Name

Age Gender Address Occupation Religion Marital Race Education

status

: : : : : : : : :

Mrs.E 61 years old Female bambu duri, karawang House wife Islam Married Sundanese Elementary School

 Autoanamnese

on 30th november 2012 at rengasdengklok ward

 Main

complaint : right foot feel hot,pain,itchy,swelling and poignant since one week ago
complaint : blurred vision,

Additional

 Patient

came to IGD RSUD karawang complaint that she had feel hot,pain,itchy,swelling and poignant since one week ago at righ foot wound. Os got wounded since 2 weeks ago, applied honey to her wound but didnt cured Dont know clearly what makes os get wounded at right foot

 Os

said always feels hungry,thirsty, and often Urinate at night

also have wound at left foot since 2 months ago Os also complaint that she had blurred vision since 1 years ago

Os

Same disease (-) DM (+) since 2 years ago, uncontrolled

Hypertention (+) Kidney disease (-)

Heart disease (-)

DM (+)

Same disease (-)

Hypertention (+)

Kidney disease (-)

Herbal medicine (-)

Smoking (-)
Alcohol compsumption (-)

Routine exercise (-)

Drugs (-)

General condition

Appreance : moderately ill Consciusness: compos mentis Weight Height BMI : 48 kg : 154 cm : 20,23

nutrition

Blood pressure :160/90 Respiration rate : 17x/min

Heart rate : 80x/min

Temperature : 36,7c

Head

Normochepaly, black hair, good distribution Anemic conjungtiva -/-, Icteric sclera -/-

Eyes Ears

Hiperemic (-/-), tenderness (-/-), secret (-/-)

Septum deviation (-), hiperemic concha (-/-), secret (-/-), mass (-/-)

Nose

Mouth

Red lip (+) dry (-) Tongue (N). Arcus faring (N). Tonsil (N). Posterior Pharyng (N)

Neck
Lymph node: enlargement (-), tenderness (-) Thyroid: enlargement (-), tenderness (-) JVP: 5+1 cmH2O

 LUNG

Inspection

: Symmetrical Palpation : Equal vocal resonance Percussion : Sonor in both lungs Auscultation : Vesicular breath sound in both lung,ronchi (-/-),wheezing (-/-)

THORAX

INSPECTION

Ictus cordis is invisible PALPATION

Ictus cordis is palpable at 5th ICS LMCS

Right heart border: ICS III-V LSD Left heart border: ICS V 1cm medial LMCS Upper heart border: ICS III LPSS Regular I - II absence of murmurs and gallop in hearts sound

PERCUTION

AUSCULTATION

ABDOMEN Inspection : flat, symmetric, caput medusa (-), smiling umbilicus (-)

Palpation : Tenderness (+) Epigastrium pain (-) Distension (-) no liver and spleen enlargement Percussion : Tympanic 4 kuadran abdomen
Auscultation : bowel sound (+) 4 times/min , arterial bruit (-), venous hum (-)

 Warm

acral

+ +

+ +

Ulcus

at right foot MTP II,III,IV,V Dried ulcus at left foot ITP III
Oedem
-

Hematology
Hb leukocyte trombocyte Ht Diff count Blood chemistry Random blood glucose ureum creatinin

value
9,5 23.700 284.000 29 0/0/0/86/11/2

Normal value
12-17 G% 5.000-10.000 ul 150-450 ribu 37-48% 0-1/1-3/2-6/4070/20-40/2-8 80-140 mg/dl 10-45 mg/dl 0,4-1,5 mg/dl

277 32,0 0,96

Blood chemistry
Random blood glucose

value
289 mg/dl

symptom hot,pain,itchy,swelling and poignant since one week ago at righ foot wound Dont know clearly what makes os get wounded at right foot always feels hungry,thirsty, and often urinate at night Os also have wound at left foot since 2 months ago Os also complaint that she had blurred vision since 1 years ago Have DM since 2 years ago, uncontrolled DM in family history

sign Blood pressure :160/90 Ulcus at right foot MTP II,III,IV,V since 1 week ago Dried ulcus at left foot ITP III 2 months ago

Lab Random blood glucose 1-12-2012 : 277 mg/dl Random blood glucose 2-12-2012 : 289 mg/dl

 ULCUS

PEDIS et causa DM TYPE 2 Hypertention stage 2

 Ulcus
DVT

pedis et causa DM type 2

Buerger

disease Squamous cell carcinoma Morbus hansen

 Nacl

0,9% 20 dpm Ceftriaxone vial 1x2gr Rantin amp 2x1 Ondansentron amp 3x1 Insulin 3x12 unit OMZ 1x1 Pamol 3x1

 Bed

rest Diet DM Diabetic Shoes

 Pinprick

test Fasting blood glucose Hba1c Lipid profile

 AD

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