1612

Diapositiva 1

By :Rizki Dunniroh Kaukaba S.Ked 209.121.0014

Supervisor: dr.Rofika Hanifa Sp.PDCase ReportDiabetic FootPatient IdentityName: Mr. M (43 yo)Sex: maleReligion: islamAddress: BlitarDate of inspection: 22 feb2014

Anamnesis Chief complaint: left foot painPatient has suffering from pain since last 5 days of continuous pain, pain increase if made to walk And also there is a wound that does not heal in heels since 2 months ago started small wounds, more and more widespread, foul-smelling with pus.

Cont....patients also complain of chills and fatigue since 3 days ago, nausea (+), vomiting (-). No appetite (+)Patients also complain complain 2 much this year urination, frequent thirst, often feel hungryHistory of diseases: DM(+)

Cont....Family history of disease: HT (-), DM (+), heart diseases (-)life style: smoking (-), alcohol consumption (-), coffee consumption (-), physical exercise: not regularly

Physical ExaminationGeneral appearance: looked severely ill, GCS: 456Vital signs: BP: 100/60 mmHg (in emergency unit),; PR: 83 bpm; RR: 19 x/mnt; Tax: 36,30CHead: an (-/-) ic (-/-), palpebral edema (-/-), cyanosis (-)Neck: trachea in the middle,JVP R+2, enlargmnet of thyroid (-)Thorax:Heart: Ictus Invisible, unpalpable, s1 s2 single, murmur (-), RHM = PSL dextra, LHM at ICS VI 2 cm MCL sinistraCont..Lung: simetris, vesikuler (+), rh (-), wh (-) at throughout the lung fieldsAbdomen: soefl, BS (+) N, tenderness (+) at epigastric and the left hipokondrium, hepatomegali (-), spleenomegali (-)Extremity: edema (-)

STATUS LOCALIST

Left Pedis regionLook: ulcers (+), tissue loss (+), necrotic skin(+) at the dorsum pedis distal , pus (+) bleeding (+) Feel: painlessMove: ROM (+) is limited due to painLaboratory Finding (22february 2014)Totalbilirubin : 18,58 (n:1,00 mg/dL)Direct bilirubin : 9,76(n: 0,25 mg/dL)Alkali phosfatase: 234(n: dewasa : 100-290 u/L)SGOT: 27(n L