cc stroke dr ty

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LAPORAN PAGIJULY, 21ST 2014



PATIENT IDENTITY1

Name : Mr. A

Age : 46 yo

Address : solo

Admmted : 21st july, 2014

MR : 01262977

Ward : Melati 1/ 6E



ANAMNESIS2KU : badan lemas (alloanamnesis)

- The patient complained of

weakness in his arms and right leg

since 2 days ago. Weakness

suddenly, constantly. Patients can

raise right hands and feet but was

unable to hold it. Weakness does

not improve with feeding.

Complaints not accompanied by

dizziness, no history of trauma, notaccompanied by convulsions, fever.

2 days

ago

The patient came with complaints

wound on the right leg.Originally

feet reddish then start blackened

on the ring finger and middlefinger.Complaint not improved by

administering an ointment, and

patients to the doctor andamputated on a finger blackening.

1

month

ago



ANAMNESIS2

• Urinate 6-8 times, @1 glasses,

feels pain (-), anyang-anyangan

(-), sand (-). Dfecation once aday, liquid (-), blood (-)



Past History Disease2

Time Place of admission History of Therapy ortreatment

2004 puskesmas DM tipe 2

glibenclamid

Family History Disease 3Diabetes mellitus : denied

Hypertension : denied

Cardiac : denied



Pemeriksaan Fisik5

Tampak menahan nyeri

GCS E4V5M6 , Compos Mentis

Keadaan Umum :

T : 130/80 mmHg N : 88x/menit

R : 18x/menit

S : 36, oC (aksiler)

BB : 50 kg TB : 150cm

BMI : 23 kg/m2

VAS : 2

GDS : 171

Tanda Vital :



Pemeriksaan Fisik5 Mata :

conjunctiva pucat -/-

Sklera ikterik -/-

Papil lidah atrofi (-)

Tifoid Tongue (-)

JVP R+2 cm,

KGB tak membesar

Paru Depan :

I. Pengembangan dada

kanan= kiriP. Fremitus raba kanan=kiri,

P: Sonor=sonor

A SDV (N/N), RBH (-/-)

Oedem superior -/-

Oedem inferior -/- Akral dingin -/-

Motorik 4 / 5

4/ 5

Cor:

I. IC tak tampak

P. IC tak terabaP. Batas jantung tidak melebar

A. BJ I-II murni, intensitas

normal, bising (-), gallop

(-)

AbdomenI : DP //DD, venektasi (-)

A :Peristaltik (+) N

P :tympani, area troube tympani

P. supel, nyeri tekan (-) regio epi

gastrium,

Paru belakang :

I. Pengembangan dadakanan= kiri

P. Fremitus raba kanan=kiri,

P: Sonor=sonor

A SDV (N/N), RBH (-/-)

R. Pedis dx: looked ulcer resonated pedis

uk 6x3x1 cm, , pussy ( + ), blood ( + ),

digiti, ii are blackish in color, krepitasi ( + ),amputated digiti ii and iv. ABI dx 0,



Tanggal 21/7/2014 satuan Nilai rujukan

Hemoglobin 11,6 g/dl 13,5 - 17,5

Eritrosit 4.00 106/ul 4,50 - 5,90

Hematokrit 35 % 33 - 45

Lekosit 14.7 103/ul 4,5 - 11

Trombosit 450 103/ul 150 - 450

Ureum 36 mg/dl 10 - 50

Creatinin 0,9 mg/dl 0,6 - 1,1

GDS 216 mg/dL 60 - 140

SGOT 16 u/l 0 - 35SGPT 29 u/l 0 - 45

Natrium 135 Mmol/L 136 - 145

Kalium 4,5 Mmol/L 3,3 - 5,1

Clorida 104 Mmol/L 98 - 106

6 Pemeriksaan Laboratorium



6 Pemeriksaan Laboratorium

Urin Stik Nilai

Glu ±

Bil -

Keton -

BJ 1.020

Blood -

pH 6.0

Prot -

Uro -

Nitrit -Leu ±



Foto pedis AP-lat : menyokong selulitis gangrenosa disertai gambaran charcot joint pedis dextra

Fotothorax PA : cor dan pulmo tak ada kelainan



Infark di ganglia

basalis kiri



7 DAFTAR DIAGNOSIS

Geriatri dengan:

1. Infark ganglion basalis sinistra

2. DM tipe II NO

3. Ulkus DM pedis dextra wagner IV and charcot joint pedis dextra

4. Mild hyponatremia



7 IPDX

GDP/2JPP/A1C/Profil lipid

Urin rutin

USG doppler



7 IPTX

1. Bed rest tidak total

2. Diet DM 1700 kkal RP 40g/hr RG > 5g/hr

3. O2 2 lpm

4. Inf NaCl 20 tpm

5. Inj ceftriaxone 2 g/24 hr

6. Inf Metronidazol 500 mg/8 hr

7. Inj novorapid 4-4-4 iu sc ac8. Aspilet 1x80 mg

9. Amlodipin 1x5mg

10. Gabapentin 1x30 mg

11. Inj Citicolin 250mg/12jam

12. Inj vit B12 1amp/24 jam



7 IPMX

1. Kuvs

IPEX

Edukasi penyakit, komplikasi serta tatalaksananya



TERIMA KASIH

cc stroke dr ty

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