Download - 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
-
7/29/2019 Cc Dr TY English Ulcus
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.
-
7/29/2019 Cc Dr TY English Ulcus
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
-
7/29/2019 Cc Dr TY English Ulcus
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
-
7/29/2019 Cc Dr TY English Ulcus
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 -/-
-
7/29/2019 Cc Dr TY English Ulcus
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
-
7/29/2019 Cc Dr TY English Ulcus
7/12
1. HR: 130 x/mnt
2. Ritme: sinus
3. Zona transisi: V1-v2
4. Aksis: normo axis
5. Morfologi gelombang: gel
P
-
7/29/2019 Cc Dr TY English Ulcus
8/12
Problem list
Ulcus DM pedis sinistra wagner IV
DM type 2 non obese
Moderate Hyponatremia
Anemia normositik normokromik
-
7/29/2019 Cc Dr TY English Ulcus
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
-
7/29/2019 Cc Dr TY English Ulcus
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
-
7/29/2019 Cc Dr TY English Ulcus
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
-
7/29/2019 Cc Dr TY English Ulcus
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