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  • DR - Irra 30-08 Joe

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    Alma Wijaya
    54 vistas40 páginas
    This medical document summarizes the case of multiple patients. It includes information on Mr. Jakfar such as his age, admission date, consultant, working diagnoses including ulcers and diabetes, and treatment including wound care and antibiotics. It also summarizes cases of Boy Ramdan with skin cancer, and Mr. Asep Taofik who was admitted post surgery for burns, including clinical photos and laboratory results over time. Management plans are outlined for wound care, reconstruction, and antibiotics.

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    dr.Irra 30-08 Joe

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    This medical document summarizes the case of multiple patients. It includes information on Mr. Jakfar such as his age, admission date, consultant, working diagnoses including ulcers and diabetes, and treatment including wound care and antibiotics. It also summarizes cases of Boy Ramdan with skin cancer, and Mr. Asep Taofik who was admitted post surgery for burns, including clinical photos and laboratory results over time. Management plans are outlined for wound care, reconstruction, and antibiotics.

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    © All Rights Reserved
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    54 vistas40 páginas

    DR - Irra 30-08 Joe

    Cargado por

    Alma Wijaya
    This medical document summarizes the case of multiple patients. It includes information on Mr. Jakfar such as his age, admission date, consultant, working diagnoses including ulcers and diabetes, and treatment including wound care and antibiotics. It also summarizes cases of Boy Ramdan with skin cancer, and Mr. Asep Taofik who was admitted post surgery for burns, including clinical photos and laboratory results over time. Management plans are outlined for wound care, reconstruction, and antibiotics.

    Copyright:

    © All Rights Reserved
    Descargue como PPTX, PDF, TXT o lea en línea desde Scribd
    Marcar por contenido inapropiado
    de 40

    Parade Dr.

    Irra R, SpB,
    SpBP-RE(K)
    30Agustus 2015
    Jocliedian G. Lilihata

    Mr. Jakfar / 72 y.o / Fresia 2


    Admission : August 19th, 2015
    Consultant : Irra Rubianti dr., Sp.B., SpBP-RE

    Working Diagnosis :

    (patient was consulted from emg internal dept)


    - Ulcus decubitus gr 2-3 ar scrum, trochanter dx,
    pedis bilateral
    - DM type 2 with neuropathy, Anemia inflamasi,
    Hiponatremia, susp TB paru

    Present State
    CM
    BP : 110/80 mmHg
    RR : 22 x/min
    HR : 88 x/min
    t
    : 36,4

    clinical picture 19/8/2015

    21/08/2015

    Clinical Pictures 24/08/2015

    27/8/15

    Post Local ND

    Laboratory Finding
    Lab

    19/08/2015

    21/08/15

    24/08/2015

    Hb

    8,2

    9,0

    8,9

    Hct

    25

    27

    27

    Leukosit

    13.200

    13.900

    13.800

    Trombosit

    278.000

    320.000

    382.000

    Ur / Cr
    Na / K

    16,0,6
    123

    Alb/ Tot. Prot


    gdp/2jpp
    GDS

    128/4.0
    1,7/4,9

    150/235

    90/195
    114

    Kultur Pus 19/8/15

    Management
    Internal Department Department

    - IVFD NaCl 0,9% 1500 cc /24 h


    - Diet DM 1500 kkal/ day
    - Novorapid 6-6-6 u/SC , Lantus 0-0-10 u/SC
    - Meropenem 3x500mg iv
    - Check BTA sputum SPS
    Plastic Department:
    Moblization every 2 hours
    Target Hb >10, Na >135, Alb >2,5
    Wound Hygiene + Local Necrotic debridement
    Dressing change with hydrogels + moist gauze
    Consult to IKFR dept to mobilization + chest
    fisiotherapy

    boy Ramdan/ 9 y.o / Kemuning 2


    Admission : August 10th, 2015
    Consultant : Irra Rubianti dr., Sp.B., SpBP-RE(K)

    Working Diagnosis :
    Residive Squamous Cell Carcinoma + Xeroderma
    Pigmentosa + heliophobia
    Operation history :
    - 2009 : excisi + STSG +FTSG
    - 2010 : excisi + STSG
    - 2011 : biopsi excisi +stsg
    - 2014 : radical excisi + FTSG
    Present State

    CM
    BP : 100/60 mmHg
    RR : 18 x/min HR : 88 x/min T :
    36,7C
    At nasal : nostrils (+), nose (-)
    At left frontal : mass (+), brown, immobile, pain (+)
    At fascial, trunk, extremities supeior et inferior bilateral :
    brownish pigmentation (+)

    Clinical picture 14/8/2015

    Laboratory Finding
    Lab

    18/8/2015

    Hb

    14,1

    Hct

    39

    Leukosit

    8600

    Trombosit

    336.000

    Ur / Cr

    18/0,35

    Na / K

    135/3,5

    GDS

    151

    SGOT/PT

    19/8

    PT/INR/APT
    T

    14,9/35,9/1,
    13

    management
    Join conference
    Plan for recontruction ( excisi +
    Flap )

    Mr. Asep Taofik/ 26 yo/kemuning 4


    Admission : July 4th, 2015
    Consultant : Irra Rubianti dr., Sp.B., SpBP-RE(K)
    Working Diagnosis :
    Post necrotomy debridement due to vein compromis in patient post closed
    defect with latisimus dorsi + craniectomy debridement due to Neglected
    electrical burn injury grade 2-3 TBSA 14 % at scalp, posterior trunk, right
    hand, bilateral lower extremities and genitalia with bone expose and
    temporoparietal osteomyelitis at cranial region
    Operation History :
    - 6-8-2015 : closed defect with latisimus dorsi + craniectomy debridement
    -12-8-2015 : necrotomy debridement
    - 18-8-2015 : necrotomy debridement
    Local state
    At cranial : bone expose (+), necrotic (+)
    State
    BP : 110/80 mmHg RR : 20 x/min
    HR : 88 x/min Temp : 36.5oC

    Clinical picture (4/7/2014)

    Clinical picture (27/7/2015)

    Clinical picture 31/7/2015

    Clinical picture 2/8/2015

    6-8-2015

    12-8-2015

    12-8-2015

    14-08-2015

    Intra op ND 18-08-2015

    20-08-2015

    22-08-2015

    24-08-2015

    30/08/2015

    Laboratory Findings
    Lab
    PT/APTT/INR
    Hb
    Hct
    Leukosit
    Trombosit

    24-07- 31/07/20
    2015
    15
    12.4/22.8/ 13,2/29,2/ 10,4/23,8/
    1.16
    0,97
    0,96
    13.5
    15,2
    14,7
    40
    45
    44
    9700
    10.400
    8.300
    532000
    379,000
    328.000
    4/7/15

    18-082015

    11,5
    34
    8700
    339.000

    24-082015
    9,7/0,90/2
    2,8
    14,2
    45
    9500
    509.000

    Ur / Cr

    21/0.44

    23/0,69

    19/0,45

    17/0,40

    Na / K
    Random
    Glucose
    Alb/TP

    128/5.3

    135/5,2

    134/4,3

    138/4,1

    139/4,6

    117

    130

    141

    113

    87

    2.8/5.7

    3.4/6.4

    3,6/6,1

    3,7/6,2

    4,0/6,4

    Schedel AP/L

    Necrotic tissue Culture (12-08-2015)


    Antibiotik

    Result

    Amikacin

    Ampicillin Sulbactam

    Aztreonam

    Cefepime

    Ceftazidime

    Ceftriaxon

    Cephazolin

    Ciprofloxacin

    Cotrimoxazole

    Gentamycin

    Meropenem

    Piperacillin Tazobactam

    Tigecyclin

    Founded Klebsiella pneumoniae

    Management

    IVFD RL:D5 2:1 1500 cc/24 hour


    Regular diet 2000kkal/24 hour
    Ciprofloxacine 2x 500 mr IV
    Metronidazole 3x 500 mg IV
    PCT 3x1 gr IV
    Bed preparation
    Dressing change with tulle, moist
    gauze every day
    R/ STSG + lokal flap

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