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8/10/2019 cc stroke dr TY
http://slidepdf.com/reader/full/cc-stroke-dr-ty 1/17
LAPORAN PAGIJULY, 21ST 2014
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PATIENT IDENTITY1
Name : Mr. A
Age : 46 yo
Address : solo
Admmted : 21st july, 2014
MR : 01262977
Ward : Melati 1/ 6E
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ANAMNESIS2KU : badan lemas (alloanamnesis)
- The patient complained of
weakness in his arms and right leg
since 2 days ago. Weakness
suddenly, constantly. Patients can
raise right hands and feet but was
unable to hold it. Weakness does
not improve with feeding.
Complaints not accompanied by
dizziness, no history of trauma, notaccompanied by convulsions, fever.
2 days
ago
The patient came with complaints
wound on the right leg.Originally
feet reddish then start blackened
on the ring finger and middlefinger.Complaint not improved by
administering an ointment, and
patients to the doctor andamputated on a finger blackening.
1
month
ago
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ANAMNESIS2
• Urinate 6-8 times, @1 glasses,
feels pain (-), anyang-anyangan
(-), sand (-). Dfecation once aday, liquid (-), blood (-)
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Past History Disease2
Time Place of admission History of Therapy ortreatment
2004 puskesmas DM tipe 2
glibenclamid
Family History Disease 3Diabetes mellitus : denied
Hypertension : denied
Cardiac : denied
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Pemeriksaan Fisik5
Tampak menahan nyeri
GCS E4V5M6 , Compos Mentis
Keadaan Umum :
T : 130/80 mmHg N : 88x/menit
R : 18x/menit
S : 36, oC (aksiler)
BB : 50 kg TB : 150cm
BMI : 23 kg/m2
VAS : 2
GDS : 171
Tanda Vital :
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Pemeriksaan Fisik5 Mata :
conjunctiva pucat -/-
Sklera ikterik -/-
Papil lidah atrofi (-)
Tifoid Tongue (-)
JVP R+2 cm,
KGB tak membesar
Paru Depan :
I. Pengembangan dada
kanan= kiriP. Fremitus raba kanan=kiri,
P: Sonor=sonor
A SDV (N/N), RBH (-/-)
Oedem superior -/-
Oedem inferior -/- Akral dingin -/-
Motorik 4 / 5
4/ 5
Cor:
I. IC tak tampak
P. IC tak terabaP. Batas jantung tidak melebar
A. BJ I-II murni, intensitas
normal, bising (-), gallop
(-)
AbdomenI : DP //DD, venektasi (-)
A :Peristaltik (+) N
P :tympani, area troube tympani
P. supel, nyeri tekan (-) regio epi
gastrium,
Paru belakang :
I. Pengembangan dadakanan= kiri
P. Fremitus raba kanan=kiri,
P: Sonor=sonor
A SDV (N/N), RBH (-/-)
R. Pedis dx: looked ulcer resonated pedis
uk 6x3x1 cm, , pussy ( + ), blood ( + ),
digiti, ii are blackish in color, krepitasi ( + ),amputated digiti ii and iv. ABI dx 0,
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Tanggal 21/7/2014 satuan Nilai rujukan
Hemoglobin 11,6 g/dl 13,5 - 17,5
Eritrosit 4.00 106/ul 4,50 - 5,90
Hematokrit 35 % 33 - 45
Lekosit 14.7 103/ul 4,5 - 11
Trombosit 450 103/ul 150 - 450
Ureum 36 mg/dl 10 - 50
Creatinin 0,9 mg/dl 0,6 - 1,1
GDS 216 mg/dL 60 - 140
SGOT 16 u/l 0 - 35SGPT 29 u/l 0 - 45
Natrium 135 Mmol/L 136 - 145
Kalium 4,5 Mmol/L 3,3 - 5,1
Clorida 104 Mmol/L 98 - 106
6 Pemeriksaan Laboratorium
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6 Pemeriksaan Laboratorium
Urin Stik Nilai
Glu ±
Bil -
Keton -
BJ 1.020
Blood -
pH 6.0
Prot -
Uro -
Nitrit -Leu ±
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Foto pedis AP-lat : menyokong selulitis gangrenosa disertai gambaran charcot joint pedis dextra
Fotothorax PA : cor dan pulmo tak ada kelainan
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Infark di ganglia
basalis kiri
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7 DAFTAR DIAGNOSIS
Geriatri dengan:
1. Infark ganglion basalis sinistra
2. DM tipe II NO
3. Ulkus DM pedis dextra wagner IV and charcot joint pedis dextra
4. Mild hyponatremia
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7 IPDX
GDP/2JPP/A1C/Profil lipid
Urin rutin
USG doppler
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7 IPTX
1. Bed rest tidak total
2. Diet DM 1700 kkal RP 40g/hr RG > 5g/hr
3. O2 2 lpm
4. Inf NaCl 20 tpm
5. Inj ceftriaxone 2 g/24 hr
6. Inf Metronidazol 500 mg/8 hr
7. Inj novorapid 4-4-4 iu sc ac8. Aspilet 1x80 mg
9. Amlodipin 1x5mg
10. Gabapentin 1x30 mg
11. Inj Citicolin 250mg/12jam
12. Inj vit B12 1amp/24 jam
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7 IPMX
1. Kuvs
IPEX
Edukasi penyakit, komplikasi serta tatalaksananya
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TERIMA KASIH