SlideShare a Scribd company logo
LIST PASIEN ORTHOPAEDI & TRAUMATOLOGI
Senin, 07 Agustus 2023
AnF
KEMUNING
Ruang Identitas Diagnosis Anamnesis Laboratorium DPJP PT SIO H-2 Permasa
lahan
Rencana
KMG 2
7-4
Mardiana
46 thn
01.08.63
0002070215
23151055
MRS 23.07.23
Post Ankle Arthrodesis with
intramedullary nailing, plate
and screw at left ankle joint
CC:
Rencana lepas implant, nyeri pada kaki kiri
HT :
2 tahun SMRS pasien mengeluhkan nyeri pada
pergelangan kaki kirinya. Pasien kemudian
dilakukan pemasangan implant dalam untuk
mengurangi nyeri pada pergelangan kakinya. 1
tahun SMRS pasien mengeluhkan nyeri pada
pergelangan kaki kirinya. Pasien kemudian kontrol
ke RSHS untuk pemeriksaan lebih lanjut
27/06/23
Hb/ Ht/ L/ Er/ Tr
16.4/50/7.11/5.86/300
AnF
(RAP)
AnF
- + + - R/
Debridement
and Remove
Implant
(Senin,
07.08.23)
KMG 2
10-3
Ase Kurnia
63thn
01.08.63
0002164804
23150994
MRS 23.07.23
- Post posterior stabilization
due to Radiculopathy at L3 due
to Unstable burst fracture at
level VL3 Frankle E POD 10
- Post debridement + ORIF
screw + Immobilization with
posterior slab due to Open
fracture at right calcaneus
comminutive displaced Essex-
Lopresti joint depression type
POD 10
- Post debridement, local
transpositional flap and STSG
due to Skin loss regio pedis
dextra POD 2
OD 27.07.23
CC:
• Nyeri pada kaki kanan
• Nyeri pada pinggang sebelah kiri
HT:
9 jam SMRS saat pasien sedang menaiki tangga
untuk membetulkan genteng masjid didaerah
Celak, ketinggian kurang lebih 2 meter, pasien
terpeleset dan terjatuh dengan kaki kanan
menumpu berat badan. Setelah kejadian, pasien
mengeluhkan nyeri dan luka pada kaki
kanan,sehingga pasien tidak mampu menumpu
berat badannya. Pasien juga mengeluhkan nyeri
pada pinggang kiri yang dirasakan menjalar ke
paha kiri. Pasien kemudian dibawa ke RS Karisma
Cimareme dan dirujuk ke RSHS untuk tatalaksana
lebih lanjut.
01/08/23
Hb/ Ht/ L/ Er/ Tr
11.2/33/8.95/3.98/308
Trauma
(AKH)
Spine
Trauma
(RAP)
AnF
- + + Anemia Orthopaedic
and
Traumatology
Department:
- GV sesuai B.
Plastik
- Active and
passive knee
and ankle joint
ROM exercise
- Pregabalin
2x75 mg PO
- Consult to
internal
medicine for
blood glucose
regulation
Plastic
Surgery
Division:
- GV POD 3
(Senin,
07.08.23)
- Wound toilet
dengan
chlorhexidine,
NaCl 0.9%,
hydrogel,
kassa, dan
elastic
verband. GV/
3 hari atau bila
rembes
- Pertahankan
boot slab
- Saran
pertahankan
Hb target >10
gr/dL.
- Periksa
albumin
target >2,5
gr/dL
RIK
Ruang Identitas Diagnosis Anamnesis Laboratorium DPJP PT SIO H-2
Permasal
ahan
Rencana
RIK 3
302 D
Neti Wati
53thn
05.10.70
0002163942
23003805
MRS
21.07.23
- Post necrotomy debridement
due to Left diabetic foot
Wagner grade III POD IV
- Post CTT insertion at bilateral
due to Bilateral pleural effusion
POD V
KU: Luka pada kaki kiri
AK: Sejak 2 bulan SMRS, pasien mengeluh terdapat
luka pada kaki kiri. Luka muncul setelah terapi
dengan menggunakan batu panas pada telapak kaki
kiri. Keluhan disertai kaki kiri terasa baal. Luka
berwarna kemerahan, basah dan tidak kunjung
28/07/23
Hb/Ht/L/Eri/Tro
10/30/38.98/3.57/609
Na/K 131/3.4
Ur/Cr 60.5/2.08
30.07.23
AnF
(RAP)
AnF
- + +
-
Uncontrol
led
diabetes
mellitus
type 2
with
Plastic Surgery
Division:
- Wound toilette
dengan
chlorhexidine
dan NaCl 0.9%.
Rawat luka
- Diabtetes mellitus type 2 with
complication DKD, Neuropathy
- Hypertensive heart disease
with controlled hypertension
- Anemia Inflammation
(perbaikan)
- Hypoalbuminemia
OD 02.08.23
sembuh. Pasien mendapatkan perawatan luka di
rumah oleh perawat. Namun, luka semakin melebar,
terasa nyeri dan berbau. Keluhan demam disangkal.
Oleh karena itu, pasien dibawa ke RS Bandung
Kiwari dan dilakukan fasciotomy dan pembersihan
luka 1 bulan SMRS. Pasien memiliki riwayat
kencing manis sejak 7 tahun SMRS. Pasien berobat
rutin ke RSUD Bengkulu dan diberikan galvus 50
mg dari dokter penyakit dalam dikonsumsi 1 kali
sehari. Saat ini pasien dikonsulkan dari TS IPD
untuk penanganan lebih lanjut.
Alb : 2.01 complicati
on DKD,
Neuropath
y
-
Hypertens
ive heart
disease
with
controlled
hypertensi
on
- Anemia
Inflamma
tion
dengan
hydrogel, kassa
dan elastic
verban.
- Elevasi
ekstremitas
inferior sinistra
- Saran
pertahankan Hb
target > 10
gr/dL, koreksi
albumin target >
2.5 gr/dL,
koreksi Natrium
target 135-145
mEq/L
- Optimalisasi
KU
- Saran
amputasi
(Keluarga
menolak
amputasi)
Orthopaedic and
Traumatology
Department:
- GV sesuai TS
Bedah Plastik
- Gentamycin 7
mg/kgbb/24 jam
IV bolus dalam
30 menit
- Ceftazidime 3
x 1 gr IV drip
dalam 3 jam
- R/ Below knee
amputation
electively -->
Keluarga
menolak operasi
amputasi
Jumlah pasien : 3 Pasien

More Related Content

Recently uploaded

481605266-11-CPOB-ppt.ppt FARMAKOLOGI NEW UP
481605266-11-CPOB-ppt.ppt FARMAKOLOGI NEW UP481605266-11-CPOB-ppt.ppt FARMAKOLOGI NEW UP
481605266-11-CPOB-ppt.ppt FARMAKOLOGI NEW UP
nadyahermawan
 
Asam, Basa, Garam - materi kimia kelas 7
Asam, Basa, Garam - materi kimia kelas 7Asam, Basa, Garam - materi kimia kelas 7
Asam, Basa, Garam - materi kimia kelas 7
ArumNovita
 
PPT Partikel Penyusun Atom dan Lambang Atom.pptx
PPT Partikel Penyusun Atom dan Lambang Atom.pptxPPT Partikel Penyusun Atom dan Lambang Atom.pptx
PPT Partikel Penyusun Atom dan Lambang Atom.pptx
emiliawati098
 
MI-P2-P3-Metabolisme Mikroorganisme.pptx
MI-P2-P3-Metabolisme Mikroorganisme.pptxMI-P2-P3-Metabolisme Mikroorganisme.pptx
MI-P2-P3-Metabolisme Mikroorganisme.pptx
almiraulimaz2521988
 
MATERI KIMIA KELAS X NANOTEKNOLOGI.pptx
MATERI KIMIA KELAS X  NANOTEKNOLOGI.pptxMATERI KIMIA KELAS X  NANOTEKNOLOGI.pptx
MATERI KIMIA KELAS X NANOTEKNOLOGI.pptx
emiliawati098
 
SOAL GEOGRAFI-SMA NEGERI 1 YOGYAKARTA BAB 7_ ULANGAN HARIAN DINAMIKA HIDROSFE...
SOAL GEOGRAFI-SMA NEGERI 1 YOGYAKARTA BAB 7_ ULANGAN HARIAN DINAMIKA HIDROSFE...SOAL GEOGRAFI-SMA NEGERI 1 YOGYAKARTA BAB 7_ ULANGAN HARIAN DINAMIKA HIDROSFE...
SOAL GEOGRAFI-SMA NEGERI 1 YOGYAKARTA BAB 7_ ULANGAN HARIAN DINAMIKA HIDROSFE...
athayaahzamaulana1
 
Sistem Pencernaan Manusia Sains Tingkatan 2
Sistem Pencernaan Manusia Sains Tingkatan 2Sistem Pencernaan Manusia Sains Tingkatan 2
Sistem Pencernaan Manusia Sains Tingkatan 2
LEESOKLENGMoe
 
Presentasi vitamin secara umum yang terdiri dari vitamin larut lemak dan laru...
Presentasi vitamin secara umum yang terdiri dari vitamin larut lemak dan laru...Presentasi vitamin secara umum yang terdiri dari vitamin larut lemak dan laru...
Presentasi vitamin secara umum yang terdiri dari vitamin larut lemak dan laru...
ProfesorCilikGhadi
 

Recently uploaded (8)

481605266-11-CPOB-ppt.ppt FARMAKOLOGI NEW UP
481605266-11-CPOB-ppt.ppt FARMAKOLOGI NEW UP481605266-11-CPOB-ppt.ppt FARMAKOLOGI NEW UP
481605266-11-CPOB-ppt.ppt FARMAKOLOGI NEW UP
 
Asam, Basa, Garam - materi kimia kelas 7
Asam, Basa, Garam - materi kimia kelas 7Asam, Basa, Garam - materi kimia kelas 7
Asam, Basa, Garam - materi kimia kelas 7
 
PPT Partikel Penyusun Atom dan Lambang Atom.pptx
PPT Partikel Penyusun Atom dan Lambang Atom.pptxPPT Partikel Penyusun Atom dan Lambang Atom.pptx
PPT Partikel Penyusun Atom dan Lambang Atom.pptx
 
MI-P2-P3-Metabolisme Mikroorganisme.pptx
MI-P2-P3-Metabolisme Mikroorganisme.pptxMI-P2-P3-Metabolisme Mikroorganisme.pptx
MI-P2-P3-Metabolisme Mikroorganisme.pptx
 
MATERI KIMIA KELAS X NANOTEKNOLOGI.pptx
MATERI KIMIA KELAS X  NANOTEKNOLOGI.pptxMATERI KIMIA KELAS X  NANOTEKNOLOGI.pptx
MATERI KIMIA KELAS X NANOTEKNOLOGI.pptx
 
SOAL GEOGRAFI-SMA NEGERI 1 YOGYAKARTA BAB 7_ ULANGAN HARIAN DINAMIKA HIDROSFE...
SOAL GEOGRAFI-SMA NEGERI 1 YOGYAKARTA BAB 7_ ULANGAN HARIAN DINAMIKA HIDROSFE...SOAL GEOGRAFI-SMA NEGERI 1 YOGYAKARTA BAB 7_ ULANGAN HARIAN DINAMIKA HIDROSFE...
SOAL GEOGRAFI-SMA NEGERI 1 YOGYAKARTA BAB 7_ ULANGAN HARIAN DINAMIKA HIDROSFE...
 
Sistem Pencernaan Manusia Sains Tingkatan 2
Sistem Pencernaan Manusia Sains Tingkatan 2Sistem Pencernaan Manusia Sains Tingkatan 2
Sistem Pencernaan Manusia Sains Tingkatan 2
 
Presentasi vitamin secara umum yang terdiri dari vitamin larut lemak dan laru...
Presentasi vitamin secara umum yang terdiri dari vitamin larut lemak dan laru...Presentasi vitamin secara umum yang terdiri dari vitamin larut lemak dan laru...
Presentasi vitamin secara umum yang terdiri dari vitamin larut lemak dan laru...
 

Featured

How to Prepare For a Successful Job Search for 2024
How to Prepare For a Successful Job Search for 2024How to Prepare For a Successful Job Search for 2024
How to Prepare For a Successful Job Search for 2024
Albert Qian
 
Social Media Marketing Trends 2024 // The Global Indie Insights
Social Media Marketing Trends 2024 // The Global Indie InsightsSocial Media Marketing Trends 2024 // The Global Indie Insights
Social Media Marketing Trends 2024 // The Global Indie Insights
Kurio // The Social Media Age(ncy)
 
Trends In Paid Search: Navigating The Digital Landscape In 2024
Trends In Paid Search: Navigating The Digital Landscape In 2024Trends In Paid Search: Navigating The Digital Landscape In 2024
Trends In Paid Search: Navigating The Digital Landscape In 2024
Search Engine Journal
 
5 Public speaking tips from TED - Visualized summary
5 Public speaking tips from TED - Visualized summary5 Public speaking tips from TED - Visualized summary
5 Public speaking tips from TED - Visualized summary
SpeakerHub
 
ChatGPT and the Future of Work - Clark Boyd
ChatGPT and the Future of Work - Clark Boyd ChatGPT and the Future of Work - Clark Boyd
ChatGPT and the Future of Work - Clark Boyd
Clark Boyd
 
Getting into the tech field. what next
Getting into the tech field. what next Getting into the tech field. what next
Getting into the tech field. what next
Tessa Mero
 
Google's Just Not That Into You: Understanding Core Updates & Search Intent
Google's Just Not That Into You: Understanding Core Updates & Search IntentGoogle's Just Not That Into You: Understanding Core Updates & Search Intent
Google's Just Not That Into You: Understanding Core Updates & Search Intent
Lily Ray
 
How to have difficult conversations
How to have difficult conversations How to have difficult conversations
How to have difficult conversations
Rajiv Jayarajah, MAppComm, ACC
 
Introduction to Data Science
Introduction to Data ScienceIntroduction to Data Science
Introduction to Data Science
Christy Abraham Joy
 
Time Management & Productivity - Best Practices
Time Management & Productivity -  Best PracticesTime Management & Productivity -  Best Practices
Time Management & Productivity - Best Practices
Vit Horky
 
The six step guide to practical project management
The six step guide to practical project managementThe six step guide to practical project management
The six step guide to practical project management
MindGenius
 
Beginners Guide to TikTok for Search - Rachel Pearson - We are Tilt __ Bright...
Beginners Guide to TikTok for Search - Rachel Pearson - We are Tilt __ Bright...Beginners Guide to TikTok for Search - Rachel Pearson - We are Tilt __ Bright...
Beginners Guide to TikTok for Search - Rachel Pearson - We are Tilt __ Bright...
RachelPearson36
 
Unlocking the Power of ChatGPT and AI in Testing - A Real-World Look, present...
Unlocking the Power of ChatGPT and AI in Testing - A Real-World Look, present...Unlocking the Power of ChatGPT and AI in Testing - A Real-World Look, present...
Unlocking the Power of ChatGPT and AI in Testing - A Real-World Look, present...
Applitools
 
12 Ways to Increase Your Influence at Work
12 Ways to Increase Your Influence at Work12 Ways to Increase Your Influence at Work
12 Ways to Increase Your Influence at Work
GetSmarter
 
More than Just Lines on a Map: Best Practices for U.S Bike Routes
More than Just Lines on a Map: Best Practices for U.S Bike RoutesMore than Just Lines on a Map: Best Practices for U.S Bike Routes
More than Just Lines on a Map: Best Practices for U.S Bike Routes
Project for Public Spaces & National Center for Biking and Walking
 
Ride the Storm: Navigating Through Unstable Periods / Katerina Rudko (Belka G...
Ride the Storm: Navigating Through Unstable Periods / Katerina Rudko (Belka G...Ride the Storm: Navigating Through Unstable Periods / Katerina Rudko (Belka G...
Ride the Storm: Navigating Through Unstable Periods / Katerina Rudko (Belka G...
DevGAMM Conference
 
Barbie - Brand Strategy Presentation
Barbie - Brand Strategy PresentationBarbie - Brand Strategy Presentation
Barbie - Brand Strategy Presentation
Erica Santiago
 
Good Stuff Happens in 1:1 Meetings: Why you need them and how to do them well
Good Stuff Happens in 1:1 Meetings: Why you need them and how to do them wellGood Stuff Happens in 1:1 Meetings: Why you need them and how to do them well
Good Stuff Happens in 1:1 Meetings: Why you need them and how to do them well
Saba Software
 
Introduction to C Programming Language
Introduction to C Programming LanguageIntroduction to C Programming Language
Introduction to C Programming Language
Simplilearn
 

Featured (20)

How to Prepare For a Successful Job Search for 2024
How to Prepare For a Successful Job Search for 2024How to Prepare For a Successful Job Search for 2024
How to Prepare For a Successful Job Search for 2024
 
Social Media Marketing Trends 2024 // The Global Indie Insights
Social Media Marketing Trends 2024 // The Global Indie InsightsSocial Media Marketing Trends 2024 // The Global Indie Insights
Social Media Marketing Trends 2024 // The Global Indie Insights
 
Trends In Paid Search: Navigating The Digital Landscape In 2024
Trends In Paid Search: Navigating The Digital Landscape In 2024Trends In Paid Search: Navigating The Digital Landscape In 2024
Trends In Paid Search: Navigating The Digital Landscape In 2024
 
5 Public speaking tips from TED - Visualized summary
5 Public speaking tips from TED - Visualized summary5 Public speaking tips from TED - Visualized summary
5 Public speaking tips from TED - Visualized summary
 
ChatGPT and the Future of Work - Clark Boyd
ChatGPT and the Future of Work - Clark Boyd ChatGPT and the Future of Work - Clark Boyd
ChatGPT and the Future of Work - Clark Boyd
 
Getting into the tech field. what next
Getting into the tech field. what next Getting into the tech field. what next
Getting into the tech field. what next
 
Google's Just Not That Into You: Understanding Core Updates & Search Intent
Google's Just Not That Into You: Understanding Core Updates & Search IntentGoogle's Just Not That Into You: Understanding Core Updates & Search Intent
Google's Just Not That Into You: Understanding Core Updates & Search Intent
 
How to have difficult conversations
How to have difficult conversations How to have difficult conversations
How to have difficult conversations
 
Introduction to Data Science
Introduction to Data ScienceIntroduction to Data Science
Introduction to Data Science
 
Time Management & Productivity - Best Practices
Time Management & Productivity -  Best PracticesTime Management & Productivity -  Best Practices
Time Management & Productivity - Best Practices
 
The six step guide to practical project management
The six step guide to practical project managementThe six step guide to practical project management
The six step guide to practical project management
 
Beginners Guide to TikTok for Search - Rachel Pearson - We are Tilt __ Bright...
Beginners Guide to TikTok for Search - Rachel Pearson - We are Tilt __ Bright...Beginners Guide to TikTok for Search - Rachel Pearson - We are Tilt __ Bright...
Beginners Guide to TikTok for Search - Rachel Pearson - We are Tilt __ Bright...
 
Unlocking the Power of ChatGPT and AI in Testing - A Real-World Look, present...
Unlocking the Power of ChatGPT and AI in Testing - A Real-World Look, present...Unlocking the Power of ChatGPT and AI in Testing - A Real-World Look, present...
Unlocking the Power of ChatGPT and AI in Testing - A Real-World Look, present...
 
12 Ways to Increase Your Influence at Work
12 Ways to Increase Your Influence at Work12 Ways to Increase Your Influence at Work
12 Ways to Increase Your Influence at Work
 
ChatGPT webinar slides
ChatGPT webinar slidesChatGPT webinar slides
ChatGPT webinar slides
 
More than Just Lines on a Map: Best Practices for U.S Bike Routes
More than Just Lines on a Map: Best Practices for U.S Bike RoutesMore than Just Lines on a Map: Best Practices for U.S Bike Routes
More than Just Lines on a Map: Best Practices for U.S Bike Routes
 
Ride the Storm: Navigating Through Unstable Periods / Katerina Rudko (Belka G...
Ride the Storm: Navigating Through Unstable Periods / Katerina Rudko (Belka G...Ride the Storm: Navigating Through Unstable Periods / Katerina Rudko (Belka G...
Ride the Storm: Navigating Through Unstable Periods / Katerina Rudko (Belka G...
 
Barbie - Brand Strategy Presentation
Barbie - Brand Strategy PresentationBarbie - Brand Strategy Presentation
Barbie - Brand Strategy Presentation
 
Good Stuff Happens in 1:1 Meetings: Why you need them and how to do them well
Good Stuff Happens in 1:1 Meetings: Why you need them and how to do them wellGood Stuff Happens in 1:1 Meetings: Why you need them and how to do them well
Good Stuff Happens in 1:1 Meetings: Why you need them and how to do them well
 
Introduction to C Programming Language
Introduction to C Programming LanguageIntroduction to C Programming Language
Introduction to C Programming Language
 

AnF 07.docx

  • 1. LIST PASIEN ORTHOPAEDI & TRAUMATOLOGI Senin, 07 Agustus 2023 AnF KEMUNING Ruang Identitas Diagnosis Anamnesis Laboratorium DPJP PT SIO H-2 Permasa lahan Rencana KMG 2 7-4 Mardiana 46 thn 01.08.63 0002070215 23151055 MRS 23.07.23 Post Ankle Arthrodesis with intramedullary nailing, plate and screw at left ankle joint CC: Rencana lepas implant, nyeri pada kaki kiri HT : 2 tahun SMRS pasien mengeluhkan nyeri pada pergelangan kaki kirinya. Pasien kemudian dilakukan pemasangan implant dalam untuk mengurangi nyeri pada pergelangan kakinya. 1 tahun SMRS pasien mengeluhkan nyeri pada pergelangan kaki kirinya. Pasien kemudian kontrol ke RSHS untuk pemeriksaan lebih lanjut 27/06/23 Hb/ Ht/ L/ Er/ Tr 16.4/50/7.11/5.86/300 AnF (RAP) AnF - + + - R/ Debridement and Remove Implant (Senin, 07.08.23) KMG 2 10-3 Ase Kurnia 63thn 01.08.63 0002164804 23150994 MRS 23.07.23 - Post posterior stabilization due to Radiculopathy at L3 due to Unstable burst fracture at level VL3 Frankle E POD 10 - Post debridement + ORIF screw + Immobilization with posterior slab due to Open fracture at right calcaneus comminutive displaced Essex- Lopresti joint depression type POD 10 - Post debridement, local transpositional flap and STSG due to Skin loss regio pedis dextra POD 2 OD 27.07.23 CC: • Nyeri pada kaki kanan • Nyeri pada pinggang sebelah kiri HT: 9 jam SMRS saat pasien sedang menaiki tangga untuk membetulkan genteng masjid didaerah Celak, ketinggian kurang lebih 2 meter, pasien terpeleset dan terjatuh dengan kaki kanan menumpu berat badan. Setelah kejadian, pasien mengeluhkan nyeri dan luka pada kaki kanan,sehingga pasien tidak mampu menumpu berat badannya. Pasien juga mengeluhkan nyeri pada pinggang kiri yang dirasakan menjalar ke paha kiri. Pasien kemudian dibawa ke RS Karisma Cimareme dan dirujuk ke RSHS untuk tatalaksana lebih lanjut. 01/08/23 Hb/ Ht/ L/ Er/ Tr 11.2/33/8.95/3.98/308 Trauma (AKH) Spine Trauma (RAP) AnF - + + Anemia Orthopaedic and Traumatology Department: - GV sesuai B. Plastik - Active and passive knee and ankle joint ROM exercise - Pregabalin 2x75 mg PO - Consult to internal medicine for blood glucose regulation
  • 2. Plastic Surgery Division: - GV POD 3 (Senin, 07.08.23) - Wound toilet dengan chlorhexidine, NaCl 0.9%, hydrogel, kassa, dan elastic verband. GV/ 3 hari atau bila rembes - Pertahankan boot slab - Saran pertahankan Hb target >10 gr/dL. - Periksa albumin target >2,5 gr/dL RIK Ruang Identitas Diagnosis Anamnesis Laboratorium DPJP PT SIO H-2 Permasal ahan Rencana RIK 3 302 D Neti Wati 53thn 05.10.70 0002163942 23003805 MRS 21.07.23 - Post necrotomy debridement due to Left diabetic foot Wagner grade III POD IV - Post CTT insertion at bilateral due to Bilateral pleural effusion POD V KU: Luka pada kaki kiri AK: Sejak 2 bulan SMRS, pasien mengeluh terdapat luka pada kaki kiri. Luka muncul setelah terapi dengan menggunakan batu panas pada telapak kaki kiri. Keluhan disertai kaki kiri terasa baal. Luka berwarna kemerahan, basah dan tidak kunjung 28/07/23 Hb/Ht/L/Eri/Tro 10/30/38.98/3.57/609 Na/K 131/3.4 Ur/Cr 60.5/2.08 30.07.23 AnF (RAP) AnF - + + - Uncontrol led diabetes mellitus type 2 with Plastic Surgery Division: - Wound toilette dengan chlorhexidine dan NaCl 0.9%. Rawat luka
  • 3. - Diabtetes mellitus type 2 with complication DKD, Neuropathy - Hypertensive heart disease with controlled hypertension - Anemia Inflammation (perbaikan) - Hypoalbuminemia OD 02.08.23 sembuh. Pasien mendapatkan perawatan luka di rumah oleh perawat. Namun, luka semakin melebar, terasa nyeri dan berbau. Keluhan demam disangkal. Oleh karena itu, pasien dibawa ke RS Bandung Kiwari dan dilakukan fasciotomy dan pembersihan luka 1 bulan SMRS. Pasien memiliki riwayat kencing manis sejak 7 tahun SMRS. Pasien berobat rutin ke RSUD Bengkulu dan diberikan galvus 50 mg dari dokter penyakit dalam dikonsumsi 1 kali sehari. Saat ini pasien dikonsulkan dari TS IPD untuk penanganan lebih lanjut. Alb : 2.01 complicati on DKD, Neuropath y - Hypertens ive heart disease with controlled hypertensi on - Anemia Inflamma tion dengan hydrogel, kassa dan elastic verban. - Elevasi ekstremitas inferior sinistra - Saran pertahankan Hb target > 10 gr/dL, koreksi albumin target > 2.5 gr/dL, koreksi Natrium target 135-145 mEq/L - Optimalisasi KU - Saran amputasi (Keluarga menolak amputasi) Orthopaedic and Traumatology Department: - GV sesuai TS Bedah Plastik - Gentamycin 7 mg/kgbb/24 jam IV bolus dalam 30 menit - Ceftazidime 3 x 1 gr IV drip dalam 3 jam - R/ Below knee amputation electively --> Keluarga