case st. yusup
DESCRIPTION
baca saja sendirilahTRANSCRIPT
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CASERS St. Yusup
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RESUME
• Nama : Tn. TS• Umur : 59 tahun• NRM : 023713• Pekerjaan : Wiraswasta • Alamat : Komp. Riung Bandung 11• Ruang : Maria 1-1 Lukas 10-1• Masuk Tanggal : 1 Sept 2010• Diagnosis Kerja : Abscess + Gangren a/r
punggung dextra• Terapi : pro debridement dalam NU
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Anamnesis
• KU : luka di punggung kanan• KL :
Keluhan dirasakan sejak 2 minggu yang lalu dengan timbulnya bisul pada punggung kanan sebesar kelereng, makin lama makin besar meluas hingga bahu dan tengkuk kanannya. Nyeri tekan +. Juga disertai demam terus menerus, menggigil. Hal tersebut menggangu pasien tidur.
Sebelumnya pasien pernah menderita keluhan yang sama 6 bulan yll di daerah leher belakang, berobat ke dokter dan sembuh.
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Pasien juga memiliki riwayat DM sejak 20 tahun yll. Setelah pasien tahu memiliki DM pasien langsung berobat dan menggunakan insulin ½ jam sebelum makan secara teratur. Pasien juga tertur mengukur gula darahnya di Puskesmas setiap bulan. Pasien masih mengeluh sering merasa kencing, sering minum karena sering haus, pasien merasa lebih kurus dan lemas. Pasin juga mulai mengontrol makanannya. Pasien tidak merasa kesemutan, gatal, mata kabur, dll.
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Mual -, muntah -, batuk -, pilek -.
BAB : jumlah dan frekuensi dbn, darah-, lendir-, konsistensi normal
BAK : jumlah dan frekuensi dbn, darah-, batu-, pasir-.
RPD : -, r. operasi -.
RPK : Ibu pasien menderita DM
UB : pasien langusng berobat ke RS untuk keluhan saat ini
R. Kebiasaan : dahulu pasien suka makan makanan manis.
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Pemeriksaan Fisik
• KU : sedang• Sakit : Sedang• Gizi : Normal• TTV : TD : 150/70, N : 124, R : 20, S : 38.• Kesadaran : CM• Kepala : B/U simetris, mata (pupil bulat isokor
RC +/+, konjungtiva anemis -/-, sklera ikterik -/-).• THT : hidung (pch -/-, sekret -/-), mulut (bibir
lembab, mukosa basah, faring hiperemis -, tonsil T1/T1), telinga (sekret -/-)
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• Leher : KGB ttm, trakea sentral, JVP 5+0 cmH2O.• Thorax : B/P simetris retraksi iga -, posisi paksa -, nyeri
tekan-, taktil fremitus ki=ka, sonor, vocal fremitus ki=ka.– Paru : VBS ka=ki, Wh -/-, Rh -/-– Cor : BJM, reguler, murmur-, A2>A1, P2>P1, A2>P2, M1>M2
• Abdomen : cembung, DC -, DS -, bekas op -. BU + Normal, tymphani, soepel, nyeri tekan -, hepatospelnomegali.
• Ekstremitas : akral hangat, CRT < 2”, edema -, keringat -, muscle atrofi -, sensorik +, motorik +, clubbing finger -.
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• Diagnosis Kerja : abscess + gangrene a/r punggung dextra e.c. DMT 2
• Diagnosis Tambahan : Hipertensi Stage 2
• Prognosis : – Quo ad vitam ad bonam– Quo ad functionam dubia ad malam.
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Follow up & Terapi
1 Sept 2010• Px baru • Th / Novomix, Metronidazole, Ciprofloxacin
2 Sept 2010• Abses luas • Saran : debridemen, Thorax foto PA lat, Periksa
CT BT, HBsAg, Sysmex, Ureum, Creatinin, SGOT, SGPT
• Pro debridemen
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• Keluarga menolak Ro dan Lab sebelum op• Periksa : SGOT, SGPT, Ureum, Kreatinin, Sysmex, LED
1 2, Leukosit, Tc, BT, CT, Gol dara• Lapor lab tunda op, transfusi PRC 3 U, cek GD
operasi besok, Sanmol 3x1• Th / Glucobion, Clindamicin, Sanmol3 Sept 2010• Lapor hasil GD – tidak perlu Novorapid, rencana op
ditunda sampai selesai transfusi• Sp.B rencana op setelah transfusi, diet cair• Sulit BAB – skibala +2 koreksi
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Hasil Pemeriksaan
1 Sept 2010• GD 2 jam pp : 183• EKG : dbn2 Sept 2010• GD 2 jam pp : 123• Hb 7,8 (rendah)• Ht 23,6 (rendah)• L 12700 (tinggi)• Tc 210000
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• BT 1’30’’• CT 7’• Kreatinin 1,11• SGOT 10• Gol darah AB• Rhesus +• Foto Thorax AP lateral : gangren di bahu kanan. Tidak
tampak osteomielitis pada clavicula dextra. Cor normal tidak tampak aktif KP.
3 Sept 2010• GD puasa : 89
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Tq GBU