Post on 04-Jun-2018
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
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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 %'()
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eluhan Utama
Luka di kaki kanan
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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.
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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$a mudah haus.
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Pasien men$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.
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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.
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Pemeriksaan /isik
Status 0eneralis
eadaan Umum : Composmentis tampak sakitsedan$
#ekanan darah : %)'1()' mm2$Nadi : 93 4 1 menit
Respirasi : %' 1 menit
Suhu : a6e!ris
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epala : on"un$ti7a tidak anemis Sklera tidakikterik
Leher : 0- tidak tera!a mem!esar J8P tidak
menin$kat
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#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 =,>
$allop =,>
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A!domen : ?atar lem!ut 2epar dan lientidak tera!a mem!esar tidak ada nyeri tekan !isin$usus normal
@kstremitas : Lihat status lokalis
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Status Lokalis
?i$iti ke,5 : $an$ren
?orsalis pedis de4tra :a!ess ukuran B(5m
pus =>darah =,>
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?ia$nosis er"a
Ulkus dia!etikum $rade I8 at re$io dorsalis pedisde4tra
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Usul Pemeriksaan
?arah Rutin
0ula darah se+aktu dan % "am PP
Ront$en ,ray kaki kanan
Ront$en thora4
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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$1dL
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2asil Pemeriksaan Penun"an$
#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.
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,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.
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#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($r
Amlodipin ta! (4('m$
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Pro$nosis
Guo ad 7itam : ad !onam
Guo ad 6un$sionam : du!ia ad !onam
Guo ad sanasionam : du!ia ad !onam
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‘DIABETICS SHOULD
TREAT THEIR FEET LIKE THEY DO THEIR FACE’
?ia!eti 6oot
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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
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?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
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Neuropathy
Sen!"# Loss o6 proteti7e sensation
Loss o6 position sense
M!$!" *usle +eakness /oot de6ormity
A%$!n!&'( Poor !lood 6lo+ re$ulation
?ry sti66 skin
Unaware of minor
cuts/bruises
Poor weight
distribution
Cracked skin
allows easy
entry of bacteria
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/ore6oot uler due to Neuropathy
Inappropriately
high pressure
distribution
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8asulopathy
Aelerated Atheroslerosis ?ia!etes
2ypertension
&!esity
A$e
?yslipidemia
Decreased
local blood flow
Poor
wound
healing
Poor
antibiotic
penetration
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*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
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Classi6iation
;a$ners Classi6iation o6?ia!eti Uler
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0RA?@ ',, IN#AC# SIN=Impendin$Uler>
0RA?@ ( SUP@R/ICIAL
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0RA?@ (F SUP@R/ICIALULC@RS
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0RA?@ %F ?@@P #& #@N?&N -&N@&R LI0A*@N#
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0RA?@ )F &S#@&*LI#IS
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0RA?@ F 0AN0R@N@ &/ #&@ &R/&&#
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0RA?@ 5F 0AN0R@N@ &/ @N#IR@/&&#
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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
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?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 $ood !lood supply
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Priniples o6 #reatment
S%",'(+) -e*"'-e&en$ ?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
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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$nosis o6 6oot pro!lems
@arly inter7ention to pre7ent 6urther deterioration that maylead to amputation
Patient eduation 6or proper are o6 the the 6eet and 6oot+ear
Care o6 6eet in a dia!eti
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Care o6 6eet in a dia!eti
( . Any in"ury has to !e a7oided
% miroellular ru!!er =mr> 6oot+ear must !e used
) 6eet has to !e kept lean and dry espeially the
toes and le6ts hyperkeratosis has to !e a7oided
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Summary
/oot uleration sepsis and amputation are kno+nand 6eared !y almost e7ery person +ho has dia!etesdia$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
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