MORNING CASE MORNING CASE REPORTREPORTAugust 5th, 2014

By: Ayu Trisna Dewi, Widi Mas Gunanthi, Angga Pradana, Bagus Anggaraditya, Prayoga Ariguna, Rozan Fikri

PATIENT IDENTITY• Name : SA• Gender : Male• Age : 46 yo• Religion : Hindu• Address : Pedungan, Denpasar• Status : Married• ToA : August 5th 2014 / 14.30 WITA• No. MR : 14045957

ANAMNESISChief Complaint: wound and swelling at left footPresent HistoryPatient came to hospital with chief complaint wound and swelling at his left foot since 1 week ago. The complaint become worsen. The wound appeared when he use foot reflexion tools.He felt pain on his left right and the wound discharged pus. He also feel numbness on his footHe has no complaint of blurred visionHe has diabetes since 4 year ago and the diabetes was uncontrolled. History of nausea, vomiting, cough, dyspnea was denied

Past HistoryHe has history of DM type 2 since 4 years ago. He takes Glibenclamide and Metformin Family HistoryHis brother has history of diabetesHistory of hypertension, heart disease, and kidney disease was denied Social HistoryAlcoholic and smoking was denied

PHYSICAL EXAMINATION• General app. : Moderately ill• Consc. : Compos mentis• GCS : E4V5M6• BP : 160/100 mmHg• Pulse rate : 140x / minute• Respi. Rate : 29x/ minute• Axillary temp. : 38.5 ̊C

Status Present

•Eyes : anemis (-/-), icterus (-/-),pupil reflex (+/+) isochoric, Oedem palpebrae (-/-)

•ENT : Tonsil, Pharynx, tongue WNL•Neck : JVP + 0 cmH2O, gland enlargement (-)•Thorax : symmetry

COR– Insp : ictus cordis not visible– Palp : ictus cordis not palpable– Perc : UB : ICS II

LB : MCL S ICS V RB : PSL D

– Ausc : S1S2 single regular murmur (-)

PULMO– Insp : symmetrical– Palp : tactile fremitus N/N– Perc : sonor/sonor– Ausc : vesicular +/+ ; ronchi -/- ; wheezing -/-

• Abdomen- Inspection : distension (-)- Auscultation : bowel sound (+) normal- Percussion : tympani- Palpation : hepar and spleen unpalpable,

tenderness (-)Extremities : warm +/+ edeme -/-

+/+ -/-

LABORATORY EXAMINATION

Parameter Result Unit Normal Range Remarks WBC 11,4 103µL 4,10-11,00Ne % 74,6 % 47,00-80,00

Lym% 15,4 % 13,00-40,00

Mo % 7,49 % 2,00-11,00

Eo % 1,40 % 0,00-5,00

Ba % 1,11 % 0,00-2,00

Ne# 11,4 x10^3/µL 2,50-7,50 High

Ly# 1,77 x10^3/µL 1,00-4,00

Mo# 0,857 x10^3/µL 0,10-1,20

Eo# 0,160 x10^3/µL 0,00-0,50

Ba# 0,125 x10^3/µL 0,00-0,80

Complete Blood Count

Parameter Result Unit Normal Range Remarks

RBC 2,91 x10^6/µL 4,50-5,90

HGB 6,76 g/dL 12,0-16,0 Low

HCT 23,5 % 36,0-46,0

MCV 80,5 fL 80,0-100,0

MCH 23,2 pg 26,00-34,00 Low

MCHC 28,8 g/dL 31,00-36,00 Low

RDW 14,2 % 11,60-14,80

PLT 427 x10^3/µL 140,0-440,00

MPV 5,74 fL 6,80-10,00 Low

Blood Chemistry PanelParameter Result Unit Reference

rangeRemarks

Natrium 128 mmol/L 136–145 Low

Kalium 4,3 mmol/L 3,50 –5,10

Parameter Result Unit Reference range

Remarks

SGOT 14 U/L 11- 27

SGPT 11 U/L 11-34

Albumin 1,8 mg/dL 3,4 – 4,8 Low

BUN 16 mg/dL 8,00 – 23,00

Creatinin 1,3 mg/dL 0,50 – 0,90 High

Hb A1C 13,13 < 6,5 High

Blood Gas AnalysisParameter Result Unit Remarks Reference range

pH 7,44 7,35-7,45

pCO2 45 mmHg 35,00-45,00

pO2 101 mmHg High 80,00-100,0

BEecf 6,4 mmol/L -2-2

HCO3- 30,6 mmol/L High 22,00-26,00

SO2c 98 % 95%-100%

TCO2 32 mmol/L High 24,00-30,00

Parameter Result Unit Normal Range Remarks Specific gravity 1,015 negative

pH 5 7,35 – 7,45 Low

Leucocyte Negative Leuco/uL Negative

Nitrite Negative Negative

Protein (urine) 150 (+++) Mg/dL Negative

Glucose (urine) 1000 (4+) Mg/dL Normal

KET 15 (++) Negative

Urobilinogen Normal Mg/dL Normal

Bilirubin (urine) Negative Mg/dL Negative

ERY 25 (++) Ery/uL Negative

Colour p. Yellow P yellow – yellow

Urinalysis

IMAGINGThorax photo•Cor: shape and size WNL, calsification of aortic knob•Pulmo: infiltrate ait left parahiler and both paracardial•Pleural sinus: sharp•Both diaphragma are normal

Conclusion:AortosclerosisPneumonia

ASSESSMENT• Diabetes Melitus type 2• Diabetic foot grade III pedis with ketosis

and ketoalbuminemia• Hypertension stage II• CKD ec suspect DKD• Moderate anemia ec CKD

TREATMENT• Hospitalized • IVFD NaCl 0,9% 20 dpm• Drip insulin 4 U/h if BS > 250 2 U/h if BS 200-250

1 U/h if BS < 200• Fasting during insulin drip • Cefotaxime 3 x 1 gram (IV)• Metronidazole 3 x 500mg (IV)• Captopril 2 x 20 mg per oral• Paracetamol 3 x 500 mg per oral• Transfusi PRC until Hb = 9 gr/dL

PLANNING• Check BSN, Blood sugar 2hours post

prandial, lipid profile, blood culture• Consult to surgery for debridement• Monitoring vital sign and complaints• BS every hour and Na-K every 6 hours