Post on 03-Apr-2018
7/28/2019 Visite Besar
1/1
Mrs.Sarmawati, 35 y.o, Room 3 bed 1, Lontara 3 RSWS
Enter to the hospital: May 21st 2013
FOLLOW UP
21/5/13 S: Ulcers arise for quail eggs, initially
in the area of the eyebrows and face,then came around the ears, feet, andnavel, initially for seed corn, gradually
enlarged and burst into sores and pus,itching (+), pain (+) experienced since
2 weeks ago.
-History of treatment (+) inhospitalization in hospitals Tenriwaru
bone for 1 week, but no change. drugsgiven ointment and oral medications
are forgotten by the patient-History of the illness (+) + IBDinfection stomach bleeding, DM (+)
-History of food allergy (+) seafood-History of drug allergy is not clear
O:Dermatology status:Location: Facialis regio
Eff: eritematous plaque, crustae,hiperpigmentation
Location: auricularis sinistra regioEff: ulcus, pusLocation: Umbilical regio
Eff: hiperpigmentationLocation: inferior extremities dextra
eff: ulcus, erythema, pus,
hiperpigmentation, edema, crustae
A: Pyoderma
R/
IVFD RLGentamicyn inj 80 mg (1 amp)/12h/iv
Compress 0.9% NaCl for 10minutes (morning-afternoon) to
the ulcus
Gentamicyn cream (morning-afternoon) after being compressedCeterizine 10 mg
(0-0-1)
Consultations to:NeurologistInternist
laboratory examinations:
Routine blood, urine routine,
urea, creatinine, GOT, GPT,GDS, HbA1c
22/5/13 S: loss of consciousness (+) but had
response, patients sometimes scratch.
R/
IVFD RL 20dpm
O:Dermatology status:
Location: Facialis regioEff: eritematous plaque, crustae,hiperpigmentation
Location: auricularis sinistra regioEff: ulcus, pus
Location: Umbilical regio
Eff: hiperpigmentationLocation: inferior extremities dextraEff: ulcus, erythema, pus,
hiperpigmentation, edema, crustae
A: Pyoderma ganggrenosum
Gentamicyn inj 80 mg (1 amp)/
h/ivCompress 0.9% NaCl for 10
minutes (morning-afternoon) tothe ulcusGentamicyn cream (morning-
afternoon) after being compressCeterizine 10 mg
(0-0-1)
P/ head CT Scan
Laboratory exam result:HB: 9,4
PLT: 607WBC: 12,8.103
23/5/13 S: patients still can not talk normally,can not sleep, restless, detachable
infusion (already requested reattach),the foul wound in occlusion compress
(dont do occlusion compress,compress ordinary)
O:
Dermatology Status:Location: Facialis regio
Eff: eritematous plaque, crustae,hiperpigmentationLocation: auricularis sinistra regio
Eff: ulcus, pusLocation: Umbilical regio
Eff: hiperpigmentationLocation: inferior extremities dextra
Eff: ulcus, erythema, pus,hiperpigmentation, edema, crustae
A: Pyoderma ganggrenosum
R/
IVFD RL 20dpm
Gentamicyn inj 80 mg (1 amp)/h/iv
Compress 0.9% NaCl for 10minutes (morning-afternoon) tothe ulcus
Gentamicyn cream (morning-
afternoon) after being compressCeterizine 10 mg
(0-0-1)