LAPORAN KASUS

ULKUS DEKUBITUS

Oleh :
I Komang Surya Mertayasa
15710360

Supervisor :
dr. Dyah Ratri Anggarini,Sp.KK

SMF ILMU PENYAKIT KULIT DAN KELAMIN

RSU DR. WAHIDIN SUDIROHUSODO MOJOKERTO
FAKULTAS KEDOKTERAN
UNIVERSITAS WIJAYA KUSUMA SURABAYA
2021

LEMBAR PENGESAHAN

i
 LAPORAN KASUS

SMF ILMU PENYAKIT KULIT DAN KELAMIN

“Ulkus Dekubitus”

Oleh:

I Komang Surya Mertayasa 15710360

Laporan Kasus ini telah diujikan dan dipresentasikan di depan dokter

pembimbing SMF Ilmu Penyakit Kulit dan Kelamin kepaniteraan klinik
RSU dr. Wahidin Sudiro Husodo kota Mojokerto pada :

Hari : Selasa

Tanggal : 11 Mei 2021

Mengetahui

Dokter Pembimbing

dr. Dyah Ratri Anggarini,Sp.KK

KATA PENGANTAR

ii
 Puji syukur kehadirat Tuhan Yang Maha Esa karena atas karunia nya saya
dapat menyelesaikan tugas Laporan Kasus. Laporan Kasus ini disusun untuk
memenuhi tugas kepaniteraan klinik di SMF Ilmu Penyakit Kulit dan Kelamin
dengan judul “Ulkus Dekubitus”.

Saya mengucapkan terima kasih kepada dr. Dyah Ratri Anggarini, Sp.KK
selaku dosen pembimbing serta teman yang turut membantu dalam penyusunan
Laporan Kasus ini hingga selesai.

Saya menyadari Laporan Kasus ini masih banyak kekurangan, sehingga

kritik dan saran yang membangun sangat saya harapkan demi kesempurnaan
Laporan Kasus ini. Semoga bermanfaat bagi pembaca.

Mojokerto, 10 Mei 2021

Penulis

DAFTAR ISI

iii
LEMBAR PENGESAHAN.....................................................................................ii
KATA PENGANTAR............................................................................................iii
DAFTAR ISI...........................................................................................................iv
CHAPTER I.............................................................................................................1
CASE REPORT.......................................................................................................1
A. PATIENT IDENTITY..................................................................................1
B. HISTORY.....................................................................................................1
C. GENERAL STATUS....................................................................................2
D. LOCALIST STATUS...................................................................................3
E. CLINICAL PHOTOS...................................................................................3
F. EXAMINATION SUPPORT........................................................................4
G. DIAGNOSIS.................................................................................................6
H. PLANNING..................................................................................................6
I. PICTURE OF DURANTE OP. (HERNIORAPHY)....................................7
J. FOLLOW UP................................................................................................7
CHAPTER II..........................................................................................................11
LITERATURE REVIEW......................................................................................11
A. Definition.......................................................................................................11
B. Etiology..........................................................................................................11
C. Classification.................................................................................................11
D. Anatomy and Physiology..............................................................................14
E. Pathophysiology.............................................................................................16
F. Clinical Manifestations..................................................................................18
G. Physical Examination....................................................................................18
H. Supporting Examination................................................................................21
I. Differential Diagnosis.....................................................................................21
J. Complications.................................................................................................21
K. Management..................................................................................................22
L. Prognosis........................................................................................................23
CHAPTER III........................................................................................................24

iv
CONCLUSION......................................................................................................24
REFERENCES.......................................................................................................25

v
 BAB I

LAPORAN KASUS

A. IDENTITAS PASIEN
Nama : Ny. Kweni Ningsih
Umur : 77 tahun
Tempat & Tanggal lahir : Mojokerto, 31 Desember 1943
Alamat : Pecuk Ngabar Jetis
Pekerjaan : Ibu Rumah Tangga
Status Menikah : Menikah
Agama : Islam
Suku : Jawa
Tanggal MRS : 20 April 2021
Tanggal KRS : 24 April 2021
No. RM : W2103334181

B. ANAMNESIS
Keluhan utama :
Luka pada bagian atas bokong, lutut kiri, dan kelamin.
Riwayat penyakit sekarang :
Pasien baru masuk dengan keluhan adanya luka pada bagian atas bokong,
lutut kiri dan kelamin yang dialami sejak +1 bulan yang lalu. Luka
tersebut dengan ukuran bervariasi. Ukuran terbesar pada bagian bokong.
Pada bagian bokong luka berwarna kemerahan serta terasa nyeri. Selain itu
pasien juga mengeluh nafsu makannya menurun. dan susah BAB. Riwayat
demam tidak ada, mual dan muntah tidak ada. Buang air kecil biasa.
Menurut keluarga, pasien mempunyai riwayat jatuh saat di rumah kurang
lebih 2 bulan yang lalu. Akibat dari jatuh tersebut pasien menjadi sulit
untuk berjalan. Sehingga pasien dirawat di rumah sakit selama 1 minggu.
Setelahnya pasien pulang, pasien hanya berbaring dan terlentang ditempat

1
 tidur selama kurang lebih 1 bulan. pasien jarang bergerak di tempat tidur
dan selalu terlentang.
Riwayat penyakit sebelumnya :
Riwayat Diabetes Melitus (-), Hipertensi (-), alergi makanan dan obat-
obatan (-) Riwayat penyakit keluarga : Tidak ada keluarga yang
mempunyai riwayat yang sama dengan pasien. Riwayat Diabetes Melitus
(-), Riwayat Penyakit hipertensi (-).

C. PEMERIKSAAN FISIK
Status Generalisata : Sakit sedang
Tanda Vital :
TD : 120/70 mmHg Pernapasan : 22 x/menit
Nadi : 88 x/menit Suhu : 36,9 0C
Kepala : Bentuk normocephali
Conjunctiva anemis - / -
Sclera ikterik - / -
Leher : Pembesaran kelenjar getah bening (-)
Pembesaran kelenjar tiroid (-)
Thorax

Paru-Paru

- Inspeksi : simetris bilateral

- Palpasi : vocal fremitus kanan = kiri
- Perkusi : sonor (+) pada seluruh lapang paru
- Auskultasi : Vesikuler (+/+), Rhonki (-/-), Wheezing (-/-)

Jantung

- Inspeksi : Ictus cordis tidak tampak

- Palpasi : Ictus cordis teraba pada SIC V midclavicula sinistra
- Perkusi : batas jantung normal
- Auskultasi : Bunyi jantung I/II reguler (+), Gallop (-),Murmur (-)

2
Abdomen

- Inspeksi : kesan datar

- Auskultasi : peristaltik (+), kesan normal
- Perkusi : tympani (+) pada seluruh lapang abdomen
- Palpasi : Nyeri tekan (-) Hepatomegali (-), Splenomegali (-)
Ekstremitas
- Superior : akral hangat (+/+), edema (-/-)
- Inferior : akral hangat (+/+), edema (-/-)

D. Status Lokalis :
Regio sacrum
- Inspeksi : Tampak luka terbuka berukuran 12 x 9 cm, eritema (+) dengan
pinggir kehitaman , dasar otot, pus (-), jaringan nekrotik (-).
- Palpasi : nyeri tekan (+), fluktuatif (-)
Regio Genu sinistra :
- Inspeksi : Tampak luka berukuran 5x3 cm, eritema (+), jaringan nekrotik
(-),pus (-).
- Palpasi : nyeri tekan (+), fluktuatif (-)

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 E. Foto Klinis

Regio Sacrum

F. Pemeriksaan Penunjang

1. Darah Lengkap

PARAMETER RESULT NORMAL VALUE

Leukosit 9.80 3.60 – 11.00
Hemoglobin L 10.2 11.7 – 15.5
Eritrosit 3.88 3.80 – 5.20
Hematokrit L 32.4 35.0 – 47.0
Trombosit H 431 150 – 400
PDW 9.4 9.0 – 17.0
MPV L 8.7 9.0 – 13.0
P-LCR 14.8 13.0 – 43.0
MCV 83.5 80.0 – 100.0
MCH 26.3 26.0 – 34.0
MCHC L 31.5 32.0 – 36.0

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 RDW-CV H 14.8 11.5 – 14.5
RDW-SD 47.4 37.0 – 54.0
Neutrofil 63.2 50.0 – 70.0
Limfosit 26.3 25.0 – 40.0
Monosit H 10.5 2.0 – 8.0
Jumlah Netrofil 6.20 1.50 – 7.00
Jumlah Limfosit 2.60 1.00 – 3.70
Jumlah Monosit 1.00 0 – 0.7
Ratio N / L 2.38 < 3.13
Glukosa Sewatu LL 33 < 200
BUN H 19.4 7.0 – 18.0
Kreatinin Darah 1.16 0.50 – 1.06
Kalsium 9.20 8.40 – 10.20
Natrium 136.5 136.0 – 145.0
Kalium 4.05 3.5 – 5.1
Chlorida Darah 107.0 98.0 – 107.0
Antigen SARS-COV-2 Negatif Negatif

G. DIAGNOSIS

Diagnosis : Ulkus Dekubitus Grade III Regio Sacrum

H. PLANNING

Planning Diagnose : Complete Blood

Thorax Photo
ECG
Planning Therapeutic : Inf. RL 21 tpm
Cefuroxim 2 prophylaxis vial drip PZ 100 cc
Inj. Ketorolac 3x30 mg

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 Planning Action : Install NGT
Install catheter
Trendelenburg Position
Total Fasting
Planning Monitoring : TTV
Clinical

I. PICTURE OF DURANTE OP. (HERNIORAPHY)

J. FOLLOW UP

Pre Op

10/02/2020

S The patient said pain in a lump in the right abdomen.

Nausea (-), vomit (-).
Past medical history: BPH had surgery 2 weeks ago
O General circumstances : enough
BP : 110/70 mmHg
Temperature : 36°C

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 Pulse : 84×/minute
Pain Scale :3

A Hernia Inguinalis Lateralis Inkarserata Dextra

P Planning Diagnosis :
- Complete Blood
- Thorax’s Photos
- ECG

Therapy Planning :

- Inf. RL 21 tpm
- Prophylaxis of Cefuroxim 2 vial drip PZ 100 cc
- Inj. Ketorolac 3x30 mg

Action Planning :

- Trendelenburg position
- Install NGT
- Install the Catheter
- Total fasting
- Cardio anesthesia report
- The program tomorrow morning at 8 a.m. at OK
IGD

Planning Monitoring :

- TTV
- Clinical

Post Op

11/02/2020

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S The patient complained of post op pain

O General circumstances : enough

TD : 110/70 mmHg
Pulse : 92× / minute
Temperature : 36 ° C
A Post op hernioraphy day 1
P Therapy Planning:
- Bed rest 12 hours
- Diet 6 hours drinking, 8 hours eating rice
- Inf. RL 21 tpm
- Inj. Metamizole 3×1 g
- Inj. Ketorolac 3×10 mg
- Cefuroxime 2×750 mg
Planning Monitoring :
- TTV
- Clinical

12/02/2020
S The patient says pain is reduced
O General circumstances : weak
Febris (-)
Pain scale 3
Scrotum is somewhat edema
A Post op hernioraphy day 2
P Therapy Planning:
- PO Meloxicam 2×15 mg
- PO Cefixime 2×100mg
Action Planning:
- Can KRS at any time
Planning Monitoring :

8
 - TTV
- Clinical

13/02/2020

S The patient said post op pain was reduced

O General circumstances : enough

Febris (-)

A Post op hernioraphy day 3

P Therapy Planning :

- PO Meloxicam 2×15 mg
- PO Cefixime 2×100mg
Action Planning :

- Acc KRS
- Control February 18, 2020

Planning Monitoring :

- TTV
- Clinical

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 CHAPTER II

LITERATURE REVIEW

A. Definition

A hernia is an abnormal protrusion of part or all of the intra-abdominal

organs through a hole or defect in the abdominal wall that is coated by the

peritoneum.

The lateral inguinal hernia (indirect) is a hernia that passes through the

internal inguinal ring located lateral to the inferior epigastric vasa, along the

inguinal canal and out into the abdominal cavity through the external inguinal

ring.

B. Etiology

In general, hernias are caused by :

1. The existence of an open vaginal processus

2. Chronic increased intra-abdominal pressure such as chronic cough, prostatic

hypertrophy, constipation, ascites

3. Abdominal wall muscle weakness and connective tissue degeneration due to

old age

4. Multiparous pregnancy and obesity

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C. Classification

There are so many explanations regarding the classification of hernias, here is an

explanation :

1. Hernia based on occurrance is divided into 2 groups:

a. Congenital hernias

Where the incidence of a hernia was born. This is due to the weak abdomen

walls. Usually inguinal hernia and umbilical hernia.

b. Akuisita hernias

Where there hernia occurs because it is acquired.

2. Regional hernias:

a. Inguinal hernia

The inguinal hernia itself is divided into:

1) Indirect / lateral

These hernias occur through the inguinal ring and pass through the

spermatic cords through the inguinal canal. This generally occurs in men

than women. Generally patients complain of a lump in the groin and can

shrink or disappear during sleep.

2) Direct / medial

These hernias pass through the abdominal wall in the area of muscle

weakness. This hernia is called direct because it goes directly to the

external inguinal ring so that even though the internal inguinal ring is

pressed when the patient stands or pushes a lump will still arise.

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 b. Femoral

Femoral hernias occur through the femoral ring and are more common in

women than in men. This starts as a blockage of fat in the enlarged femoral

canal and gradually draws the peritoneum and is almost unavoidable into the

bladder into the sac.

c. Umbilical

Umbilical hernias in adults are more common in women because of

increased abdominal pressure. This usually occurs in obese people or

multiparous women.

d. Incisional

Intestinal trunks or other organs protrude through weak scar tissue or

surgical scars.

3. Based on the occurrence of hernias divided into:

a. Congenital / congenital hernias

Congenital hernias can occur since the baby is born due to the process of

vaginalis that does not close completely when the baby is in the womb.

b. Get a hernia

Hernia acquisition is due to a trigger factor.

4. Based on its nature hernias are divided into:

a. Reponible hernias

Namely if the contents of the hernia can go out and enter. Intestine exits

when standing or straining and comes back when lying down or pushed in,

there are no complaints of pain or symptoms of intestinal obstruction.

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 b. Ireponible hernias

That is if the contents of a hernia bag cannot be returned to the cavity. This

usually occurs due to adhesions of the contents of the bag in the hernia sac

peritoneum.

c. Incarcerated or strangulated hernias

That is if the contents of the hernia are pinched by the hernia ring.

Incarcerated hernia means the contents of the trapped bag and cannot return

to the abdominal cavity accompanied by a result of intestinal passage and

vascularity disorders. Strangulated hernias result in necrosis of the contents

of the abdomen in them because they do not get blood due to pinched blood

vessels.

D. Anatomy and Physiology

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 The abdominal wall muscles are divided into four namely musculus

rectus abdominis, musculus obliqus abdominis internus, musculus transversus

abdominis. The inguinal canal arises due to the descending testiculorum, where

the testis does not penetrate the abdominal wall but instead pushes the ventral

wall of the abdomen forward. This channel runs from cranio-lateral to medio-

caudal parallel to the inguinal ligament, length : + 4 cm.

The inguinal canal is limited in the craniolateral by the internal inguinal

ring which is an open part of the transverse fascia and aponeurosis of the

transversus abdominis muscle in the lower medial, above the pubic tubercle.

This canal is limited by the external ring. The roof is the external aponeurosis

of the obliqus musculus and at the base there is the inguinal ligament. The

canal contains the sperm cord and the sensitivity of the inguinal region,

scrotum and a small portion of the skin, the upper limb proxymedially.

In a state of relaxation of the abdominal wall muscles, the part that limits

the internal annulus is loose. In this situation the intra-abdominal pressure is

not high and the inguinal canal runs more vertically. We recommend that if the

abdominal wall muscles contract the inguinal canal goes more transversely and

the inguinal ring is closed so that it can prevent intestinal entry into the

inguinal canal. In healthy people there are three mechanisms that can prevent

inguinal hernia, namely the inguinal canal which runs obliquely, the muscular

structure of the obliqus internus abdominis that closes the internal inguinal ring

when contracting and the presence of a strong transversal fascia that covers the

hasselbach trigonum which is generally almost non-muscular so that there is an

14
 muscular obliqus internus interference with this mechanism can cause inguinal

hernias.

E. Pathophysiology

Hernias consist of 3 elements, namely hernia pouches consisting of

peritoneum, hernia contents that usually consist of intestine, omentum,

sometimes containing other intraperitoneal organs or extraperitoneal organs

such as ovaries, appendices, diverticles and bladder. The last element is the

structure that covers the hernia pouch which can be in the form of umbilical

skin (scrotum) or other organs such as the lung and so on. Usually hernias in

adults occur due to old age, because in old age the muscles of the abdominal

wall become weakened. As we get older, our organs and tissues undergo a

degeneration process. In adults the canal has closed. However, because this

area is a locus minoris resistance, in situations that cause increased

intraabdominal pressure such as chronic coughing, strong sneezing, straining

and lifting heavy items. Canals that have been closed can open again and arise

lateral inguinal hernia due to pushing something body tissue and out through

the defect.

Potential complications occur adhesions between the hernia nucleus with

the hernia bag wall so that the contents of the hernia cannot be reinserted.

There is an emphasis on the hernia ring, due to the increasing number of

intestines that enter, the hernia ring becomes narrow and causes flatulence,

vomiting, constipation. If the incarceration is left unchecked, it will cause

15
edema resulting in blood vessel pressure and necrosis. Complications of

hernias depend on the circumstances experienced by the contents of the hernia.

These include simple bowel obstruction to intestinal perforation which can

eventually lead to local abscesses and peritonitis.

In the lateral inguinal hernia (indirect) the bowel curves exits through the

inguinal canal and follows the spermatic cords (male) or the surrounding

ligaments (female). This is caused by the failure of the prosessus vaginalis to

close the testicles down into the scrotum or ovary fixation.

In fetal growth (about 3 weeks) the testicles which are located initially

above experience a decrease (desensus) towards the scrotum. When the testes

descend through the inguinal until the peritoneal vaginal process in the open

peritoneal cavity is obliterated and after the testis reaches the scrotum, the

peritoneal vaginalis prosessus is completely closed (obliteration). If there is

obliteration, then the entire peritoneal vaginalis process is open, a lateral

inguinal hernia occurs. Lateral inguinal hernias are more commonly found on

the right side (about 60%). This is because the process of desensus and the

right testis is slower than the left. Indirect inguinal hernias occur through the

inguinal ring and pass through the spermatic cords through the inguinal canal.

This generally occurs in men and women. The incidence is highest in infants

and young children. Hernias can become very large and often descend into the

scrotum.

Direct inguinal hernias occur through the abdominal wall in areas of

muscle weakness, not through canals as in indirect inguinal and femoral

16
 hernias. This is more common in the elderly.

F. Clinical Manifestations

In general, complaints from adults in the form of a bump in the inguinal

arises when straining, coughing or lifting heavy loads and disappearing at

recess, it is called an reponible hernia. If the contents of the hernia cannot be

re-entered, it is called an irreponible hernia. If there is clamping of the contents

of the hernia by the annulus and a passage of intestinal content occurs and/or a

vascular disorder, it is called an incarcerated hernia.

Signs and symptoms include :

a. A lump in the groin folds.

b. If the contents are squeezed will cause feelings of pain in that place

accompanied by feelings of nausea.

c. If there is an inguinal hernia strangulate the feeling of pain will get worse

with the skin over it becomes red and hot.

d. Small femoral hernias may contain bladder walls causing symptoms of

urinary pain (dysuria) accompanied by hematuria (blood urine), a lump

under the groin.

e. Diaphragmatic hernias cause feelings of pain in the abdomen accompanied

by shortness of breath.

f. If the patient strains or coughs, the hernia lump will increase

17
G. Physical Examination

 Inspection: note asymmetrical conditions on both sides of the groin,

scrotum or labia in a standing or lying position. The patient is asked to

strain or cough so that a lump or asymmetrical condition can be seen.

 Palpation : performed in the presence of a hernia lump, palpated in

consistency, and tried to encourage whether the lump can be replicated.

After the lump has been repositioned with the index finger or little finger

in children, sometimes the hernia ring can be felt in the form of a widening

inguinal annulus.

Special Inspection :

1. Ziemann test

- Right hernia examined with right hand

- Patients are told to push or cough

- 2nd finger in the internal annulus, 3rd finger in the external annulus,

4th finger in the ovalis fossa (1 cm above the inguinal ligament)\

- HIL : push on the 2nd finger

- HIM : push on the 3rd finger

- Femoral Hernia : push on the 4th finger

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2. Finger test

- Using a finger inserted through the scrotum through the external

annulus into the inguinal canal

- Sufferers are told to push

- HIL : felt at the fingertips

HIM : felt on the side of the finger

3. Thumb test

- Annulus inetrnus is pressed with the thumb and the patient is told to

push

- HIL: The lumps did not come out

- HIM : lumps out

19
 - Femoral Hernia: lumps out

H. Supporting Examination

Investigations in inguinal hernias include:

1. Complete blood count and serum electrolytes can show hemoconcentration

or increase in hematocrit, increase in white blood cells and electrolyte

imbalance in hernias.

2. Ultrasound examination can help distinguish incarcerated hernias with

lymph node abnormalities and other masses.

3. Abdominal X-ray can show abnormal gas levels in the intestine or

intestinal obstruction.

I. Differential Diagnosis

 Medial or femoral inguinal hernia

 lymphadenitis

 Varicocele, hydrocele

 Testicular tumor

20
  Orchitis

 Cryptokismus

 Lipoma

J. Complications

If not treated immediately, the hernia will get bigger and more pressing

on the surrounding tissue or organs. This condition can cause complications

that can be experienced by hernia patients. These complications include:

1) Incarcerated hernia (hernia obstruction), which is a condition when the

intestine is trapped in the abdominal wall or in the hernia sac (ingunal

canal), so that it interferes with the intestinal work such as electrolyte

disturbances, fluid balance and acid base.

2) Strangulated hernias, which are conditions when the intestine or tissue is

pinched, so that blood flow or supply is obstructed. If not treated

immediately, this condition can be life-threatening. Strangulated hernias

usually occur when hernia obstruction is not treated immediately. Surgery

must be done immediately to prevent tissue death.

K. Management

1. Conservative : Reposition and position of trendelenburg

 Bimanual repositioning method: the left hand holds the contents of the

hernia while forming a funnel while the right hand pushes it toward the

hernia ring with a slight gentle pressure that remains until repositioning

21
 occurs.

2. Definitive : Performed surgery.

 The principle of hernia surgery is to remove the peritoneal sac and close

the inguinal base defect. These goals are achieved by herniotomy

surgery (cutting the hernia sac), hernioraphy (closing the inguinal base

defect with the tissue around the defect), and hernioplasty (closing the

defect or strengthening the inguinal base with a prosthesis).

L. Prognosis

Prognosis depends on the general condition of the patient and the

accuracy of treatment. But it is generally 'good' because recurrence after

surgery is rare. Except in recurrent hernias or large hernias that require the use

of prosthetic material. In hernias this is important is to prevent predisposing

factors.

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 CHAPTER III

CONCLUSION

In history taking, the patient complains of pain in a lump in the lower right

abdomen. Lumps existed since ± 7 years ago, but never painful. Fever (-), nausea /

vomiting (-). The lump cannot enter alone. Flatus (+). History of BPH surgery 2

weeks ago. After surgery, urinate often straining. Normal bowel movements.

Good appetite / drinking.

Past Medical History : BPH (+), DM (-), HT (-)

Family History : denied

Treatment History : denied

On physical inspection, it was found that there were lumps in the right

inguinal region, erythema (-), the same color as the surrounding tissue. While on

palpation there are lumps, springy consistency, firm boundaries, tenderness (+),

unable to re-enter the abdominal cavity.

23
 On Supporting examination, complete blood obtained increased leukocytes

(leukocytosis).

From the results of history, physical examination, and supporting

examination the diagnosis patient has a Hernia Inguinalis Lateralis Inkarserata

Dextra.

REFERENCES

Brunicardi CF, et al. 2009. Inguinal Hernias. Schwartz’s Manual of Surgery 8th
Edition. McGraw-Hill Medical Publishing. New York.
Sherwinter, D.A. 2011. Open Inguinal Hernia Among Adults In The US
Population. Am J Epidemiol.
Sjamsuhidajat, R. 2011. Bukuajar Ilmu Bedah Edisi 3. Jakarta: EGC.

Townsend, Courtney M. 2010. Hernias. Sabiston Textbook of Surgery 17th

Edition. Philadelpia. Elsevier Saunders.

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