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)