ROOM REPORT
TH
13 JANUARY
2016
GP on duty:
dr. Gerald & dr.
Indri
Co-Ass on duty:
Sabilla & Oki
PATIENT RECAPITULATION
1.
2.
3.
4.
5.
6.
7.
PATIENTS IDENTITY
Name
:
Sex
:
Age
:
Occupation
Religion
:
Status
:
Address
:
Med. Record
AS
Male
46 Years Old
: Employee
Islam
Married
Ksatrian, East Jakarta
: 367382
ANAMNESIS
Autoanamnesis and
Alloanamnesis on 13th January
2016 at 10.30 P.M.
Chief Complaint
Wounds on sole of right foot and
left toe for 7 days.
Family History
No known family member with same
complaint.
Social History
Tobacco or Alcohol uses (-)
PHYSICAL EXAM
General State : Moderatel illness
Consciousness : Compos Mentis
Vital Signs
Blood Pressure: 130/70
Pulse : 104 x/mnt
Respiratory Rate : 18 x/mnt
Temperature : 36.8oC
Body Weight : 68 kg
Body Height : 168 cm
BMI : 24,1 (Normoweight)
Head : Normocephal
Eye
: Anemic Conjuctiva (-/-),
Icteric Sclera (-/-)
Ear
: Normotia, Dischare (-)
Nose : Septum Deviation (-),
Discharge (-/-)
Throat : Dry mucous (-), Tonsil T1-T1,
Hyperemic Pharynx (-)
Neck : JVP 5-2 cmH2O, Nodes
Enlargement (-)
Thorax : Normochest
Pulmo : VBS (+/+), Rales (-/-), Wheezing
(-/-)
Cor : Regular 1st and 2nd heart sounds,
murmur (-), gallop (-)
Abdomen : Distended (-), normal bowel
sound, tenderness (-), Liver and Spleen
enlargement (-), tymphanic percussion
sound
Extremities : Warm, CRT <2 sec, edema (-),
cyanosis (-).
Right foot: Ulcer (+) on sole, pus (+), blood
(-), tenderness (+), reddish-black color
Left foot: Ulcer (+) on ring finger, pus (+),
PEDIS SCORE
P : 1st degree , there is no involvement of
peripheral arterial surrounding the wound.
E : Right foot : 3 x 3 cm
Left foot: 1 x 0.5 cm
D : 1st degree, superficial ulcer.
I : 2nd degree, infection on the skin and subcutan
tissue without involvement any depper tissue. Ex:
swollen and tenderness at the wound site.
S : 1st degree, no loss sensibility.
LABORATORY DATA
Haematology Test (14th January 2016)
Hb
Ht
RBC
Results
15.7
43
5.3
WBC
10.370
PLT
186.000
Normal Value
13-18 g/dl
40-52 %
4.3 6.0
million/ul
4.800
10.800/ul
150.000450.000/ul
Results
23
0.6
453
135
4.0
Cl
100
Aseton
Normal Value
20-50 mg/dl
0.5-1.5 mg/dl
<140 mg/dl
135-147
mmol/L
3.5 5.0
mmol/L
95 105
mmol/L
-
RESUME
A 46 y.O man presented with wounds on
his sole of right foot and toe on his left foot
for 7 days. It was swollen at first time and
pus oozed from the wound. The color of the
wound was reddish-black and he felt pain
from the wound site.
He diagnosed with DM type 2 for 2 years
and Hypertension for 3 years. Both
diseases are poorly controlled with
Metformin, Captopril and Amlodipin.
PROBLEM LIST
Diabetic Ketosis
The patient presents without nausea and vomit.
He was diagnosed with DM type 2 since 2 years
ago, poorly controlled. Classic symptoms were
exist (polyuria, polydipsia, polypaghi).
Lab test revealed hyperglicemia and ketosis.
Diagnostic plan : Therapeutic plan : Insulin, control blood sugar
Type 2 DM
Based on his past medical history
that he was diagnosed with DM type
2 since 2 years ago. The classic
symptoms were still exist
(polyphagia, polydipsi, polyuri).
Lab test revealed that hes
hyperglicemia.
Diagnostic plan: HbA1C, lipid profile,
daily blood sugar level
Therapeutic plan: Metformin 3 x 500
mg, Insulin
Hypertension
Based on his past medical history
that he has hypertension since 3
years ago and poorly controlled.
From PE revealed that the BP within
normal condition.
Diagnostic Plan: EKG, kidney function
test, liver function test
Therapeutic plan: Amlodipin 3 x 5
mg, captopril 1 x 25 mg
PROGNOSIS
Quo ad Vitam : Dubia ad Bonam
Quo ad functionam : Dubia ad
Malam
Quo ad sanationam : Dubia ad
Bonam