MORNING

REPORT
Identity
• Name : Mr. A
• Age : 41 y.o
• Sex : Male
• Address : Mandonga
• Admission : Desember 12th 2019 (11.13 AM)
• DPJP : dr. Saktrio D. Subarno, Sp.BP-RE
 • Chief Complainment :
Boils on the left buttock
• Anamnesis :

History Boils in the left buttocks since 2 weeks ago. Boils broke 1 week ago.
More widespread and deep, accompanied by blood and no fever, no
taking nausea and vomiting. Pooping and Urinating both. DM history has not
been controlled since 2 months ago. History of stroke 2 months ago.
There is no history of the same complaint in the family
Phisical Examination

KU : Compos Mentis, moderate sick. obsity

Blood Pressure : 140/100 mmHg

Heart Rate : 92 bpm

Respiratory Rate : 22 breath/min

Temperature : 35,4º C
Localized • Localized state :
Regio Gluteus Sinistra :
Status
I : visible ulcer with a size of ± 10 cm, deep, there
is blood, there is pus. There is a hematoma,
There is edema.
P : There is no tenderness
 Plan of • Laboratory Test:
 Routine blood test
diagnose  Blood chemistry test
 Laboratory
Findings
Result Unit Normal Result Unit Normal
Hematology Leukocyte
HB 14.8 g/dl 12.0 – 16.0 NEUT 6.66 10^3/uL 1.50 – 7.00

WBC 9.19 10^3/uL 4.0 - 10.0 LYMPH 1.40 10^3/uL 1.00 – 3.70

PLT 232 10^3/uL 150-400 MONO 8.8 10^3/uL 0.00 – 0.70

RBC 5.00 10^6/uL 4.00- 6.00 EO 0.26 10^3/uL 0.00 – 0.40

MCV 84.2 fL 80.0 – 97.0 BASO 0.03 10^3/uL 0.00 – 0.10

MCH 29.6 Pg 26.5 – 33.0

MCHC 35.2 g/dl 31.9 – 37.0
PCT 0.26+ % 0.15 – 0.55
Diagnose Ulcus diabetic region gluteus
sinistra
Management
IVFD
Antibiotik
PPI
Analgetik

Consult to Plastic Surgeon