Kurnia Ari / 23 thn / MR : 16020635

Admission : 01-02-2016
Consultant : dr. Almahitta, SpBP-RE
Working Diagnosis :
-

Raw Surface at scrotum, perineal, and bilateral inguinal due to bilateral inguinal
abscess, perianal abscess, fornier gangren that had been performed incision drainage

Signet ring cell ca recti 1/3 distal T4N0M0 in Chemoteraphy with Colostomy

Present State
State
BP
: 130/80x/min
HR
: 80 x/min

RR : 20x/min
Temp : 36,7oC

Lokal status :
oedema (-), hyperemic (+), pus (+) minimal, slough (+) minimal,

Clinical Picture

Laboratori
um

01-022016

02-0216

05-0216

07-02-16

12-2-2016

18-022016

PT

12.3

APTT

26.2

INR

1.10

Haemoglob
n

10.0

12.1

13.2

11.8

8.6

Haematocr
it

29

35

40

36

26

27.000

20.900

18.600

17.800

10.700

Trombosit

314.000

287.000

451.000

541.000

261.000

Na / K

122/3.8

Ur/Cr

30/0.75

AST/ALT

142/4.6

Leukosit

GDS

119

134/4.9

129/3.5

115

Laboratori
um

20-2-2016

28-2-2016

PT

12.3

APTT

26.2

INR

1.10

5/3/2016

Haemoglobn

11.2

10.0

10.3

Haematocrit

36

29

32

16.100

8.900

12.900

614.000

781.000

Leukosit
Trombosit
Na / K
Ur/Cr
AST/ALT
GDS
Alb/prot

129/3.8

132/4.1
30/0.75
35/60
99
2.5/5.5

3.8/7.0

Pus Cultur 02/02/16

Sample : Pus
Bacteria: E. Coli
Sensitive : Amikasin, ampicilin sulbaktam,
cefepim, ceftazidim,
ceftriaxone,
cephazoline, ciprofloxacin, gentamicin,
meropenem, tigecyclin
Resisten : (-)

Pus Cultur 16/02/16

Sample : Pus
Bateria : E. Coli
Sensitive : Amikasin, ampicilin sulbaktam,
cefepim, ceftazidim,
ceftriaxon,
cephazolin, ciprofloxacin, gentamicin,
meropenem, tigecyclin
Resisten : (-)

Management
IVFD RL 1500 cc/24 jam
Diet High Calorie high protein 1500 Kkal + protein 1-2gr/KgBB/24 jam
Stoma care +hygiene control
Ciprofloxacin 2x500mg po
Wound care 1x/day with Prontosan solution
Plan to defect closure with STSG