MORNING

REPORT
7 October 2023
IDENTITY

● Name : Mr.S
● Age : 72 yo
● Gender : Male
● Address : Batu
● Arrival date : 7 October 2023
● Patient type : non Trauma
 ANAMNESIS

Main complaint: Left leg pain

Curret medical status : left leg pain has been aching since a week
ago, the pain feels throbbing, with VAS 4, the pain increases when
moving. Nauseous vomit
History : Uncontrolled Diabetes, Hypertension
Medication : Diabetes medication (patient doesn't remember the
name)
Family History : Diabetes -, hypertension
Social History : Construction worker
 GENERALIST STATUS

BP: 154/74 mmHg

N: 120 x/min
RR: 25 x/minute
SpO2: 96% on RA
Tax: 37.7°C
 Physical Examination
Head: THORAX :
Konjungitva anemis (-/-), sklera ikterik Cor:
(-), PBI 3mm|3mm (isochor), direct light Inspection: ictus cordis not seen
reflex +/+, indirect light reflex +/+, Palpation: ictus cordis palpable in ICS 5
ptosis (-/-) MCL S
Auscultation: S1|S2 single, murmur (-),
Neck : gallop (-)
Inspektion: trachea deviation(-) Pulmo:
Palpation: lymph node enlargement(-) Inspection: chest shape normal,
Auscultation : Bruits (-) retraction (-)
Palpation: chest D/S simetric wall chest
movement
Perkusi: sonor
Auscultation:
Ves/ves, rh (-), wh (-)
 Physical Examination

Abdomen
Inspection:
Flat, inflammation (-) scar (-) eritema (-) defans
muscular (-)
Auscultation : BS(+) 16 x/minute Local Status :
Percution: timpani Status Localis Cruris & Pedis Sinistra
Palpation:
Soefl (+) Pain (+) superficial and deep. Look: edema and hyperemia at the level of 1/3
--- of the cruris to the pedis, visible pus on the
--- dorsal pedis, necrotic tissue on the V pedis
--- digits
Feel: tenderness (+), heat +, dolor +
Extremity: Move : free ROM
Red Dry Warm Acral, CRT< 2, pitting oedem
--
--
Clinical
Pictures
 PROBLEM LIST & PLANNING
Problem list Initial Diagnosis Planning Planning Therapy
Diagnosis

• Male, 72 years old has left leg pain • Gangrene digiti V • Complete • IFVD NS 20 tpm
• History of DM pedis S blood count • Inj. OMZ 40 mg
• Selulitis • X ray AP & • Inj. Metamizole 1g
• Diabetes melitus Oblique • Inj. Metronidazole
• Status Localis Cruris & Pedis Sinistra Pedis S 500 mg
• Look: edema and hyperemia at the level of 1/3 of • Fasting
the cruris to the pedis, visible pus on the dorsal
pedis, necrotic tissue on the V pedis digits
• Feel: heat +, dolor +
• Move : free ROM
Laboratorium 7
October 2023
Laboratorium
7 October
2023
X Ray
Pedis
sinistra
AP
Obliqu
e
 PROBLEM LIST & PLANNING
Problem list Definitive Diagnosis Planning Planning Therapy
Diagnosis

• Male, 72 years old has left leg pain • Gangrene digiti V • - • IVFD NS 20 tpm
• History of DM pedis S • Inj. Ceftriaxone 2x1
• Selulitis cruris et pedis g
S • VIP Albumin 2x1 tab
Status Localis Cruris & Pedis Sinistra • Diabetes melitu • Insuline apidra 10 IU
• Look: edema and hyperemia at the level of 1/3 of hyperglicemia • Ketorolac 30 mg &
the cruris to the pedis, visible pus on the dorsal • Hypoalbuminemia Ranitidine 50 mg pre
pedis, necrotic tissue on the V pedis digits • Hyponatremia op
• Feel: heat +, dolor + • Debridement pedis S
• Move : free ROM • Amputatum digiti V
pedis S
• X Ray Pedis AP&Oblique Pedis S: tampak edema
disertai area luscent pada sisi lateral pedis
sinistra, tulang masih intak

• Albumin : 2.6 L
• Na 130 L
THANK YOU