responsi interna qori

7/23/2019 Responsi Interna Qori

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GANGREN CRURIS DEXTRA ET SINISTRADAN HIPOGLIKEMIA E.C LOW INTAKEDENGAN DIABETES MELLITUS TIPE 2 DAN

KATARAK

Responsi Intern

O!e"#

$ori A%&i'"

H(A))*)+,

Pe-i-in/#

%r. I Ge%e P!/0n%i1 Sp.PD. INASIM



IDENTITAS

N- # Tn. M

Usi # 3) t"0n

4enis 5e!-in # L5i6!5i

A!-t # Mon7o5 Brt1 Se!prn/1 Mtr-

S050 # Ss5Bn/s # In%onesi

A/- # Is!-

Stt0s # Meni5"

Pen%i%i5n ter5"ir # SD

Pe5er7n # Non7o

No. RM # 89)3*(

MRS # () 4n0ri 2)(+

Tn//! Pe-eri5sn # (2 4n0ri 2)(+



S07e:ti;e

Keluhan Utama # !05 %i 55i 5nn %n 5iri

Riwayat Penyakit Sekarang:

Psien %tn/ %!- 5e%n s%r %n %intr o!e"5e!0r/n' 5e UGD RSUP NTB %en/n 5e!0"n !05 %i 55i

5nn %n 5iri se75 9 0!n 'n/ !!0. L05 &!n' -0n:0!%i i0 7ri 55i 5nn %en/n %i-eter se5itr 2 :-er&rn :o5e!t 5e-er"n tetpi ti%5 %i"ir05n o!e"psien. L05 %irs5n se-5in !- se-5in -e!0s %n-en/e!0r5n nn". I0 7ri 55i 5nn %i50i ter!epssen%iri se5itr 8 7- SMRS. Se!in it01 -0n:0! !05 'n/s- %i etis 5nn se5itr 2 0!n 'n/ !!0 %n etis 5irise5itr (18 0!n 'n/ !!0. Psien -si" %pt -ers5nn'eri p% %er" 'n/ !05. Ke!0"n %e-- 'n/-en'erti !05 'n/ se-5in -e!0s <6=.



S07e:ti;e

Psien -en/50 te!" %i%i/nosis 5en:in/ -nis %ip0s5es-s se75 8 t"0n 'n/ !!01 tetpi ti%5 pern"5ontro! t0 p0n -in0- ot6otn %ri p0s5es-s.Psien -ers n>s0 -5n is <-5n 9 5!i se"ri

st0 pirin/ pen0"=1 serin/ -ers "0s <-in0- se5itr 2oto! ir -iner! esr se"ri=1 serin/ 0n/ ir 5e:i!<se5itr (8 5!i?"ri %en/n ;o!0-e se5itr @ /e!s%!- se5!i 5en:in/= ter0t- p% -!- "ri1 %nert %nn' -en0r0n.

Psien 70/ -en/e!0" %n !e-s se75 ( -in//0see!0- -s05 r0-" s5it. Ke!0"n !e-s %i5t5nter0s6-ener0s %n ti%5 -en/"i!n/ &!0p0n psiente!" eristir"t. N>s0 -5n %irs5n er50rn/se75 ( -in//0 SMRS. Psien -en/50 "n' -5n

00r 9 5!i se"ri 269 sen%o5 -5n %n -in0- se5itr2?9 oto! ir -iner! esr per "ri. N'eri 0!0 "ti



S07e:ti;e

Psien 70/ -en/e!0"5n -t 0r- se75 8t"0n 'n/ !!0 'n/ %irs5n sepertipn%n/nn' er50t. Ri&'t in>e5si -tsee!0-n' <6=. Ri&'t tr0- -t <6=.

Psien -en/t5n 0n/ ir esr nor-!seperti is er&rn 50nin/ 5e:o5!tn1 %en/n>re50ensi ( 5!i per "ri. B0n/ ir 5e:i! er&rn50nin/ 7erni" %en/n >re50ensi se5itr (8 per

"ri %en/n ;o!0-en' 50rn/ !ei" @ /e!s tip5!i 5en:in/ 'n/ %irs5n !ei" serin/ p%-!- "ri1 rs n'eri <6= %n %r" <6=.



S07e:ti;e

Riwayat Penyakit Dahulu Ri&'t HT <6= Ri&'t 5en:in/ -nis <= se75 8 t"0n 'n/ !!0

Ri&'t s- <6=

Ri&'t s5it 7nt0n/ <6= Ri&'t s5it -/ <6=

Riwayat Penyakit Keluarga Ri&'t HT <=

Ri&'t 5en:in/ -nis <= Ri&'t s5it s- <6= Ri&'t s5it 7nt0n/ <6= Ri&'t s5it -/ <6=



S07e:ti;e

Riwayat Pengobatan

Psien ti%5 pern" -e-in0- OHO t0 p0n -en//0n5n in7e5siins0!in see!0-n'. Psien "n' -en/5ons0-si ot6otn "er!<Genton/ Ms= se75 8 t"0n 'n/ !!0 %n ti%5 r0tin. Ke!0"nn'5 5en:in/ %n n'5 -in0- %irs5n ti%5 er50rn/.

Riwayat Pribadi dan Sosial

Psien s0%" ti%5 e5er7 !/i se75 8 t"0n 'n/ !!0 5ren5e!0"n -t 5nn 0r- 'n/ %irs5n ti%5 -e-i5 %en/n-en//0n5n 5: -t. Psien -e-i!i5i ri&'t 5eisn-ero5o5 <= ( 0n/50s per"ri se75 se5itr +) t"0n 'n/ !!01tetpi s0%" er"enti se75 8 t"0n 'n/ !!0. Ri&'t-en/5ons0-si !5o"o! <6=. Ri&'t 7-067-0n <= %n ri&'t-in0- 5opi <= 2 9 /e!s per "ri.

Riwayat Alergi

Ri&'t !er/i -5nn <6=. Ri&'t !er/i ot6otn <6=



O7e:ti;e



Status Generalis

Ke%n 0-0- # se%n/

Kes%rn # :o-pos -entis

GCS # E+8M3

Stt0s /iFi <(2?)(?2)(+=

BB# +) 5/ TB# (3) :-. IMT (81328 <0n%er&ei/"t=

Vital Sign

Te5nn %r"# ())?3) --H/ N%i # ,2 ?-enit re/0!r1 50t n/5t

re50ensi n>s # 2) ?-enit1 tipe tor5o%o-in!

S0"0 # 931*oC



Status Lokalis

Keala E5spresi &7" # nor-!

Bent05 %n 050rn #nor-!

R-0t # nor-!

E%e- <6=

M!r rs" <6=

Prese N II <6=

Hiperpi/-entsi <6=

N'eri te5n 5ep! <6=

Mss <6=

!ata

Si-etris

A!is # nor-!

Eopt"!-0s <6?6=

Ptosis <6?6=

N'st/-0s <6?6=

Stris-0s <6?6=

E%e- p!per <6?6=

Kon70n/ti;# ne-is <6?6=1 "ipere-i <6?6=

S:!er# i:ter0s <6?6=1 "'pere-i <6?6=1

pter'/i0- <6?6=

P0pi! # iso5or1 0!t1 -iosis <?=1 -i%risis

<6?6= Korne # nor-!

Lens # 5tr5 <?6=

Per/er5n o! -t 5e se/! r" #

nor-!

N'eri <6=



Status Lokalis

Telinga

Bent05 # nor-! si-etrisntr 5iri %n 5nn

L0n/ te!in/ # nor-!1se:ret <6?6=

N'eri te5n <6?6=

Per%n/n p% te!in/ <6=

Pen%en/rn # nor-!

"idung

Si-etris1 %e;isi sept0- <6?6=

Nps :0pin/ "i%0n/ <6?6=

Per%r"n <6?6=1 se:ret <6?6=

Pen:i0-n nor-!

!ulut

Si-etris

Biir # sinosis <6=1 sto-titis n/0!ris <6=1p0rse% !ips ret"in/ <6=.

G0si # "ipere-i <6=1 per%r"n <6=

Li%"# /!ositis <6=1 tropi ppi! !i%" <6=1 !i%"erse!p0t <6=1 5e-er"n %i pin//ir <6=1tre-or <6=1 !i%" 5otor <6=

Gi/i # 5ries <6=

M05os # nor-!

#eher

Si-etris

K50 50%05 <6=

S:ro>0!o%er- <6=

Pe-esrn KGB <6=

4P # 8 2 <ti%5 -enin/5t=

Pe-esrn otot sterno:!ei%o-stoi%e0s <6=

Otot nt0 n>s SCM ti%5 5ti>

Pe-esrn 5e!en7r tiroi% <6=



Status Lokalis

Thora$

Inspeksi:

Bent05 050rn# si-etris1 barrel chest <6=

Per/er5n %in%in/ %%# si-etris

Per-05n %%# pp0! <6=1 pete:"ie <6=1 p0rp0r <6=1e5i-osis <6=1 spi%er ne;i <6=1 ;en 5o!ter! <6=1 -ss <6=

Pen//0nn otot nt0 n>s# SCM ti%5 5ti>1 t5 t-p5

"ipertro SCM1 otot nt0 %o-en ti%5 5ti>

I/ %n se! i/# si-etris

oss s0pr:!;i:0!ris1 >oss in>r:!;i:0!ris# si-etris oss 70/0!ris# %e;isi <6=

Tipe pernpsn# tor5o6%o-in!

I:t0s :or%is# t-p5 %i ICS !ine -i%5!;i50! sinistr



Status Lokalis

P!psi# Tr5e# ti%5 % %e;isi Ger5n %in%in/ %%# si-etris I5t0s 5or%is ter %i ICS !ine -i%5!;i50! sinistr. N'eri te5n <6=1 en7o!n <6=1 e%e- <6=1 5repitsi <6=1 s0"0 nor-!.

re-it0s ;o:!# N?N

Per50si# Sonor p% 5e%0 !pn/ pr0 Bts pr06"epr#

Inspirsi# ICS I1 E5spirsi# ICS 1 E5s50rsi# ( ICS

Bts pr067nt0n/# Knn # ICS II prstern! !ine %etr Kiri # ICS -i%:!;i:0! !ine sinistr

A0s50!tsi#

Cor# S( S2 t0n//! re/0!r1 -0r-0r <6=1 /!!op <6=

P0!-o# esi50!er <?=1 r"on5i <6?6=1 &"eeFin/ <6?6=



Status Lokalis

Abdomen

Inspeksi:

Distensi <6=

U-i!i50s -s05 -ert

Per-05n 50!it# tn%6tn% inJ-si <6=1 sinosis <6=1;ene5tsi <6=1 i5teri5 <6=1 -ss <6=1 ;en 5o!ter! <6=1:p0t -e%0s <6=1 pp0! <6=1 pete5ie <6=1 p0rp0r <6=1e5i-osis <6=1 spi%er ne;' <6=1 sites <6=

A0s50!tsi# Bisin/ 0s0s <= (3 5!i?-enit

Metallic sound <6=

Bisin/ ort <6=



Status Lokalis

Perkusi: Ti-pni #

Shifting dullness <6= N'eri 5eto5 CA <6?6=

Palpasi: N'eri te5n #

6 6 6 6 6 6

6 6 6

Tes 0n%0!si <6=

Hepr # ti%5 ter

Lien # ti%5 ter Ren # ti%5 ter



Status Lokalis

Ekstremitas

A5r! "n/t #

E%e- # 6 6

6

I5teri5 # 6 6 6 6

Sinosis # 6 6

6 6

Clubbing nger # 6 6

6 6

%enitourinaria : Ti%5%ie;!0si



Ter%pt se0" !05 %i :r0ris %etr er050rn 9) :- :-%en/n 50!it 'n/ te!" -en/e!0ps1 erts te/s %n ti%5

ert0rn1 tepi !05 er&rn "it-. Ter!i"t otot se/i %sr !05

%n %n' p0s %i tepi !05. <U!50s %ieti: 5!si5si W/ner 9=.

Des5ripsi !05 %i :r0ris %etr



Ter%pt %0 0" !05 %i %ors0- pe%is %etr er050rn ( :- ( :- %en/n 50!it 'n/te!" -en/e!0ps1 erts te/s %n erent05 !in/5rn1 50!it tepi !05 -en/"it-.

Ter!i"t %n' p0s st !05 %ipen:et. <U!50s %ieti: 5!si5si W/ner 2=.

Ter%pt se0" !05 %i persen%in te-pt ter!epsn' %i/iti I pe%is %etr er050rn 9

:- 8 :- %en/n 50!it 'n/ te!" -en/e!0ps1 erts te/s %n erent05 ti%5ert0tn1 50!it tepi !05 -en/"it-. <U!50s %ieti: 5!si5si W/ner +=.

Des5ripsi !05 %i pe%is %etr

C!i 5 i t %% i t



Ter%pt se0" !05 %i :r0ris sinistr er050rn () :- 8 :-%en/n 50!it 'n/ te!" -en/e!0ps1 erts te/s %nerent05 o;!1 tepi !05 s- %en/n 50!it se5itrn'. Ter!i"t

otot se/i %sr !05 %n %n' p0s st !05 %ipen:et. <U!50s%ieti: 5!si5si W/ner 2=.

Des5ripsi !05 %i :r0ris sinistr

C!i:5 i:on to %% pi:t0re



Ter%pt se0" !05 %i %ors0- pe%is sinistr er050rn ( :- (:- %en/n 50!it 'n/ -si" 0t0" er&rn p0ti"1 erts te/s%n erent05 !in/5rn1 tepi !05 s- %en/n 50!it se5itrn'.

Ti%5 ter!i"t %n' p0s st !05 %ipen:et <U!50s %ieti:5!si5si W/ner (=.

Des5ripsi !05 %i pe%is sinistr



RESUME

Psien !5i6!5i1 3) t"0n1 %tn/ %en/n 5e!0"n !05 %i55i 5nn %n 5iri se75 9 0!n 'n/ !!0. L05 &!n'-0n:0! %i i0 7ri 55i 5nn %en/n %i-eter se5itr 2 :-er&rn :o5e!t 5e-er"n. L05 %irs5n se-5in !-se-5in -e!0s %n -en/e!0r5n nn". I0 7ri 55i 5nn

%i50i ter!eps sen%iri se5itr 8 7- SMRS. Se!in it01 -0n:0!!05 'n/ s- %i etis 5nn se5itr 2 0!n 'n/ !!0 %netis 5iri se5itr (18 0!n 'n/ !!0. Psien -si" %pt-ers5n n'eri p% %er" 'n/ !05.

Psien -en/50 te!" %i%i/nosis 5en:in/ -nis %i

p0s5es-s se75 8 t"0n 'n/ !!01 tetpi ti%5 pern"5ontro! t0 p0n -in0- ot6otn %ri p0s5es-s. Psien-ers n>s0 -5n is <-5n 9 5!i se"ri st0 pirin/pen0"=1 serin/ -ers "0s <-in0- se5itr 2 oto! ir-iner! esr se"ri=1 serin/ 0n/ ir 5e:i! <se5itr (8

5!i?"ri %en/n ;o!0-e se5itr @ /e!s %!- se5!i 5en:in/=



Psien 70/ -en/e!0" !e-s se75 ( -in//0 see!0- -s05r0-" s5it. Ke!0"n !e-s %i5t5n ter0s6-ener0s %n ti%5-en/"i!n/ &!0p0n psien te!" eristir"t. Ke!0"n ini %irs5n

%i se!0r0" t00". N>s0 -5n %irs5n er50rn/ se75 ( -in//0

SMRS. Psien -en/50 "n' -5n 00r 9 5!i se"ri 269 sen%o5

-5n %n -in0- se5itr 2?9 oto! ir -iner! esr per "ri.Psien 70/ -en/e!0"5n -t 0r- se75 8 t"0n 'n/ !!0

'n/ %irs5n seperti pn%n/nn' er50t. Ri&'t in>e5si-t see!0-n' <6=. Ri&'t tr0- -t <6=.

Psien -en/t5n 0n/ ir esr nor-! seperti is er&rn50nin/ 5e:o5!tn1 %en/n >re50ensi ( 5!i per "ri. B0n/ ir 5e:i!

er&rn 50nin/ 7erni" %en/n >re50ensi se5itr (8 per "ri %en/n;o!0-en' 50rn/ !ei" @ /e!s tip 5!i 5en:in/ 'n/ %irs5n

!ei" serin/ p% -!- "ri1 rs n'eri <6= %n %r" <6=.



Dri pe-eri5sn si5 %i%pt5n#

Te5nn %r"# ())?3) --H/

N%i # ,2 ?-enit re/0!r1 50t n/5t

re50ensi n>s # 2) ?-enit1 tipe tor5o%o-in!

S0"0 # 931*C Stt0s /iFi # BB# +) 5/ TB# (3) :-. IMT (81328

<0n%er&ei/"t=

E5stre-its#

E%e- # 6 6 6

L05 # 6 6

Pr-eter ()?)(?2)(+ ()?)(?2)(+ Ni!i nor-!



<post o!0s D+)=

Dr" !en/5p

HGB ()1+ ↓ L# (91) (*1) /?%L

RBC 91*8 ↓ L# +18 818 ()3?µL

HCT 9212 ↓ L# +)1) 8)1)

MC *913 *21) ,21) >L

MCH 21) 21) 9(1) p/

MCHC 9219 921) 91) /?%L

WBC (318 ↑ +1) ((1) ()9?µL

PLT 2 (8) +)) ()9?µL

Ki-i %r"

GDS 82 (2( (3) -/?%L

Ure0- 2)1+ () 8) -/?%L

Kretinin L# )1, (19 -/?%L

SGOT 3)1( ↑ +) -/?%L

SGPT 8,12 ↑ +( -/?%L

P e - e r i 5

s n

L . o r t o r i 0 -

Pr-ete (9?)(?2)( (3?)(?2)( (*?)(?2)( Ni!i nor-!



r + + +

GDP 99+ ↑ ) ()3 -/?%L

G2PP 9(9 ↑ (3) -/?%L

GDS 9)) ↑ 9+) ↑ (3) -/?%L

Ure0- () () 8) -/?%L

Kretinin )13 L# )1, (19 -/?%L

A!0-in 1,3 ↓ 1,6 ↓ 918 81) /

P e - e r i 5

s n

L . o r t o r i 0 -



• Gn/ren Cr0ris Detr et Sinistr

• Hipo/!i5e-i e.: Lo& Int5e• Dietes Me!!it0s Tipe 2

• Ktr5

Assess-ent



Diagnostik

Dr" Len/5p1 SGOT1 SGPT1 0re0-1 5retinin1 GDS

GDP1 GD2PP1 HDL1 LDL1 tri/!iseri%

Urin!isis

K0!t0r p0s 07i sensiti;its

!onitoring

Ke!0"n %n tn% ;it! "rin

GDS "rin

P!nnin/



TERAPI

!edikamentosa

In>0s D() 2) tp-

In7e5si D+) o!0s 2 Js"

In7e5si A-pi:i!!in (/r ( -p0!?*7-In>0s CiproJo:in 2)) -/ ( Js"?(2 7-

it-in B 5o-p!e5s 9%%(

R&t !05 setip "ri

Kons0! %r. Sp.M

P!nnin/



P!nnin/

Tanggal &'()&(*)&+ %DS: ')) mg(d#

Dieri5n ins0!in 5er7 :ept <No;orpi%= 3 U se:r s050tn15e-0%in %i!n70t5n %en/n %osis r0-tn 9 3 U se:r s050tn.

Tanggal &,()&(*)&+ %DP: ''+ mg(d#- %*PP: '&' mg(d#-

albumin: &-' g.Dieri5n# Ins0!in s! <Lnt0s= () IU se:r s050tn setip "ri p050! 22.))

In>0s A!0-in 2) ()) ::

Tanggal &0()&(*)&+

%DS: '+) mg(d#- albumin: &-, g.Dieri5n# Ins0!in 5er7 :ept <No;orpi%= 3 U se:r s050tn1 5e-0%in %i!n70t5n

%en/n %osis r0-tn 9 3 U se:r s050tn.

In>0s A!0-in 2) ()) ::



P!nnin/

Non1!edikamentosa

Dieri5n %iet DM6G. Diet DM6G -er0p5n %ietDM6B( %it-" %en/n#

Kn%0n/n r/inin tin//i Sert 28 98 /?"ri

Ko!estero! 9)) -/?"ri

E5str >o!t

it-in B3

it-in B(2

Dpt -en/0rn/i"o-osisteine-i



P!nnin/

Bert %n re!ti> <BBR=

Unt05 psien %en/n ert %n 50rn/ <BBR ,)=15e0t0"n 5!ori se"ri +) 3) 5!?5/BB. 4%i1 %!-se"ri %i0t0"5n +) 5! +) 5/ (3)) 5!.



P!nnin/

P% %iet DM6B(1 persentse 5!orin' 3)5ro"i%rt1 2) !e-51 2) protein. 4%i15e0t0"n 5ro"i%rt1 !e-5 %n protein %!-se"ri %!"#



Tanggal S O A P

13/01/2014 Pasien mengeluh lemas (+).

Nafsu makan membaik.

Nyeri paa keua kaki (+).

!" # baik

!esaaran # $%

&$'# 4*%6

- 0/60 mmg

N - 0 /mn

- 16 /mn

- 36.* $

&'# 300 mg/5

iperglikemia +

gangren ruris era e

sinisra + % ipe 2 +

kaarak

7 8nfus * 12 pm

7 8nfus $ipr9fl9ain 200

mg 1 flash/12 :am

7 iamin ; k9mpleks

31

7 a<a luka

14/01/2014 Pasien mengeluh lemas (+).

Nafsu makan membaik.

Nyeri paa keua kaki (+).

!" # ;aik

!esaaran # $%

&$'# 4*%6

- 100/60 mmg,

N- /mn

- 20 /mn

- 36.3 $

iperglikemia +

gangren ruris era e

sinisra + % ipe 2 +

kaarak

7 8nfus * 12 pm

7 8nfus $ipr9fl9ain 200mg 1 flash/12 :am

7 iamin ; k9mpleks

31

7 a<a luka

OLLOW UP

Tanggal S O A P



1*/01/2014 Pasien mengeluh lemas (+). Nafsu

makan membaik. Nyeri paa

keua kaki (+).

!" # ;aik

!esaaran # $%

&$'# 4*%6

- 100/60 mmg,

N- 0 /mn

- 20 /mn

- 36.6 $

iperglikemia + gangren

ruris era e sinisra +

% ipe 2 + kaarak

7 8nfus * 12 pm

7 8nfus $ipr9fl9ain 200 mg 1

flash/12 :am

7 iamin ; k9mpleks 31

7 a<a luka

16/01/2014 Pasien mengeluh lemas (+). Nafsu


keua kaki (+).

!" # ;aik

!esaaran # $%

&$'# 4*%6

- 0/60 mmg,

N- =6 /mn

- 20 /mn

- 36.3 $

&P# 334 mg/5

&2PP# 313 mg/5

>lbumin# 1,3 g?



% ipe 2 +

hip9albuminemia + kaarak

7 8nfus * 12 pm

7 8nfus albumin 20? 100


flash/12 :am


7 a<a luka

1=/01/2014 Pasien mengeluh lemas (+). Nafsu


keua kaki (+).

!" # ;aik

!esaaran # $%

&$'# 4*%6

- 100/60 mmg,

N- =6 /mn

- 20 /mn

- 36.3 $



% ipe 2 +


7 8nfus * 12 pm



flash/12 :am


7 a<a luka

1/01/2014 Pasien mengeluh lemas (+). Nafsu


keua kaki (+).

!" # ;aik

!esaaran # $%

&$'# 4*%6

- 100/60 mmg,

N- 0 /mn

- 20 /mn

- 36.1 $

&'# 340 mg/5

>lbumin# 1,6 g?



% ipe 2 +


7 8nfus * 12 pm



flash/12 :am


7 a<a luka




L05 %i pe%is %etr <(,?)(?2)(+=





L05 %i :r0ris %etr <(,?)(?2)(+=





L05 %i pe%is sinistr <(,?)(?2)(+=




TERIMA KASIH

responsi interna qori

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