PATIENT IDENTITY

Name : Ms. M
Birth of date : 20th August1969
Age : 49 years old
Gender : Female
Medical Record : 831895
Religion : Moeslem
Marital Status : Married
HISTORY TAKING

Present history
The patient came in complaining something like BISUL in his left arm.
She was a patient in Kolaka Hospital 2 weeks ago. Her left arm has
already got blister and fester. At first we found feels like she had
punctured by needle. In a week the wound getting worse and his son
brought her to hospital. Current condition, the patient got no fever, not
feeling nauseous, not dizzy. Defecation and urination is normal. She
feel pain 3/10. It was 7/10 before debridement.
The patient got gout history and declared Diabetes Mellitus ,2 years
ago. He did not take his Diabetes Mellitus pills regularly. The patient
often feels her limb cramps. Sensoric ability is decreasing. Patient got
Hypertension with maximum blood pressure is 160. She was given
amlodipine for now.
She consumed a lot of sugar before diagnosed Diabetes Mellitus. The
family has Diabetes Mellitus history.
PHYSICAL EXAMINATION
GENERAL DESCRIPTION :
- Impression : Moderate illness
- Nutritional Status : Well nourish
- Consciousness : compos mentis
- Weight : 70 kg
- Height : 160 cm
- BMI : 27,3kg/m2

VITAL SIGN :
- Blood Pressure : 130/80 mmHg
- Heart Rate : 88 x/minute
- Respiratory Rate : 20 x/minute
- Temperature : 36,7oC
Eyes : Isocor pupils, normal light reflex, normal conjungtivae, no
icteric sclera
Ear : No abnormalities, otorrhea (-)
Nose : No abnormalities, epistaxis (-)
Lips : No abnormalities, cyanosis (-)
Oral cavity : Gingival hypertrophy (-), oral trush (-),
Throat : No abnormalities, pharynx non hyperemia
T1-T1 normal
Neck : JVP R + 2 cmH2O, no lymphadenopathy
Lung
 Inspection : Simetris
 Palpation : Crepitation (-)
 Percussion : Sonor
 Auscultation : Normal

Heart
 Inspection : Ictus cordis is invisible
 Palpation : Ictus cordis is not palpable
 Percussion : Normal
 Auscultation : Heart sound I / II, regular. No gallop , no murmur
Abdomen
 Inspection : Distended, follow the motion of breath
 Auscultation : Peristaltic (+), normal
 Palpation : Liver and spleen are not palpable
Pain Tenderness (-)
 Perkusi : Tympani (+)

Ekstremity
 Edem kedua kaki, penurunan sensorik di kaki, non pittim
 Tangan kanan normal, tangan kiri ada gangren diabetik
LABORATORY TEST
URINALYSIS

Parameter Results Normal value

WBC 15,4 103/uL - 4,0 – 11,0 x 103/uL
RBC 4.71 x 106/uL - 4.5, – 5.5, x 106/uL
HGB 8.5 g/dL - 13-16 g/dL
HCT 40.9 % - 40-50 %
MCV 86.8 fL - 80 – 100 fL
MCH 28.0 pg - 27-34 pg
MCHC 32.3 g/dL – 31,0 -36,0 g/dL
PLT 261000 /uL + 150 – 450 x 103/uL
Neutrofil 74.4 % + 50,0 –70,0 %
Lymphosit 1.14 1.2 – 3.2
LABORATORY TEST
BLOOD CHEMISTRY
PARAMETER RESULTS NORMAL VALUE
GDS 217 mg/dl 140 mg/dl
GDP 2,3
Ureum 105 mg/dl 10-50 mg/dl
Kreatinin 5,13 mg/dl L(<1,3); P(<1,1)
mg/dl
SGOT 10 U/L <38U/L
SGPT 4 U/L <41 U/L
Albumin 2,6 gr/dl 3,5-5,0 gr/dl
Natrium 135 mmol/l 136-145 mmol/l

Kalium 3,2 mmol/l 3,5-5,1 mmol/l

Klorida 99 mmol/l 97-111 mmol/l
RADIOLOGY EXAMINATION

USG Doppler Extremitas

a. brachialis, a. radialis et a. ulnaris -

ASSESSMENT
Problem Planning Treatment

1. Gangren regio manus - Diet DM - Diet DM 1700

sinistra - Albumin kkal/day
2. Diabetes melitus tipe 2 - GDS - Ceftriaxone
Non Obese 2gr/24 jam/IV
3. Hipoalbuminemia - Ciprofloxacin
4. Ski soft tissue infection 0,2 gr/12 jam
- Metronidazole
0,9 gr/8 jam
- Novorapid 8-8-8
- Levemir 0-0-10