POMR (Problem Oriented Medical Record) Name Age : Tn.Abd Muntolib : 60 th CLUE AND CUE DATA BASE Tn.

Abd Muntolib 60 th KU: luka di pergelangan kaki kiri sejak 4 hari yll Anamnesis: Keluhan dirasa sejak hari yll, penderita duduk dikursi bambu, kemudian pada pergelangan kaki kiri terkena paku RPD: DM Rpk : DM Pemeriksaan fisik: T=140/100mmHg,Nadi= 84x/mnit reguler, t=38,5C, GCS 456t, TB= 166 cm, BB=70 kg Abdomen: liver dan limpa tidak teraba, bising usus normal Ekstremitas: Ulkus pedis sinistra pus +, nekrotik +, bau menyengat +, gringgingan, oedem Laboratorium GDA 502 mg/dl Laki2 60 th Ulkus pedis sinistra, pus, nekrotik, riwayat DM GDA 502 mg/dl PROBLEM LIST 1. Ulkus di kaki INITIAL DX 1.1 Ulkus diabetic DIAGNOSIS Cek GDA PLANNING THERAPY MONITORING pus, sansulin R 4 U/jam 4 x Ulkus, Sansulin R 3x10 U SC nekrotik, bau sblm makan PZ 20 tetes/menit Ceftriaxon 2x1 g Metronidazol 3x500 g tab Diet B 2100 kal Debridement EDUCATION Hygiene life syle

Laki2 60 th DM

2. DM 2.1 DM Tipe 2 2.2 DM Tipe 1

GDA, GD2PP, GDP

GDA, GDP

GD2PP,

Life style

Nyeri +/Laki2 60 th DM, gringgingan

3. Neuropa
ti perifer

Pmx fisik saraf 3.1 neuropati sensorik 3.2 neuropati motorik 3.3 nuropati autonomik

Life style Monitoring gula darah

SOAP
SUBJECTIVE 5 maret 2011 luka di kaki, oedem Ulkus OBJECTIVE ASSESMENT Diabetic foot, MODS, sepsis PLANNING Dx : konsul ke spesialis bedah, cek GDA Tx : sansulin R 4 U/jam 4 x Sansulin R 3x10 U SC sblm makan PZ 20 tetes/menit Ceftriaxon 2x1 g Metronidazol 3x500 g tab Diet B 2100 kal Dx : foto pedis Tx : due to one Debridement

6 maret 2011 luka di kaki, oedem 7 maret 2011

T: 140/80 mmHg, t: 36,6 C, N: 88 x/menit, GDA: 274 mg/dL

Diabetic foot, MODS, sepsis