MR=Korning report 17 maret 2024 ppt.pptx

PPT MR

1. CUE AND CLUE Problem List Initial Diagno s is Planning Diagnosis Planning Therapy Planning monitoring Mr. A/ 54 y.o Wound on right leg since 3 days ago, initially the skin blistered, and then became sore and festered. Wound still bleeding and having a bad smell. Pain (+) Febris (+) since 1 day ago Tingling in both legs has been recurring for 2 weeks History of Diabetes Mellitus since 5 years ago. 1. Selulitis Plantar Pedis Dextra (gas ganggrene +) with DFU Wagner 2 Pedis sinistra Wound base culture Non-Pharmacology: Diet DM 1500 kkal /day Pharmacology: Inj. Ceftriaxone 1 g/12 hour Inf. Metronidazole 500mg/8 hour Inj. Lanzoprazol 30 mg/24 jam Inf. Antrain 1gr/8 jam Subcutaneous Levemir 0-0-10 IU Novorapid 3x6 IU Gentamicin ointment for wounds on the left leg where the wound is dry Consult to foot ulcer division for the wound care Plan Monitoring: Check for blood routine after 3 days after admission Symptom: pain VAS Plan Education: Educate that the condition and what its aetiology of the disease Educte patient about the planning therapy Objective T : 38,5° C GDS : 546 mg/dL Loading 1000cc —> 328 mg/dL VAS 2-3 Status localis a/r pedis dextra L: Looks clean, edema (+), erythema (+) F: tenderness (+), the dorsal pedis artery is palpable with strong lift (+), the posterior tibial artery is palpable strongly, fluctuation (+), pus (+) M: Limited ROM due to pain Status localis a/r pedis sinistra L: Looks dirty, edema (+), erythema (-), blackening (+), F: Numbness (-) tenderness (-), the dorsal pedis artery is palpably raised (+), the posterior tibial artery is palpable strongly M : Limited ROM ABI Score ABI score pedis dextra 1.0 ABI score pedis sinistra 1.0 SpO2 dex / Sin Digiti 1 : 99% / 95% Digiti 2 : 99% / 95% Digiti 3 : 96% / 94% Digiti 4 : 98% / 96% Digiti 5 : 98% / 98% Laboratory results: Lab 21/03/24 RSUD Ulin Leukosit 27.100 Neut 89.9 Limf 4.5 GDS 534 Urinaalysis 20/03/24 RSUD Ulin Glucose 3+ Keton – Blood Gas Analysis 20/03/24 pH 7.443 Hco3 23.1 Ro. Pedis Dextra AP/Lat 4/20/2024 Intact bone, gas gangrene (+) pedis sinistra KAD Criteria (ADA 2023) - GDS >200 ✅ - Urine keton >= +2 ❌ - PH <7.3 ❌ atau HCO3 <18 ❌