POMR

CUE AND CLUE PL IDx PDx PTx PMo

Male/58 yo 1. Diabetic Pus Diet DM 1800 Kcal/day, Wound
foot W IV culture, low salt < 2 gram/day, Tax
A: gram Inj Ceftriaxon 2x1 g iv Leucocy
DM since 8 years staining Inf metronidazol 3x500mg te
Wound at pedis D since and Wound toilet Lab
20 days ago sensitivity Debridement result
test
PE arteriogra
Tax : 37.3 phy
Wound at pedis S,
swelling, redness, pus
(+)

Lab :
RBG : 294
Leuco :26.970
Ro pedis : gas gangren
(+)

Male/58 yo 2. DM Type II Diet DM 1800 Kcal/day, S,VS

History of DM Normowe low salt < 2 gram/day FBG,
Routine consume OAD ight on Inj. Insulatard 0-0-10 iu sc BG 2 PP
BMI: 23.44 OAD Inj. Actrapid 4-4-4 iu sc HbA1c
RBS 295 mg/d
 POMR
CUE AND CLUE PL IDx PDx PTx PMo
Male/58 yo 3. Septic 3.1 Diabetic Sputum, , Diet DM 1800 Kcal/day, Subj
A: condition foot Pus gram, low salt < 2 gram/day Vs
Cough 3.2 Lung culture Inj Ceftriaxon 2x1 g iv
Fever infection and Inf metronidazol 3x500mg
History of DM 3.2.2 Lung TB sensitivity Wound toilet
Wound at light pedis + secondary test Debridement
PE: infection
TD: 170/90
N: 105 regulerr, strong
RR: 204
T: 37.3
Wound a/r pedis D, Pus
(+), Blood (+), wet(+)

LAB
Hb: 8.8
WBC :26.970
 POMR
CUE AND CLUE PL Idx PDx PTx PMo
Male/58 yo 4. HT St II 4.1. Primary Fundusco PO: Captopril 3x25 mg S,VS,
History of 4.2. Secondary py UOP
hypertyension since 3
years ago
BP: 170/90 mmHg

Male/58 yo 5.Anemia 5.1. Chronic Transfusion PRC 1 kolf/day until CBC

Lab: NN inflamatory Hb>10mg/dl
Hb: 8.6 disease
MCH: 29.10 5.2. acute blood
MCV: 86.10 loss

Female/54yo 6. Azotemia 6.1 Diabetic USG Confirmed diagnosed Ur/Cr

Lab: renal kidney disease Abdomen UOP,
Ur: 131.9
Cr: 3.88
BUN/Cr: 15.88
 Problem analysis
Lung TB, UTI
Immunocomp
romised Diabetic foot

Social,low
economic,low
Diabetic foot Septic
education condition
Periferal arterial desease
Bad compliance

Macroangiopathy Nefropathy
Azotemia

DM type 2
Microangiopathy
 Risk Factor Analysis
Diabetes melitus Diabetic foot ulceration
1. Obesity 1. Diabetik neuropathy
2. Sedentary lifestyle 2. Long standing DM
3. Dislipidemia 3. Over 40% of type 2 DM
4. Unhealthy eating habit patients had significant
5. Family history and neuropath
genetics
6. Increased age
7. High Blood Pressure
and high cholesterol
8. History of gestasional
Diabetes
 Risk factor sepsis
Very young people and elderly people
Anyone who is taking immunosuppressive medications (such as transplant
recipients)
People who are being treated with chemotherapy drugs or radiation
People who have had their spleen surgically removed (the spleen helps
fight certain infections)
People taking steroids (especially over the long term)
People with longstanding diabetes, AIDS, or cirrhosis
Someone who has very large burns or severe injuries
People with infections such as
pneumonia,
meningitis,
SBP
cellulitis,
urinary tract infection
 Manajemen analysis
Emergency
1. Diabetic foot
Inj Ceftriaxon 2x1 g iv
Inf metronidazol 3x500mg
Wound toilet
Debridement
 Manajemen analysis
Urgency
2. Septic condition
Diet DM 1800 Kcal/day, low salt < 2 gram/day
Inj Ceftriaxon 2x1 g iv
Inf metronidazol 3x500mg
Wound toilet
Debridement
 Manajemen analysis
3. HT ST 2
Po: Captopril 3x25 mg
4. Anemia NN
Transfusion 2 kolf/hr until RBS>10
 Condition this morning

BP:
PR
RR:
Tax
UOP:
 Klasifikasi Wagner
Derajat 0 : Tidak ada lesi terbuka, kulit masih utuh dengan
kemungkinan disertai kelainan bentuk kaki seperti claw,
callus.
Derajat I : Ulkus superficial terbatas pada kulit.
Derajat II : Ulkus dalam menembus tendon dan tulang.
Derajat III : Abses dalam, dengan atau tanpa osteomielitis.
Derajat IV : Gangren jari kaki atau bagian distal kaki dengan
atau tanpa selulitis.
Derajat V : Gangren seluruh kaki atau sebagian tungka