Morning Report

Feb 16th 2013

FIRMAN BL
MAGMA
BAMBANG
HARIE

Name
Age
MR
Address

: Mr. A
: 30 yo
: 57 96 20
: Parang Layang, Makassar

Date on admittance :
16/2/2013

History taking
Chief Complain : Pain in Left leg
Experienced since 3 months before admission, stiff, formed a wound at
toe, getting bigger in last one month, and at last make his toe blackish
and odor. History of intermittent claudication and rest pain on his
finger and toe.
Six months ago the patient had same complained with his finger and
toe, then he admission to RSWS for 1,5 months diagnosed with
Buergers diss, and got Cilostazol, and Santa E.
No SOB, chest pain and cough.
Fever (+) since one week ago, until now.
History of smoking (+) about 10 years ago , but had stopped since 6
months ago
History of heart disease (-)
History of DM and family history of DM (-)

Physical exam
General status: Severe-ill/under nourished/conscious
Vital sign : BP 120/80 mmHg, Pulse 84 bpm, RR 20 tpm, T 38,7C
Local status :
Conj.anemic-/-), icteric (-/-)
JVP R-2 cm H2O,
HS I/II regullar, murmur (-)
Breath sound vesicular, Rales (-/-), Wh (-/-)
Normal peristaltic,) Liver and spleen not palpable

R. Palmar D/S

Extremity : R. Pedis Sin

Lytic lesions appear at distal phalang digiti I and

narrowing interphalangeal joint.

Reduced bone mineralization at proximal digiti I
V
Lusen appearance between soft tisue height 1/3
middle metatarsal
CONCLUSION :
Osteomyelitis with gangren gas height 1/3 middle of
metatarsal pedis sinistra

Lab finding
WBC : 19.200/uL Na : 130 mmol/L
HGB : 12 g/uL
K : 3,4 mmol/L
HT
: 38 %
Cl : 94 mmol/L
PLT
: 487.000/uL
RBG : 174 mg/dL
Ureum : 9 mg/dL
Cr : 0.5 mg/dL
GOT : 31 U/L
GPT : 109 U/L

Working Diagnosis

S/ Buerger Disease
Ulcus pedis Sin. With Osteomyelitis

Initial Management
IVFD NaCl 0,9% 18 gtt
Ceftriaxone 2 g / 24 hours / IV
Metronidazole 0,5 gr / 8 hours / IV
Inj. Ketorolac 30 mg / 8 hours / IV
Inj. Ranitidin 50 mg / 8 hours / IV

Planning
Consult to Thoracocardiovascular Surgery
Department
Echovascular
Arteriografi