crs ulkus diabetikum dika-ila.ppt

8/14/2019 CRS Ulkus diabetikum dika-ila.ppt

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PRESENTAN :

ANDHIKA YUDI HARTONO

PRILAVIA RAMADHANI

SMF BEDAH RS AL ISLAM

BANDUNG 2013

Case Report Session



Identitas Pasien

Nama : Ny. L

Umur : 59 tahun

Jenis kelamin : Perempuan

Alamat : e!on Jeruk Peker"aan : IR#

A$ama : Islam

#$l Pemeriksaan : %% &kto!er %'()



eluhan Utama

Luka di kaki kanan



Anamnesis

Se"ak % min$$u S*RS pasien men$eluh tim!ul lukadi kaki kanan. Luka !era+al dari mata ikan di "arike,) kaki kanan yan$ di$aruk terus menerus oleh

pasien sampai menim!ulkan luka. Luka menye!arhampir ke seluruh pun$$un$ kaki kanan sampaimenim!ulkan nanah dan !er!au !usuk.



Pasien men$aku serin$ pe$al kaki dan lemas. Sertaterkadan$ disertai kesemutan di kaki dan "u$atan$an. Pasien "u$a men$eluhkan serin$ -A pada

malam hari le!ih dari ) kali mudah lapar mudahlemas dan "u$a mudah haus.



Pasien men$aku se!elumnya tidak tertusuk oleh !enda ta"am di kaki dan tidak ada demam. Pasienmen$o!ati lukanya ke dokter dan di!erikan o!at

salep dan o!at yan$ diminum tetapi keluhan tidakmem!aik.



Pasien men$aku tidak men$etahui memiliki ri+ayathipertensi atau dia!etes. Pasien !aru men$etahuimemiliki dia!etes saat !ero!at keluhan kakinya

sekaran$.Pasien tidak memiliki an$$ota keluar$a den$an

penyakit dia!etes.



Pemeriksaan /isik

Status 0eneralis

eadaan Umum : Composmentis tampak sakitsedan$

#ekanan darah : %)'1()' mm2$Nadi : 93 4 1 menit

Respirasi : %' 1 menit

Suhu : a6e!ris



epala : on"un$ti7a tidak anemis Sklera tidakikterik

Leher : 0- tidak tera!a mem!esar J8P tidak

menin$kat



#oraks Pulmo : Inspeksi : -entuk dan $erak simetris

Palpasi : 8/ normal kiri kanan

Perkusi : sonor

Auskultasi : 8R 1 8-S normal kiri kanan Ronkhi ,1, ;hee<in$ ,1,

Cor : -unyi "antun$ murni re$ular murmur =,>

$allop =,>



A!domen : ?atar lem!ut 2epar dan lientidak tera!a mem!esar tidak ada nyeri tekan !isin$usus normal

@kstremitas : Lihat status lokalis



Status Lokalis

?i$iti ke,5 : $an$ren

?orsalis pedis de4tra :a!ess ukuran B(5m

pus =>darah =,>



?ia$nosis er"a

Ulkus dia!etikum $rade I8 at re$io dorsalis pedisde4tra



Usul Pemeriksaan

?arah Rutin

0ula darah se+aktu dan % "am PP

Ront$en ,ray kaki kanan

Ront$en thora4



2asil Pemeriksaan penun"an$

?arah rutin 2! : ('.3

Leukosit : (D.%''

2t : )(5

#rom!osit : (D.'''

0?S : (E1('1() 59 m$1dL

(91('1() (5) m$1dL =% "am PP> %(1('1() %(% m$1dL

%%1('1() %'D m$1dL



2asil Pemeriksaan Penun"an$

#hora4 : Cor mem!esar aorta elon$asi sinus ostophrenius dan kedua

dia$6ra$ma tidak ada kelainan. Pulmo hili normal 6i!rosisrin$an di lapan$an atas paru kanan. #idak tampak in6iltrat

maupun lesi konsolidasi intrapulmonal. esan : Cardiome$ali den$an elon$asi aorta tanpa !endun$an

paru. /i!rosis rin$an dilapan$ atas paru kanan.



,ray e4tremitas !a+ah "ari AP1lateral -esar dan !entuk tulan$ tarsal metatarsal dan phalan$es

pedis de4tra masih dalam !atas normal. Sela dan permukaansendi normal tidak tampak 6raktur osteo6it lesi osteolitik

maupun lesi osteo!lastik pada tulan$ pedis de4tra. #ampaklesi radioluen pada "arin$an lunak pedis de4tra.

esan : emphisema "arin$an lunak pedis de4tra. Radiolo$i ostarsal metatarsal maupun phalan$es pedis de4tra tidaktampak kelainan.



#erapi

Umum : In6ormed onsent men$enai penyakit dan penan$anan

penyakit =tindakan de!ridement dan amputasi>.

Cairan NaCl preoperasi : ('5 4 3 "am 3)' F )5

tetes1"am. Puasa se!elum operasi minimal 3 "am.

husus : *et6ormin ta! %45'' m$

Ce6ota4im 7ial %4($r

Amlodipin ta! (4('m$



Pro$nosis

Guo ad 7itam : ad !onam

Guo ad 6un$sionam : du!ia ad !onam

Guo ad sanasionam : du!ia ad !onam



‘DIABETICS SHOULD

TREAT THEIR FEET LIKE THEY DO THEIR FACE’

?ia!eti 6oot



Introdution

/oot in6etions , amon$ the most 6reHuent andserious onseHuenes o6 dia!etes mellitus

Responsi!le 6or more hospital days than any other

ompliation o6 dia!etes?ealin$ +ith this pro!lem +ill reHuire !oth a

$reater understandin$ o6 the pathophysiolo$y o6these in6etions and !etter systems 6or implementin$

pro7en e66eti7e measures



?e6inition

International Consensus on ?ia$nosin$ and #reatin$the In6eted ?ia!eti /oot Any in6etion in7ol7in$ the 6oot in a person +ith dia!etes

ori$inatin$ in a hroni or aute in"ury to the so6t tissues o6 the

6oot +ith e7idene o6 pre,e4istin$ neuropathy and1or ishemia



Neuropathy

Sen!"# Loss o6 proteti7e sensation

Loss o6 position sense

M!$!" *usle +eakness /oot de6ormity

A%$!n!&'( Poor !lood 6lo+ re$ulation

?ry sti66 skin

Unaware of minor

cuts/bruises

Poor weight

distribution

Cracked skin

allows easy

entry of bacteria



/ore6oot uler due to Neuropathy

Inappropriately

high pressure

distribution



8asulopathy

Aelerated Atheroslerosis ?ia!etes

2ypertension

&!esity

A$e

?yslipidemia

Decreased

local blood flow

Poor

wound

healing

Poor

antibiotic

penetration



*iro!iolo$y o6 ?ia!eti 6oot

P!)#&'("!*'+) Serious in6etions in hospitali<ed patients are o6ten aused !y )F5

!aterial speies

Ae"!*e

0ram,positi7e oi S. aureus is the most important patho$en

@nterooi in patients +ho ha7e pre7iously reei7ed a ephalosporin

0ram,ne$ati7e !ailli Enterobacteriaceae in patients +ith hroni or pre7iously treated in6etions

Pseudomonas speies in patients +ith +ounds that ha7e !een soaked or treated +ith +et dressin$s

An+e"!*e ;ounds +ith ishemi nerosis or that in7ol7e deep tissues



Classi6iation

;a$ners Classi6iation o6?ia!eti Uler



0RA?@ ',, IN#AC# SIN=Impendin$Uler>

0RA?@ ( SUP@R/ICIAL



0RA?@ (F SUP@R/ICIALULC@RS



0RA?@ %F ?@@P #& #@N?&N -&N@&R LI0A*@N#



0RA?@ )F &S#@&*LI#IS



0RA?@ F 0AN0R@N@ &/ #&@ &R/&&#



0RA?@ 5F 0AN0R@N@ &/ @N#IR@/&&#



Priniples o6 *ana$ement

*ultidisiplinary approah *edial

Sur$ial

&rthopedis

@7aluation o6 the patient Look 6or dan$er si$ns needin$ ur$ent inter7ention

0ood -lood $luose ontrol

Lon$ term are a6ter +ound healin$ is omplete @duation and pre7enti7e 6oot are



?an$er si$ns 6or Ur$ent ation

Redness and s+ellin$ o6 a 6oot indiates ade7elopin$ a!sess and ur$ent sur$ery may !eneeded to sa7e the le$

Cellulitis disoloration and repitus =$as in so6ttissues>

Pink pain6ul pulseless 6oot e7en +ithout $an$reneindiates ritial ishaemia that needs ur$ent arterial

in7esti$ation 6ollo+ed !y sur$ial inter7ention +hene7er possi!le

/oot an !e sa7ed only i6 there is $ood !lood supply



Priniples o6 #reatment

S%",'(+) -e*"'-e&en$ ?rain pus and a!sess a7ities and to remo7e all neroti and

in6eted tissue inludin$ de7italised and in6eted !one resultin$ 6romosteomyelitis

E"+-'(+$'!n !. 'n.e($'!n Anti!ioti hoies should optimally !e !ased on results o6 ulture

I6 empirial therapy is neessary it should o7er S. aureus and anaerobes

-roader o7era$e should !e onsidered !ased on the history Klinial "ud$ment

Re-%($'!n !. /e',$ *e+"'n, .!"(e -ed rest +ith 6oot raised



Pre7ention

Re$ular 6oot e4ams and patient eduation anpre7ent E5 o6 amputations

/our -asi Steps 6or Pre7enti7e /oot are

@arly identi6iation o6 the hi$h risk dia!eti 6oot @arly dia$nosis o6 6oot pro!lems

@arly inter7ention to pre7ent 6urther deterioration that maylead to amputation

Patient eduation 6or proper are o6 the the 6eet and 6oot+ear

Care o6 6eet in a dia!eti



Care o6 6eet in a dia!eti

( . Any in"ury has to !e a7oided

% miroellular ru!!er =mr> 6oot+ear must !e used

) 6eet has to !e kept lean and dry espeially the

toes and le6ts hyperkeratosis has to !e a7oided



Summary

/oot uleration sepsis and amputation are kno+nand 6eared !y almost e7ery person +ho has dia!etesdia$nosed

et these are potentially the most pre7enta!le o6 alldia!eti ompliations !y the simplest tehniHues o6eduation and are

#he ma"ority an also !e ured !y immediate and

ener$eti treatment

crs ulkus diabetikum dika-ila.ppt

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