cc dr ty english ulcus

7/29/2019 Cc Dr TY English Ulcus

1/12

Nama : Mr.S

Usia : 46 yoPekerjaan : petaniMRS : 10.06.13

Bangsal : melati I bed 6i


2/12

Allo dan autoanamnesa

Chief complain : Foot injury does not heal

2 weeks before admission the patient complained of left foot injurydoesnt healed. wound was in the left big toe , was originally a smallwound in the form of wood impaled former point around the garden.wound gradually widened, swollen, pus and smelling. wound initiallywas limited to only the left big toe, but over time grew wider calf left.

Because of the complaint, the patient became difficult to walk.Patien also complained of fever, sumer2, is felt throughout the body,continuous, denied cough, colds denied. since 1 month beforeentering the hospital the patient complained of limp bodies. feltweakness throughout the body, fatigue increases with activity anddecreases with rest. patients also complained of fatigue and tired.

Bleeding gums denied. nosebleeds denied. cold sweat and blurryvision also admitted denied.pasien easy thirst, hunger and irritabilityurinate 10-11 times in 1 day, urinate clear yellow, @ 1/4-1/2 cupstarfruit, pain during bowel movements small denied. urination sandydenied. 1 bowel movement a day brown, mushy konsistency mucus /blood undeniable.


3/12

Past history disease

History of diabetes ( +) 1 month

History high blood (-)

History of cardiovascular disease denied History of kidney disease denied

History of asthma denied


4/12

Vital sign

KU: CM, enough nutrition

BP: 110/70 mmHg

Pulse rate: 120x/mnt

Respirasi : 22x/mnt

Tempt : 38

Height : 165 cm Weight : 60 kg

BMI : 22,04


5/12

JVP R+2cm, KGB tak

membesar, stiff neck (-)

Mata :Pale conjungtiva +/+Sklera ikterik -/-

Anterior lungI. Development of the right chest

with the left chest,P fremitus touch with Left RightP. Sonor / resonantA. SD = Normal vesicular,

ST RBK (- / -)

oedem inferior -/+Ulcus -/+ crepitation +

Posterior lungI. Development of the right chest

with the left chest,P fremitus touch with Left RightP. Sonor / sonorA. Basic sound = Normal vesicular,

ST RBK (- / -)

Cor:I. IC invisibleP. IC palpable in SIC V 1 cm lat LMCSP. cardiac border not widenA. BJ I-II pure. noisy (-), gallop (-)

AbdomenI. DP // DDA. Peristaltik (+) NP. Timpani, PA (-), Undulasi (-)P. Hepar Lien nonpalpable

Spoon nail -/-


6/12

Pemeriksa

an

nilai

Hb 8.0Ht 24

AL 14.9

AT 201

AE 3.56GDS 336

Cr 0.8

Ur 48

Na 128K 4.2

HBsAg nonreaktif


7/12

1. HR: 130 x/mnt

2. Ritme: sinus

3. Zona transisi: V1-v2

4. Aksis: normo axis

5. Morfologi gelombang: gel

P


8/12

Problem list

Ulcus DM pedis sinistra wagner IV

DM type 2 non obese

Moderate Hyponatremia

Anemia normositik normokromik


9/12

Problem I. Ulcus DM pedis sinistra wagner V dengan sepsis

Ass : The foot injury that does not heal, the wound was initially small, then more and more stretched,and smell with crepitation +

Rontgen : gas gangren regio pedis sinistra

IPDX : kultur pus

IPTX : Un totally BedrestO2 2 lpm nasal canul

Inf Nacl 0.9 % 20tpm

Inj Ceftriaxon 2 g/24h

Inj metronidazole inj 500mg/8h

Inj dexametason 1 amp/ 8 hAspilet 80mg 1x1

Wound treatment

IPMx: M0nitoring vital signipMx: educated the family about the desease and the complication


10/12

Problem II. DM type 2 non Obese

Ass History of DM (+)

gds 336 ipDx : Gdp, 2pp, HbA 1c, Profil lipid,

monofilamen

ipTx : Inf Nacl 0,9 % 20 dmp

Diet DM 1700 ccalInf insulin 6-6-6 iu sc

ipMx : Monitoring vital sign, gds 05

IPEX : Educated the family about the desease and

complication


11/12

Problem 3

moderate HyponatremiaAss : Na 128Dd/ excretion of excess

intake lessIPDX :

IPTX : Inf Nacl 0.9 % 20 tpm

IPMX : elektrolit post corectionIPEX : educated the family about the desease


12/12

Problem 4

Anemia normositik normokromikAss : hb 8.0

Dd/ on cronic deseaseakut bleeding

IPDX : DR2, SI, TIBC, Ferritin, Reticulosit

IPTX : Transf prc 480 ccIPMX : hb post post corection

IPEX : educated the family about the desease

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