Duty Report

August 28th , 2015

elmi, 48 y.o , FW 03
Cc:

Red patch at both of leg since 10 days ago

Present

Illness History

Black patch at both of leg since 10 days ago, previously

patient inserted her leg to warm water 2 times, and then
comes out blister, ruptured and then become like now.
Pain (+)
Felt heavy at right arm and shoulder since 1 year ago,
intermittenly
Fever (-) cough (-)
Nausea and vomite (-)
Patient had been known with type 2 DM since 10 days ago,
had been known since hospitalized in RSUD pariaman

Patient

referred from internist

with diagnosis Henoch Schonlein
Purpura and type 2 DM
History of DM since 10 days ago,
highest BP >300mg/dl, got
novorapid 3x8 IU
History of HT since 5 years ago,
SBP>180mmHg, got amlodipin

Physical Examination
Consciousness

level: CMC

BP

: 140/80

HR

: 88x/min

RR

: 20x/minute

T:

36,8C

Eye

Conjunctiva are anemic -/ Sclera are icteric -/Neck

JVP 5-2 cmH20

Lung:

Inspection: symetric
Palpation: fremitus symmetric
Percussion: sonor
Auscultation: vesicular, rales
-/-,wheezing -/-

Cor:
Inspection: ictus is seen.
Palpation: ictus is palpated at 1 finger
medial LMCS ICS V
Percussion:
Left border: 1 finger medial LMCS ICS V
Right border: linea sternalis dextra
Upper border: RIC II
Auscultation: pure rhythm, murmur (-)

Abdomen:

Inspection: enlargement (-)

Palpation: liver and spleen unpalpable
Percussion: tympani
Auscultation: bowel sound (+) normal

Flank : knocking
Extremities:

pain at CVA -/-

Physiologic Reflex +/+

Pathologic Reflex -/ Edema +/+

Laboratory
Hb

12,2

WBC
Ht
Thrombocyte
PT/APTT
GDS
Ur/cr
Keton urine
pH
pCO2
pO2
HCO3BE ecf
SO2

17.100
39%
378.000
10/34,6
282
30/0,7
+

Working Diagnose
Type

2 DM uncontrolled normoweight
with pedis ulcer and ketosis
Henoch schonlein purpura

Therapy

Rest/DD 1700
IVFD NaCl 0,9% 8 hours/kolf

Inj cefoperazone 1x2 gr

Na diclofenac 3x1 tab
Drip critical ill
50 unit insulin in 50 cc NaCl 0,9% (syringe pump) start
with 1,5cc/hour
Check RBG/hour, if

<80 : o,5 cc/hour+D40% 1 flc

80-110 : 1 cc/hour
110-160 : 1,5 cc/hour
160-220 : 2cc/hour
>220 : 2,5 cc/hour + bolus 8 unit insulin