Download - Laporan jaga (duty report on ward)
DUTY REPORT (WARD)12th NOVEMBER 2014
GP on Duty : Dr AnaPPDS on Duty : Dr. RezkyCOASS ON DUTY : Deputri and Farrah
• 3Rd Floor : 2 patients (Diabetic ulcer+• 4th Floor : 3 patients (Hepatoma, CNF,
Neck Tumor)• 5th Floor : 3 patients (Anemia, Anemia +
Melena)• 6th Floor : 1 Patient (hypoglicemia)
PATIENT’S RECAPITULATION
Name : Mrs. Y
DOB : 12-06-2014
Age : 58 years
Gender : Female
Occupation : Housewife
Medical Record no. : 076438
Date of admission : 12th November 2014
PATIENT’S IDENTITY
Chief Complaint:Fever since 3 days before being admitted
Additional Complaint :
Pain on her left foot
ANAMNESIS
History of present illness:
Patients present with fever since 3 days continuously. and came abruptly. No differences of fever during morning and evening. Fever drops if the patient takes the medication like paracetamol but fever may rise again. Complaints of fever is not accompanied by rash on hands and feets, nausea, vomiting, joint pain, and patients do not travel frequently to endemic malaria region.
Patient complain about pain on her left foot because of a wound since 7 days before being admitted. Developed by uses of thight shoes in physical exercise. blister appear at first but as the running times becomes purulent and stink. The patient also had a wound in the tiptoe of index finger of foot from 3 weeks ago, that developed to dry wounds, blackened and odorless. patients had a history of diabetes mellitus since 1 month ago with symptoms of 3P (+), during regular consumption gludepatic oral medication. controlled blood sugar levels,
patient recall well, the patient did not complain of blurred in both eyes. patients admitted numbness in the feet since 1 month before being admitted.
Bowel and bladder had no complaints, shortness of breath and chest pain denied. History of hypertension, heart disease, kidney disease, allergies and asthma denied
History of past illness:• The patient denied ever experienced the same thing
• Trauma history denied
History of Allergy• No allergy, no drugs allergies
Family History:• History of diabetes, hypertension, heart disease, kidney disease, liver disease and lung
diseases, allergies and asthma denied
HabitPatient denies smoking history, alcohol consumption, and other
long term medication
History of medications:• Gludepatic 3 times per days
• Paracetamol if fever occur
GENERAL EXAMINATION
General condition : Looks moderately ill
Consciousness : Compos Mentis
Blood pressure : 160/100 mmHg
HR : 100 times/minute
RR : 20 times/minute
Body temperature : 380 C
Body Weight : 160 cm
Body Height : 50 kg
Body Mass Index : 19 kg/m2 (normoweight category)
PHYSICIAL EXAMINATION
Head : normocephal
Hair : normal distribution, grey color
Face : symmetrical, deformity (-)
Eye : pale conjunctiva -/-, icteric conjunctiva -/-
ENT : normotia, rhinorrhea (-), otorrhea (-), blood(-), hyperemic pharynx (-), calm T1-T1
Mouth : dry lips, ketone breath odor(+)
Neck : JVP 5+2 cmH2O, Lymphadenopathy (-)
Skin : dry skin
PHYSICAL EXAMINATION
8
PHYSICAL EXAMINATION
ThoraksPulmonary ExaminationsInspection : normochest, symmetrical chest
movement on static and dynamic. Spider naevi (-), ICS retraction (-)
Palpation : symmetrical chest expansion, tactile fremitus, (-) mass, (-) tenderness
Percussion : sonor at both lung fieldAuscultation : vesikuler+/+, there were no
rhonchi or wheezing
Cardiac ExaminationsInspection : invisible ictus cordisPalpation : impalpable ictus cordis Percussion
Right heart border : ICS V right sternal lineLeft heart border : ICS V left midclavicular
lineHeart waist : ICS III left sternal line
Auscultation : S1/S2 regular, gallop (-), murmur (-)
PHYSICAL EXAMINATION
AbdomenInspection : distended, (-) caput medussae, (-)
massAuscultation : normal bowel sound Palpation : tenderness (-),CVA(-),
hepatomegaly and splenomegaly (-)Percussion : tympanic sound
Extremities : warm acral, CR <2min, muscle strength 5|5
5|5PEDIS Classification:
Perfusion : 2 (80/140=0.57)
Extent : 3x3x1 cmDepth : 2 (deep
ulcer, below dermis)Infection : 4
(infection with systemic manifestation
Impaired Sensation : 2 (present)
12
pHpCO2pO2HCO3BESat O2
7.40525.0*47.9*15.8*-7.3*84.6*
7.37-7.4533-44 mmHg71-104 mmHg22-29 mmol/L(-2)-394-98%
GFR : 69,15 mL/minOsmolality : 300,61 mOsm/LAnion Gap : 22,2 mEq/L
ECG
IMPRESSION: sinus rhythm, HR 88 bpm, normal axis, no pathologic Q wave, PR interval normal , QRS duration complex normal, no ST changes
1. phalang deformity of the proximal digiti pedis 1 left, maybe one of osteomyelitis
2. pedis soft tissue thickening of the left with the formation of gas gangrene
RONTGEN OF PEDIS
14
Patient, woman, 58 years old, with chief complain fever since 3 days before being admitted. Pain on left foot (+),blister evolved to stink odor and purrulent wound, since 7 days before admitted, a wound in the tiptoe of index finger of foot from 3 weeks ago, that developed to dry wounds, blackened and odorlessdiabetes mellitus(+) since 1 month ago with symptoms of 3P (+), during regular consumption gludepatic oral medication. controlled blood sugar levels, Physical examination : BP: 160/100, dry mucous of lips, ketone breath odor (+), extremities : PEDIS score Lab. Findings : Hb 9,5, leukosit :17040, RBG:439, Na: 132Ur/Cr: 23/0.7, GFR (69,15)
1. Rontgen pedis : phalang deformity of the proximal digiti pedis 1 left, maybe one of osteomyelitis
2. pedis soft tissue thickening of the left with the formation of gas gangrene
RESUME
1. Diabetic Ulcer2. DAK
3. Hypertension Stage 2
4. Leukositosis5. Acute on CKD
6. Anemia
LIST OF PROBLEMS
Based on:
Anamnesis: history of DM, uses of thight shoes, didn’t feel the blister, then becomes purulent dan stink. Numbness on feet (phisical sign : PEDIS : ), RBG : 439, ABPI :
Diagnostic planning:
• HbA1C
• RBG
• Angiography
• Bactery cultur
Tx:
Non Pharmacology:
1. Vascular control : consult to orthopaedics (angioplasty)
2. Wound control : dressing bandages everyday
3. Pressure control : uses of right shoes, minimize the pressure
4. Education control
Pharmacology:
1. Metabolic control : blood glucose on regulated insulin or oral hipoglicemic drugs
2. Infection control : Ceftriaxone 1xII gram
ULCER DIABETICUM EC TYPE 2 DIABETES MELLITUS
• Anamnesis : history of DM, 3P (+), fever (stress metabolic)
• Exam : temp : 380C, keton breath odor, dry lips, dry skin, Extremity : diabetics ulcer (cause of infection),
• Lab: rbg :439, Na :132, aseton (+), osmolality : 300,61, pH normal, HCO3 15,8
• DD : HHS• Treatment :
1. Rehidrasi
2. Rapid Insulin 4 Unit/jam
DKA
Anamnesis :
Bladder had no complain, risk factor (DM & Hypertension)
Lab. Findings :
Ur/Cr: 23/0.7 (GFR 69,15) (II)
DD : AKI
Further examination : urinalysis
ACUTE ON CKD
ANEMIA
DKA
22
DM Diet :
Ideal weight = 90% x (TB-100) x 1 kg
= 90% x (160-100) x 1 kg
= 54 kg
For woman, calorie needs 25 cal/weight 1350 calorie
Age 58 years old - 5%
Light activity +10%
So, we can give 1417,5 kal/day for this patient, with :
Carbohydrate (65%) 921 cal
Lipid (20%) 283,5 cal
Protein (15%) 212 cal
Based on:
Anamnesis: Patient denies hypertension.
PF: 160/100 mmHg
Diagnostic planning:
Thorax Rontgen
Non-Pharmacology Pharmacology
Low Sodium Diet Captopril 3 x 12,5 mg
Exercising nn
HYPERTENSION STAGE II
JNC 7
27
Quo ad Vitam : dubia ad bonam
Quo ad functionam: dubia ad malam
Quo ad sanactionam : dubia ad bonam
PROGNOSIS
THANK YOU …