EMERGENCY ROOM REPORT13TH JANUARY

2016

GP on duty:dr. Gerald & dr. Indri

Co-Ass on duty:Sabilla & Oki

PATIENT RECAPITULATION1. Mr. S – Kolik Abdomen e.c GERD, CHF, HT2. Mr. S – Insect Bite3. Mrs. IL – Kolik Abdomen e.c Acute Gastritis4. Mr. S – DM, HT, CKD, Severe Anemia5. Mr. RH – DM, CKD, Severe Anemia6. Mr. AS – Diabetic foot, DM type 27. Mrs. UM – Ensephalopati Hepatikum e.c Cirrhosis

hepatis, hepatitis C, hypoalbumin

PATIENT’S IDENTITY• Name : AS• Sex : Male• Age : 46 Years Old• Occupation : Employee• Religion : Islam• Status : Married• Address : Ksatrian, East Jakarta• Med. Record : 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.

History of Present Illness• The pastient came to the ER with wound

on his feet for 7 days. It is located on the sole of right foot and left foot toe. His feet were swollen at the first time and pus was oozing from the wound after several days. The wound is now dark reddish-black and he feels pain at the wound site.

• He said that he had gone to a clinic to treat his wound. The wound already treated well and he has given medication from the clinic. He said that the medicine was antibiotic but the patient didn’t know what the antibiotic was.

• He mentioned that he already has DM type 2 for 2 years. He also reported that he had been hospitilized at the hospital at 2013 because of his high blood sugar level. His DM is poorly controlled.

• He mentioned that he urine a lot at night, eat so much food because he felt hungry all the time, and he always felt thirsty. He didn’t control his meal.

• He also mentioned that he had hypertension for several years (approximately for 3 years).

• He has taken Metformin, Amlodipin, Captopril for his disease but he didn’t take it routinely. He said that he controlled to the doctor rarely.

• Nausea (-), Vomit (-), Fever (-), chest pain (-), shortness of breath (-), yellowish eyes or skin (-), weight loss (-).

Past Medical History• Hypertension (+) for 3 years. Poorly

controlled. • DM type 2 (+), for 2 years. Classic

symptoms were exist (polyuri, polidipsia and polyphagia). Poorly controlled.• Heart Disease (-), Lung Disease (-),

Allergy (-), Jaundice (-).

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 (+), blood (-), Tenderness (+), reddish-black color.

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 DATAHaematology Test (14th January 2016)

Results Normal Value

Hb 15.7 13-18 g/dl

Ht 43 40-52 %

RBC 5.3 4.3 – 6.0 million/ul

WBC 10.370 4.800 – 10.800/ul

PLT 186.000 150.000-450.000/ul

Clinical Chemistry Test (14th January 2016)

Results Normal Value

Ureum 23 20-50 mg/dl

Creatinin 0.6 0.5-1.5 mg/dl

Blood Glucose 453 <140 mg/dl

Na 135 135-147 mmol/L

K 4.0 3.5 – 5.0 mmol/L

Cl 100 95 – 105 mmol/L

Aseton + -

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.

• Vital signs: BP: 130/70 mmHg, HR: 108 bpm, RR: 18 bpm, Temp: 36.8oC. Physical examination revealed within normal condition, but there were ulcer, Pus (+), blood (-), dark reddish-black color on his feet.• Haematology test shows within normal

condition.• Clinical chemistry test shows high blood

glucose and it contains aseton on his blood.

PROBLEM LIST•Diabetic foot ulcer•Diabetic Ketosis• Type 2 DM•Hypertension

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 he’s

hyperglicemia.• Diagnostic plan: HbA1C, lipid profile,

daily blood sugar level• Therapeutic plan: Metformin 3 x 500

mg, Insulin• Education plan: Modifying lifestyle,

took medication routinely, control the blood sugar

Diabetic feet ulcer• Based on patient’s complaint that he

has dark reddish-black wound on his feet. It’s located on his sole of right foot and his left ring finger’s feet.• Pus (+), blood (-), pain (+)• Diagnostic plan: wound Gram stain

and culture• Theurapeutic plan: wound care by

debridement, ceftriaxone IV 2 gr q24hr, metronidazole IV 500 mg q8hr

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