MORNING REPORT

Thursday, November 5th 2009

PHYSICIAN INCHARGE:
IA : dr. Didin Retno, dr Hidayat
IB : dr. Fajar, dr Utama Budi.
II : dr Lia
III : Dr Sri Sunarti, SpPD
MODERATOR : dr , SpPD KPTI

NEW IN PATIENT
Mr. / yo/ W
1.
1.1
1.2
2.
2.1
2.2
3.
3.1
3.2
4.
4.1
4.2

Summary of Data Base

Mrs. Isponiati/ 67 y.o/ W24B
Chief complain: Wound in her leg
Patient suffered from wound in her leg since 2
days before admitted. Her right leg got injury
when she was in a trip. Previously there were
small bulae in her right leg since 1 week ago but
there wasnt complain. And it was getting bigger
when she got that wound.
Fever (high grade fever) since 1 day before
admitted.

 Generalized weakness since 5 days ago

and some times felt headache so she
topped her medication by her self. She
usually took glibenclamide 1 tablet daily in
the morning.
History of diabetes mellitus since 5 years
ago but she didnt routinely control.

Physical examination

BP = 155 /70
mmHg

PR = 120 bpm

RR = 24 tpm

General appearance looked severely ill

GCS E4V5M6

Head

Anemic -

Icteric -

Neck

JVP R + 2 cm < 450

Thorax cor

Invisible Palpable at Ictus ICS V MCL S,

RHM SL D
LHM as ictus
S1 S2 single, mur mur -

lung

Abdomen

I:Simetric, P: SF D = S v v Rh - vv
-vv
--

Tax : 40,1 0C

Wh - ---

flat,BS + normal, Hepar unpalpable, liver span 8 cm. Spleen

unpalpable, troube space timpany. Shiffting dullnes -

Lab

Value

Leukocyte

13.700

HB

11,1

11,0-16,5g/dl

APTT

K: 30,0 dtk

MCV

89

80-97H um3

Bil Total

<1,10Mg/dl

MCH

29,9

26,5-33,5H pg

Bil Direct

< 0,25Mg/dl

PCV

33,1

35-50%

Bil Inderect

< 0,75Mg/dl

Trombo
cyte

159.000

150000390000/L

Na

133

136-145Mmol / L

RBS

661

(<200)mg/dL

4,5

3,5-5,0Mmol / L

Ureum

98,1

10-50mg/dL

Cl

96

98-106Mmol / L

Creatinine

1,71

0,7-1,5mg/dL

SGOT

11-41U/L

Albumine

2,65

3,5-5,5g/dl

SGPT

10-41U/L

210-425 U/l

SG

1,025-1,029

LDH

Lab

Value

Laboratory
3500;10000/L finding
PPT

K: 12,8 dtk

Urinalysis
SG =1.015

PH = 5,0

Keton=2
+

Leucocyte 1+

Crystal

Glucose =

Protein= 4+

Ery= 5+

Ery >100 /hpf

Leuco 2-3 /hpf

BLOOD GAS ANALISIS

pH
pCO2
pO2
HCO3
O2 sat
BE

: 7,436
: 28,8 mmHg
: 128,8 mmHg
: 19,1 mmol/L
: 98,6 %
: -2,5 mmol/L

Chest X ray
CXR :
AP position, KV enough, symetric,
trachea in the midlle, bone and soft
tissue Normal, Phrenico costalis angle on
Right and Left sharp, Hemidiaphragm D
and S dome shape, lung D& Lung S
clear, Cor site, size, shape normal CTR
50 %
Conclusion : Normal CXR

ECG

Sinus Rhytm, HR 112 x/mnt

PR Interval :0,12
QRS Interval : 0,08
QT Interval : 0,4
Frontal axis : Normal
Horisontal axis: Normal
Conclussion : Sinus Tachicardi

CUE AND
CLUE

PL

Female/ 67 yo 1.
RBG: 661
Hiperglycemia
PH: 7,436
Crisis
Anion gap:
22,4
HCO3: 19,1
Osmolalitas:
322,9
Ketonuria: 4+
PR: 120 bpm
PP: 24tpm
Tax: 40,5C
Dry skin

IDx

1.1HHS

PDx

PLANNING THERAPY

O2 3-4 l/min
IVFD Nacl 0,9%1L
initially and then 1 L/h
depending on state of
hydration
Regular insulin 0,15
units/kg as iv bolus
Regular insulin infus
0,1IU/kg bw/hour in 500cc
Nacl 0,9% (50 unit in
500cc NaCl 50 drop/min
microdrip)
Cek serum glucose
hourly. If serum glucose
does not fall by at least
50mg/dl in first hour, then
double insuline dose
hourly glucose falls at a
steady hourly rate of 5070mh/dl

PMo

CUE AND CLUE

PL

IDx

PDx

PLANNING
THERAPY

Cek electrolyte,
BUN, creatine and
glucose 2-4h until
Stable
Target insuline
250-300mg/dL and
plasma osmolality
is < 315 mOsm/kg
Chage Nacl 0,9%
to 5%Dextrose with
0,45% Nacl
Reguler insulin
0,05-0,1
iu/kgbw/hour
(25 unit in 500cc
NaCl 25 drop/min
microdrip)

PMo

CUE AND CLUE

PL

Female/ 67 yo
History of DM
for 5 years
RBG: 661
mg/dl
There were
wound in her
legs

2. DM type 2
normoweight
Poorly control

Female/ 67 yo
Ureum: 98,1
Creatinine:
1,71
BUN/Creat:
26,8

3. Azotemia
Pre renal

IDx

3.1 Due to
dehidration

PDx

PLANNING
THERAPY

PMo

As above

RBG

Rehidration 1L/h

Ureum
creat

CUE AND CLUE

PL

Female/ 67 yo
Wound in her left
leg since 1 week
Bulllae in her right
leg
New wound in her
digiti 2 & 3 pedis
dextra
Healing wound in
her left leg

4. Diabetic
Foot
wagner II

Female/ 67 yo
5. Sepsis
Wound in her legs
Fever
PR:120 bpm
RR: 24 tpm
Tax: 40,5C
Leokocyte: 13.700

IDx

5.1
Due to
dabetic
foot

PDx

PLANNING THERAPY

Wound
culture
and
sensitivity
test

Ceftriaxone 2x1 gram iv

Clocacillin 3x500mg

Blood
culture
and
sensitivity
test

As above

PMo

Thank you