DUTY REPORT 13TH Febuary 2015

DUTY REPORT31ST May 2015GP on duty:dr. GeraldDr. Karen Pandhika

Co-Assistant on duty:Susasti Hasanah and Melissa Trixiana1PATIENT RECAPITULATION2PATIENTS IDENTITYName: Mrs. TRSex: FemaleAge: 60 years oldJob: HousewifeReligion: MoslemMarital Status: MarriedRace: SundaneseAddress: Cimanggis, Depok3AnamnesisChief complain: Patient came with swollen big toe 7 days prior to admission

4HISTORY OF PRESENT ILLNESSPatient came with a chief complaint swollen at her right big toe 7 days prior to admission. At the beginning, patient had callous on her left big toe, then patient tried to diminish it by eroding it by herself until then patient realize it has became an ulcus but she felt no pain on the ulcus.The pedis also started to swollen and red as soon after the ulcus formed, and it caused pain on the pedis.The ulcus produced yellowish fluid that smelly.Sometimes patient got febrisDecrease of the appetite for 7 days prior to admission5Past IllnessDM (+)HT (-)Stroke (-)Heart disease (+)Jaundice (-)Kidney Disease (-)Gallstone (-)

6History of Family IllnessDM (-)HT (-)Stroke (-)Heart disease (-)Jaundice(-)Kidney Disease (-)Similar complaint with patient(-)7History of Socio-HabitsThe patient neither smokes, drinks alcohol, nor uses any forbidden drug. She could not eat and drink well, he is only eat 2-3 spoon/day8Allergic HistoryNo allergic history

9Physical ExaminationGeneral State:Mildly sickConsciousness:Fully alert

Vital SignsBlood Pressure:129/55 mmHgHeart rate:92 bpm (regular)Respiratory Rate:20 times/minuteTemperature:37 oC

Body Weight:52kgBody Height:153cmBMI:22 (Normoweight)10General ExaminationHead: NormocephalEye: anemic conjunctiva (-/-), icteric sclera (-/-)Ears: discharge (-)Nose: septum deviation (-), discharge (-)Mouth: coated tongue (-), hyperemic pharynx (-), normal T1-T1, pale mouth mucosa (-), dried mucosa (-)Neck : JVP 5 2 cmH2O, lymph nodes enlargement (-)11Thorax: symmetric, intercostals retraction (-)CORInspection: Ictus cordis (-)Palpation: heave (-), lift (-), thrill (-)Percussion:Right border: ICS V, linea parasternal dekstraLeft border: ICS V, linea midclavicularis sinistraHeart waist: ICS III, linea parasternal sinistraAuscultation : regular 1st and 2nd heart sound, murmur (-), gallop (-) 12PULMOInspection : chest within normal shape, symmetries on static and dynamic statePalpation : tactile vocal fremitus both lungs were symmetries, chest expansion symmetriesPercussion : resonant both lungsAuscultation : vesicular breathing sounds, rales (-/-), wheezing (-/-)Abdomen: flat, not distended, timpani, no enlargement of liver & spleenExtremities: an ulcus seen on digiti I pedis sinistra, warm, hyperemic (+), pain by pressure (+)Basah kasar?LABORATORY RESULTSExaminationResultNormal labRoutine Hematology:Hb10,813 - 18 g/dlHt3040 52 %Erythrocyte3,74.3 - 6.0 mil /ulLeukocyte136204800 - 10800/ulThrombocyte319.000150000 - 400000/ulMCV8280 96 fLMCH2927 - 32 pgMCHC3632 36 g/dL14ExaminationResultNormal labClinical Chemistry:Ureum3920 - 50 mg/dlCreatinin1,10.5 1.5 mg/dlRandom Blood Glucose372< 140 mg/dlSodium139135 147 mmol/LPotassium3,93.5 5.0 mmol/LChloride10595 105 mmol/LBlood Gas Analysis:pHpCO2pO2Bikarbonat (HCO3)Kelebihan Basa (BE)Saturasi O2 7,40229,697,618,6-4,797,77,37 7,4533 44 mmHg71 104 mmHg22 29 mmHg(-2) 3 mmol/L94 98 %15ECG

16ResumePatient came with a chief complaint swollen at her right big toe 7 days prior to admission. At the beginning, patient had callous on her left big toe, then patient tried to diminish it by eroding it by herself until then patient realize it has became an ulcus but she felt no pain on the ulcus.The pedis also started to swollen and red as soon after the ulcus formed, and it caused pain on the pedis.The ulcus produced yellowish fluid that smelly.Sometimes patient got febrisDecrease of the appetite for 7 days prior to admission

17PE an ulcus on digiti I pedis sinistra with swollen pedis and hyperemic

Lab Hb 10,8 (decreased)Ht 30 (decreased)Eritrosit 3,7 (decreased)Leukosit 13.620 (increased)Blood gas analysis: pH 7,402 ; pCO2 29,6 () ; HCO3 18,6 ()

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