfi -
n k
Nitrit + Negatif Leukocyte 37.8 ≤5
Leukosit 1+ Negatif Cristal -
Blood Trace Negatif Bacteria 118.4 x ≤ 93 x
103 /mL 103 /mL

Other Jamur ++
 BLOOD GAS ANALYSIS (NRBM 10 lpm)
LAB RESULT NORMAL VALUE
pH 7.33 7.35-7.45
pCO2 30.0 35-45
pO2 266.4 80-100
True O2 93.24 Normal pO2
HCO3 16.1 21-28
BE -10.0 (-3) – (+3)
O2 Saturation 99.9 >95
Hb 10.3
Lactic acid 2.6 Venous blood : 0.5-2.2
Artery blood : 0.5-1.6

Conclusion Metabolic acidosis with partially compensated

 ECG
• Sinus tachicardia, Heart rate 108 bpm
• Frontal Axis : normal
• Horizontal Axis : conter clock wise
• PR interval : 0.16”
• QRS complex : 0.12”
• QT interval: 0.36”
• RSR pattern at V1
Conclusion: Sinus tachicardia, Heart rate 108 bpm, complete
RBBB
.
Chest X-Ray
 CXR
• AP position, asymmetric, strong KV, less inspiration
• Soft tissue was normal.
• Trachea was in the middlle
• Hemidiaphragm D/S were in domeshaped
• Phrenicocostalis angle D/S were sharp
• Cor: site was normal, size CTR 52%, shape was normal
• Pulmo: bronchovesicular pattern was normal
Conclusion : normal CXR
 CUE AND CLUE PL IDx PDx PTx PMo
Female, 49 yo/w29 1. Septic 1.1 diabetic Pus , Bed rest Subjective
GCS: 113 Proper positioning/2 hour
Gradualy decrease of
shock foot, moderate blood and Vital signs
consciousness PEDIS urine Insert NGT Urine
Low grade fever culture Insert catheter output
Wound at right for 3 1.2 Skin and Inserted CVP CVP
month didn’t controlled
wound infection sensitivity
DM since 9 years ago test Drip NE 0.02-2
BP arm: 70/50-100/60 mcg/kgbw/minute
mmHg MAP target > 65 mmHg
Leg: /60 mmHg
PR (ER): 110-88 bpm
RR: 20-16
Anemic (+)
Chesst: makula
hyperpigmentation,
polycyclis, induration at
the edge lesion,
itchy,scaly
Pulsation at A. Tibialis
Posterior (D) unpalpable,
Extent: all area of pedis
Depth: until ligament ,
Infection: darken(+),
warmth (+), pus (+),
necrotic tissues (+)
Blood (+). Leg Swelling
(+)/(+)
WBC: 11.060
RBS: 205-188-213-202-
242
BGA: metabolic asidosis
UL:
Leukocyturia
Pedis AP and Lateral X-
ray: gas gangrene
 CUE AND CLUE PL IDx PDx PTx PMo
Female, 49 yo/w29 2. Diabetic Pus , Liquid diet 6 x 200 cc Subjective
Low grade fever foot infection blood and Microbiological control: Vital signs
Wound at right for 3 , Moderate urine Inj. Ciprofloxacin 2x200 Urine
month didn’t
controlled wound
PEDIS culture mg IV output
DM since 9 years ago and Inj. Metronidazole 3x500 RBG
BP arm: 70/50- sensitivity mg IV
100/60 mmHg test Po:
Leg: /60 mmHg Arteriogr Clindamycin 3x300 mg
PR (ER): 110-88 bpm aphy s
RR: 20-16 USG Metabolic control:
Anemic (+) doppler Intermediate insulin 10 IU
Pulsation at A.
Tibialis Posterior (D) sc
unpalpable, Extent:
all area of pedis Mechanical & educational
Depth: until control:
ligament , Infection: Use thick and soft sole
darken(+), warmth sandals and shoes
(+), pus (+), necrotic Vascular control:
tissues (+)
Blood (+). Leg Plan for USG Doppler (or
Swelling (+)/(+) arteriography)
HB: 9. 20
WBC: 11.060 Wound control:
205-188-213-202-242 Debridemant and wound
UL: dressing everyday
Leukocyturia
Pedis AP and
Lateral X-ray: gas
gangrene
 CUE AND CLUE PL IDx PDx PTx PMo
Female, 49 yo/w29 3. Skin 3.1 tinea corporis KOH Confirmed diagnosed Subjective
Diagnosed diabetes 9 lesion 3.2. atopic staining Vital signs
years ago dermatitis

Chest:
Chesst: makula
hyperpigmentation,
polycyclis, induration
at the edge lesion,
itchy, scaly

Female, 49 yo/w29 4. 4.1 hyper Albumin transfusion 20% Albumin

Diagnosed diabetes 9 hypoalbu catabolic state 100 cc until reach 2.5 g/dL post
years ago minemia 4.2 low intake transfusion
Poorly intake

Leg swelling +/+

Albumin 1.34 g/dL

 CUE AND CLUE PL IDx PDx PTx PMo
Female, 49 yo/w29 5. DM type Insulin as above Subjective
Diagnosed diabetes 2 Vital signs
9 years ago overweight FBG
unrountine 2PPBG
controlled
RBS: 205-188-213-
202-242
 Condition This Morning
• GCS : 113
• BP : 100/60 mmHg
• HR : 92 bpm
• RR : 13 tpm
• Tax : 37.1˚C
• Urine production : 100 cc/4 hour -> 25 cc/hour
 Female, 49 yo/w29

1. Septic shock
1.1 diabetic foot, moderate PEDIS
1.2 Skin infection
2. Diabetic foot infection , Moderate PEDIS
3. Skin lesion
3.1 tinea corporis
3.2. atopic dermatitis
4. Hypoalbuminemia
4.1 hyper catabolic state
4.2 low intake
5. DM type 2 overweight unrountine controlled