MORNING REPORT

April 7th, 2021

EMERGENCY ROOM
WAHIDIN SUDIROHUSODO
GENERAL HOSPITAL
MAKASSAR
MD/BN/ZQ
 IDENTITY
Name : Sarmawati

Age : 43 years old / Female

Admission : April 7th , 2021 at 20.15

Registration : 610372

Status : JKN
Phone
: 082293728428
number
 AUTO ANAMNESIS
(at 20.15)

Chief Complain : Wound of the Right Foot

 Suffered since 6 months before admitted to Wahidin General Hospital.
Patient also complained pain the wound and pus produced. There is
history of debridement at Bone Hospital on November 2020. Patient admit
to Wahidin on January 13th 2020 with chief complain hematochezia.
 There is history of wound at the same place on 2014 because of mosquito’s
bite and at that time was performed debridement on Wahidin Hospital
 After that, the wound is healed but not completed and patient still can
walk from 2014 until last 4 months.
 There was no history of hypertension
 There was no history of diabetes mellitus
 There is no history of trauma at the foot
 GENERAL STATUS
(at 20.15)

 Conscious / Well-nourished
 Vital Signs:

Blood pressure : 100/70 mmHg

Pulse rate : 80 x/min
Respiratory rate : 18 x/min
Temperature : 36,5 0C
NRS : 2/10
CLINICAL FINDING
(20.20)
CLINICAL FINDING
(20.20)
 LOCAL STATUS
(at 20.20)
Right Foot Region
Look : Deformity (-), Swelling (-), hematome (-) , multiple ulcerative
wound (+) at dorsal foot, first wound sized 9x3 cm, pus (+),
muscle and tendon based, second wound sized 3x2 cm, pus (+),
muscle based, Third wound sized 5x3 cm on lateral malleolus, pus
(+), muscle based
Feel : Tenderness (-)
Move : Active and passive movement of ankle joint cannot be evaluated
due to pain
Active and passive movement of metatarsophalangeal,
interphalangeal joint big toe cannot be evaluated due to pain
Active and passive movement of metatarsophalangeal, proximal
interphalangeal, distal interphalangeal joint digiti II,III,IV,V
cannot be evaluated due to pain
NVD : Sensibility is good .Dorsalis pedis artery and posterior tibial artery
are palpable. Capillary refill time is less than 2 seconds.
RADIOLOGY FINDING
(21.20)
RADIOLOGY FINDING
(21.20)
RADIOLOGY FINDING
(21.20)
 LABORATORY FINDING
(at 21.30)

 WBC : 13,8/uL  SGOT : 8 x103/uL

 HGB : 9,7 gr/dL  SGPT : 7 x 103 uL
 HCT : 28 %  LED : 102/159
 PLT : 663 x103/uL
 HbsAg : Non reactive
 CT : 7.00”
 BT : 4.00”
 RBS : mg/dL
 DIAGNOSIS
 Chronic ulcer right foot suspect infection process
 MANAGEMENT
 IVFD
 Analgesic
 Report to Orthopaedic senior, advice :
 Report to Orthopaedic consultant
CLINICAL FINDING
(20.20)
RADIOLOGY FINDING
(21.20)
 RADIOLOGY FINDING
(taken at Wahidin Sudirohusodo Hospital at
19/1/2021)
 RADIOLOGY FINDING
(taken at Wahidin Sudirohusodo Hospital at
19/1/2021)