Wednesday Shift

March, 3th 2021

 VISI
PROGRAM STUDI PENDIDIKAN DOKTER SPESIALIS ILMU PENYAKIT DALAM
FAKULTAS KEDOKTERAN UNIVERSITAS LAMBUNG MANGKURAT

Menjadi Institusi Program Pendidikan Dokter Spesialis Penyakit Dalam yang

unggul dan berdaya saing nasional, dalam menyelenggarakan Tri Dharma
perguruan tinggi dengan mengembangkan IPTEKDOK khususnya
berwawasan penyakit di lingkungan lahan basah.
 MISI
PROGRAM STUDI PENDIDIKAN DOKTER SPESIALIS ILMU PENYAKIT DALAM
FAKULTAS KEDOKTERAN UNIVERSITAS LAMBUNG MANGKURAT

1. Menyelenggarakan program pendidikan dokter spesialis Penyakit Dalam yang

menghasilkan SDM berkualitas sebagai pendukung pembangunan nasional terutama
permasalahan kesehatan berwawasan penyakit di lingkungan lahan basah
2. Menyelenggarakan penelitian yang menghasilkan IPTEKDOK sesuai dengan kebutuhan
prioritas pembangunan nasional terutama permasalahan kesehatan berwawasan penyakit
di lingkungan lahan basah.
3. Menyelenggarakan pengabdian kepada masyarakat dan menyebarluaskan IPTEKDOK
untuk meningkatkan kualitas hidup masyarakat terutama permasalahan kesehatan
berwawasan penyakit di lingkungan lahan basah.
4. Memantapkan kerjasama dengan pemerintah daerah diwilayah Kalimantan, perguruan
tinggi dalam dan luar negeri, pengusaha dan para pihak lainnya untuk peningkatan
pelaksanaan Tridharma Perguruan Tinggi dan Pengadaan sumber dana (Income
generating).
5. Meningkatkan transparansi dan akuntabilitas dalam manajemen pengelolaan Program
Pendidikan Dokter Spesialis Penyakit Dalam
PATIENT’s DATA

TEAM PATIENTS
PDP 12
PDW 14
ISO 4
PATIENT’s DATA (3/3/2021)
New Patients

• 2 patients

Transferred Patients

• 2 patient

Dead Patients

• 0 patient
 New Patient in ER (3/3/21)

No Name/Age Diagnosis Info

1 Ny. Norlatipah/44th 1. History of hematemesis, anemia HM, mild hipokalemi MRS Aster

2 Tn. Akhmad HB/64th 1. Obstructive Jaundice, cholelithiasis, HT, Anemia NN MRS Aster

3 Ny. Pirliana/48 thn 1. Acute superimposed on CKD stg V, hiperkalemia Stagnant di IGD

4 Tn. Dedik Marwiyanto S/34 thn 1. SOB, CKD stg V HD rutin, Anemia, HT, HF stg C fc IV Stagnant di IGD
 Consult To IPD (3/3/21)
No Name/Age Diagnosis Info

1 Ny. Norjenah/57th Covid 19 confirmed, DM, elevated liver enzyme,

hiponatremi, JF stg C FC IV

2 Ny. Rusminah/64th Probable Covid, DM tipe 2

3 Ny. Sulimah/54th Osteomyelitis kronis a/r femus Sinistra, HT,

From Orthopedi
trombositosis
 Consult To IPD (3/3/21) from from other ward
No Name/Age Diagnosis Info

1. DOC
2. Septic condition
3. HAP
1 Ny. Painem / 69 th 4. SNH
5. DM tipe 2 dgn hyperglycemia in critically ill
6. Severe hypoalbuminemia
7. Complicated UT

1. SOB
2 Tn. Nasar Ali / 69 th 2. KAD
3. T2DM with hyperglycemic crisis
4. AKI dd ACKD
 Stagnant in ER < 24 hours (3/3/21)
No Name/Age Diagnosis Info

1 Ny. Yulia Mulia Sari/42th Pansitopenia, History of Melena

1. Acute superimposed on CKD stg V,

2 Ny. Pirliana/48 thn hiperkalemia
Stagnant di IGD

3 Tn. Dedik Marwiyanto S/34 1. SOB, CKD stg V HD rutin, Anemia, HT, HF stg C fc Stagnant di IGD
thn IV
 Stagnant in ER > 24 hours (23/2/21)
No Name/Age Diagnosis Info
 New Patients (Ward) March, 3th 2021 (jam stase)

No Name/Age Diagnosis

1 Tn. Siti Hanisah/85th Acute cough+leukositosis PSI port high risk, hipoalbumin
 Transferred Patients (Ward) February, 3th 2021 (Jam Jaga)

No Name/Age Diagnosis

1 Tn. Gazali Rakhman/55th SOB, Anemia mikrositik hipokrom, CKD stg V on HD, HF Stg C fc III, Hep B

2 Tn. Shaleh/49th CINV, KNF

 Queue (Ward) February, 23th 2021 (Jam Jaga)

No Name/Age From

1 Yulia ER

2 Rusmayati Poli

9
 MORNING REPORT
Thursday, March 4th 2021

MR Facilitator : dr. Nanang Miftah Fajari Sp.PD, KEMD, FINASIM

dr. Oldi Dedya, Sp.PD

Supervisor on duty : dr. Dikara W.S. Maulidy, Sp.PD

II C : dr. Aditya
II B : dr. Bernadet, dr. Haudhiya
II A : dr. Asri
IB : dr. Rudy
IA : dr. Felix
 DATABASE

Identity : Mr. A/ 62 yo
Chief complaint : Weakness
Autoanamnesis
HISTORY OF PRESENT ILLNESS :
• Patient was admitted from the Diabetic Foot Policlinic with diagnosis Anemia and
Diabetic Foot Ulcer of Right Foot and DM type II
• Weakness is felt by the patient since 2 weeks before admission. Weakness is felt
worsen during activites and from his son he said he looked pale. This symptom is
felt if the Hemoglobin Level falls below normal. Patient denied Palpitation,
Dizziness, or Shivering.
• He also complained about wound at the Right foot since 1 year. At first, the
wound started to rise when he walked at the afternoon without footwear. At first
the wound was small and blistered at the front foot. The wound wasn’t
acompanied by blood but it was painful. After a month the wound still didn’t heal
and it extended to the back of the foot and half of the sole. The wound
produced blood, pus, and unpleasant smell.
 CONT OF D A T A B A S E
• After he went to TPT Hospital, he just knew that he had diabetes melitus. For 2
months he got medication at that hospital but the wound didn’t get better and then
he was reffered to Ulin Hospital.
• The patient routinely consumed Ciprofloxacin 300mg, clindamycin 300 mg,
gabapentin 300 mg, simvastatin 20 mg, aspilet 80 mg, lisinopril 5 mg, novorapid 8 iu
at morning afternoon, and evening. And Detemir 10 iu at night.
• He admits a year before, he felt tingling at both of his legs. He seldom use footwear
when walking at afternoon. The pain radiates to the calf sometimes. It appears
when exercising and get better when at rest. This symptoms started to appear more
frequently during one last month especially at the right foot.
• At this age he doesn’t complain any sleep disturbance, but he has some blurred near
sight. He still has good hearing.
• His appetite is good, no fever, nauseous, and vomiting.
• Her bladder and bowel habit is good, with urine about 2-3 glass per urinating. There
is no blood, sands, or dysuria. He routinely defecate once a day and never with
blood, no watery stool, or black starry tool. He doesn’t has any history of mass
coming out from his anus during defecation.
• He doesn’t have any cough, fever, anosmia, and sorethroat.
HISTORY OF MEDICINE
Twice inpatient history at Ulin Hospital due to low Hemoglobin and got blood
transfusion. Last history of opname was the end of December 2020 having
2 bag of PRC. Not taking Hypertension medication routinely fo 10 years.
The highest blood pressure ever measured 150.
PAST MEDICAL HYSTORY
-
FAMILY MEDICAL HISTORY
No Hypertension , No Diabetes mellitus , No liver disease, No Lung TB , No
cancer , No Displipidemia. No Same disease

PERSONAL AND SOCIAL HISTORY

• He is a freelancer. He already married with 2 children. He smokes one
packs a day but since he was sick, he stopped smoking. He often drinks
sweet coffee before he was sick. He never drinks alcohol. After he got
sick like now he didn’t drink sweet coffee anymore.
 Physical Examinations

General appearance: looked moderately ill weight: 165 cm Input 1500/24hours

GCS : E4V5M6 (compos mentis) Weight: 55kg Output 1000 cc/24 Hours
VAS 2 BMI : 20.2 kg/m2 Diuresis 0.65 cc/kgbw/hour

BP: 110/70 mmHg PR: 82 bpm RR: 18 bpm Tax: 36,5 oC SpO2 : 98% on room air

: Pale conjunctiva (+), sclera icteric (-), pupil isokor (3mm/3mm)

Head Eye
: Pale (-), cyanosis (-), dry lips (-)
Lip
: Papil atrophy (-)
Tongue

JVP : 5+0 cm H2O

Neck Lymphnode : Lymph node enlargement (-)
Thyroid : Symmetrical (+/+), enlargement (-/-), pain (-/-)

Axilla :Lymph node enlargement (-)

Ins : Ictus cordis not seen (-)

Pal : Ictus palpable at ICS V midclavicula line sinistra, thrill (-)
Per : LMH (Left Margin of Heart) ictus cordis at ICS V midclavicularis line sinistra
: RHM (Right Margin of Heart) : sternalis line dextra
Chest Heart
 ICS II Parasternalis Dextra ,Line: aortic valve murmur (-)
Aus  ICS II Parasternalis Sinistra, Line: pulmonal valve murmur (-)
 ICS IV-V Parasternalis Sinistra, Line: tricuspid valve murmur (-)
 ICS IV-V Mid Clavicular Sinistra, Line: mitral valve murmur (-)
 Ictus Cordis at ICS V midclavicularis sinistra line
 Physical Examinations

(At Ward) Symmetrical thorax expansion, Retraction of m.intercostalis (-)

Fremitus vocal Percussion Breath sound Rhonchi Wheezing
Chest Lung N N sonor sonor V V - - - -
N N sonor sonor V V - - - -
N N sonor sonor V V - - - -

Inspection : flat (+), distended (-),

Auscultation : Normal sound bowel
Abdomen Percussion : Tympanic, shifting dullness (-), liver span 11 cm, traube space tympani
Palpation : Hepar and lien not palpable, CVA pain (-/-), tenderness (-)

Inguinal Lymph node enlargement (-)

Spoon nails(-/-), clubbing fingers (-/-)

Edema superior (-/-), edema inferior (-/-), Warm (+/+) CRT < 2”
Extremities Petekiae (-) ROM 55/55
Lymph node enlargement (-)
localized status pedis Dextra: (in next section)

Sphincter ani clamped strongly, ampula recti not collapse, slippery mucosa nodul (-), terderness (-), mass (-)
Rectal Toucher
Handscoon : blood (-), black tarry stool (-)
Clinical manifestation (Right Foot) 3/3/2021
• Look
• Dry skin (+), Sianosis (-), Edem (+), hair
(-), pus (+), hiperemis (-), puncta (+),
Blood (+), endon (+), muscle (-), bone
(-). Scar(+) with dry wound, the inside of
the wound is filled with Cutimed
Sorbach. Charcot foot (+)
• Feel
• Warm
• A. dorsalis pedis pulse (+)
• A. tibialis posterior pulse (+)
• ABI pedis dextra = 1.2
• Move
• Pain (+) Parasthesia (+), ROM Limited

• Monofilament test reduced of

sensation (+)
Clinical manifestation (Left Foot) 3/3/2021
• Look
• Dry skin (+), Sianosis (-), Edem (-),
hair (-), pus (-), hiperemis (-),
puncta (-), Blood (-), tendon (-),
muscle (-), bone (-). Scar(-)
• Feel
• Warm
• A. dorsalis pedis pulse (+)
• A. tibialis posterior pulse (+)
• ABI pedis Sinistra = 1.1
• Move
• Pain (-) Parasthesia (-), ROM free

• Monofilament test reduced of

sensation (-)
September 2020
Clinical manifestation 3/3/2021
 Laboratory Ulin Hospital
Lab Result Normal Lab Result Normal

3/03/21

Haemoglobi
9.0 14.0 – 18.0 Basophils % 0,7 0.0 – 1.0
n

Leukocyte 7.5 4.0 – 10.5 Eosinophils % 7.2 1.0 – 3.0

Erythrocyte 3.12 4.10 – 6.00 Neutrophils % 62.5 50.0-81.0

Haematocrit 27.4 42.0 – 52.0 Lymphocyte % 21.8 20.0 – 40.0

Platelet 449 150 – 450 Monocyte % 8.0 2.0 – 8.0

MCV 87.8 75.0 – 96.0 Basophils # 0.04 <1.00

MCH 28.8 28.0 – 32.0 Eosinophils # 0.54 <3.00

MCHC 32.8 33.0 – 37.0 Neutrophils # 4.68 2.50 – 7.00

RDW-CV 13.8 12.1 – 14.0 Lymphocyte # 1.63 1.25 – 4.00

RBS 139 70-200 Monocyte# 0.6 0.30 - 1.00

Laboratory

Lab 3/03/21 Value

PT 12.8 9.9 – 13.5
INR 1.2
Control 10.8
APTT 31.7 22.2 – 37.0
Control 24.8
Albumin 2.9 3.5 – 5.2
SGOT 21 5 – 34
SGPT 25 0 – 55
Ureum 8.9 0 – 50
Kreatinin 1.4 0.72 – 1.25
Calcium 8.9 8.4-10
Natrium 138 136 – 145
Kalium 4.7 3.5 – 5.1
Clorida 99 98 – 107
Lab 04/03/2021 Ulin Hospital

Lab Result Value Lab Result Value

Urinalisis
Macroscopic Urine Sediment
Color Yellow Yellow Leukocytes 0-2 0-3
Clarity Clear Clear Erythrocytes 0-1 0-2
Specific Gravity 1.015 1.005 – 1.030 Epithelium 1+ 1+
pH 6.0 5.0 – 6.5 Cristal Negative Negative
Ketone Negative Negative Cylinder Negative Negative
Protein-
Trace Negative Bacteria negative Negative
Albumin
Glucose negative Negative Other Negative Negative
Bilirubin Negative Negative
Occult Blood Negative Negative
Leukocytes Negative Negative
Urobilinogen 0.1 0.1 – 1.0
Nitrit Negative Negative
 ECG Interpretations

Sinus Rythm QT interVal 360, msQTc 451

Q patology (-)

Regular QRS Complex : 0.14s

Amplitudo QRS < 0.5 mv extremities lead

Heart Rate 87 bpm T inverted (-)

Frontal Axis : Normoaxis

Horizontal Axis: zona transisi V3 LVH (-)

P wave : 0.1, mV (0.1S) Qtc : 451

PR interval : 0.16 s Conclusion : sinus rhythm HR 87 bpm, Normo axis

Ro/ Pedis Dextra

Foto AP / Oblique 4/9/2020

- The bone structure appears not intact prox phalank dig III
- visible bone pathological discontinuation (fracture) Phalank dig 3
- Dislocation of the pedis (-)
- Gas Gangrene (-)
Impression: Destruksi Prox phalank dig 3 dextra with dd osteomielitis
 No Keterangan  

1 RAPUH / FRAILTY Pre Frail

Status Fungsional  

2
ADL  Ketergantungan Ringan
 

IADL Fungsi Tergantung Sebagian

3 Pemeriksaan Kognitif / MMSE:  tidak ada gangguan kognitif

Pemeriksaan Status Nutrisi / MNA Risk of malnutrition

GERIATRIC 4  SCREENING Risk Of Malnutrition

ASSESSMENT  

ASSESMENT Risk of Malnutrition

5 Resiko Jatuh  resiko rendah

6 GDS/DEPRESI  kecil kemungkinan depresi

90 - 98 %
7 Komorbiditas/Charlson Comorbidity Indeks
Estimated 10-year survival

 kecil sekali/tidak terjadi

8 Norton/risiko decubitus
decubitus

9 ECOG 1

10 Frailty Indeks Apparently vulnerable

Quesioner RAPUH
Penapisan Sindrom Kerapuhan/Kerentaan/Frailty (ICD 4. Usaha berjalan : (Ambulatory)
Code : R54) -Adaptasi dan validasi kuesioner FRAIL
• Dengan diri sendiri dan tanpa bantuan,
1. R= Resistensi (Resistance) apakah anda mengalami kesulitan berjalan
kira – kira sejauh 100 sampai 200 meter ?
• Dengan diri sendiri atau tanpa bantuan alat, apakah
anda mengalami kesulitan untuk naik 10 anak tangga • Skor Ya = 1, dan Tidak =0
dan tanpa istirahat diantaranya ?
• Skor 1 = Ya, 0 = Tidak
5. H = Hilangnya berat badan : (Loss of
Weight)

2. A= Aktifitas (Fatigue) • Berapa berat badan saudara dengan

mengenakan baju tanpa alas kaki saat ini ?
• Seberapa sering dalam 4 minggu anda merasa
kelelahan ? • Satu tahun yang lalu, berapa berat badan
anda dengan mengenakan baju tanpa alas
• 1: Sepanjang waktu kaki ?
• 2: Sebagian besar waktu • Keterangan perhitungan berat badan dalam
persen : [(berat badan 1 tahun yang lalu –
• 3: Kadang – kadang berat badan sekarang)/Berat badan satu
tahun lalu)]x 100%
• 4: Jarang
• Bila hasil >5% (mewakili kehilangan berat
• Bila jawab 1 atau 2 skor =1 dan selain itu skor = 0 badan 5%) diberi skor 1 dan <5 % skor = 0

3. P= penyakit lebih dari 4 (Illnesses) • Intepretasi :

• Partisipan ditanya, apakah dokter pernah mengatakan • Skor 1-2 : Pre-Frail (Pra-Rapuh)
kepada anda tentang penyakit anda (11 penyakit • Skor >2 : Frail (Rapuh/Renta)
utama: Hipertensi, diabetes, kanker (selain kanker
kulit kecil), penyakit paru kronis, serangan jantung,
gagal jantung kongestif, nyeri dada, asma, nyeri sendi,
stroke dan penyakit ginjal )?
• Bila jawaban jumlah total penyakit skor yang tercatat
0-4 penyakit = 0 dan 5-11 penyakit =1
 NO FUNGSI SKOR Hari 1

1 Mengendalikan rangsang BAB 0-3  3

2 Mengendalikan rangsang BAK 0-2  2

PENILAIAN ACTIVITY OF
DAILY LIVING (ADL) -
INSTRUMEN INDEKS Membersihkan diri (mencuci wajah,
BARTHEL MODIFIKASI 3 menyikat rambut, mencukur kumis,
sikat gigi)
0-1  1

Penggunaan WC (keluar masuk WC,

4 melepas/memakai celana, cebok, 0-2  2
Skor Barthel Index : menyiram)
20 : Mandiri 12 – 19
: Ketergantungan 5 Makan minum 0-2  2
ringan (B)
9 – 11 : Ketergantungan
Bergerak dari kursi roda ketempa tidur
sedang (B) 6 dan sebaliknya (termasuk duduk di
0-3
 2
5 – 8 : Ketergantungan  
tempat tidur)
berat (C)
0 – 4 : Ketergantungan
total (C) Berjalan di tempat rata (atau jika tidak 0-3
7  2
bisa berjalan, menjalankan kursi roda)  

Berpakaian (termasuk memasang tali 0-2

8  2
sepatu, mengencangkan sabuk)  

0-2
9 Naik turun tangga  1
 

0-1
10 Mandi  1
 

  Jumlah/kesimpulan    18
       Nilai
a. Mampu mengoperasikan telepon secara mandiri
1
Menggunaka b. Menjawab telepon dan menelpon beberapa nomor yang dikenal
c. Mampu menjawab telepon tetapi tidak mampu menelpon 1
n telepon 1
d. Tidak mampu menggunakan telepon 1
 
0
a. Mampu berbelanja untuk semua kebutuhan secara mandiri 1
1
Instrumental Activities b. Berbelanja untuk kebutuhan kecil secara mandiri 0
0
Berbelanja c. Perlu ditemani pada saat berbelanja 0 0
of Daily Living d. Tidak mampu berbelanja 0 0
0
(IADL)
a. Merencanakan, menyiapkan dan menyajikan makanan secara
mandiri 1
Nilai skor IADL : b. Menyiapkan makanan secara adekuat jika dibantu dalam
Menyiapkan 0 
menyediakan bahan  1
makanan c. Menyiapkan makanan tetapi tidak bisa mempertahankan diet 0 
6 fungsi tergantung secara adekuat 0
sebagian d. Perlu bantuan untuk menyiapkan dan menyajikan makanan
a. Mengatur rumah sendiri atau dengan bantuan sekali-sekali
b. Melakukan tugas sehari-hari yang bersifat ringan seperti mencuci
8 : mandiri/wanita piring, merapihkan tempat tidur 1
c. Melakukan tugas sehari-hari yang bersifat ringan tetapi tidak 1
Mengatur  
mampu mempertahankan kebersihan 1
5 : mandiri : pria (pada rumah
d. Perlu bantuan untuk mengatur semua tugas rumah tangga 1
1
pasien 8) e. Tidak mampu berpartisipasi dalam tugas-tugas rumah tangga 0

a. Mencuci semua pakaian pribadi secara mandiri 1

Mencuci b. Mencuci hanya beberapa potong pakaian 1  0
c. Perlu bantuan untuk mencuci pakaian 0
0
a. Melakukan perjalanan dengan transportasi umum atau kendaraan
pribadi secara mandiri
b. Melakukan perjalanan dengan menggunakan taxi secara mandiri, 1
tetapi tidak mampu menggunakan transportasi umum 1
Menggunaka
c. Menggunakan transportasi umum dengan ditemani keluarga  
n
1
transportasi d. Memerlukan bantuan penuh untuk melakukan perjalanan dengan
menggunakan taxi atau mobil pribadi 0  1
e. Tidak mampu sama sekali untuk melakukan perjalanan 0

a. Mengambil obat atau minum obat dengan dosis dan waktu yang
Menyiapkan benar 1
dan minum b. Mampu minum obat sendiri jika disiapkan oleh keluarga 0
 1
obat c. Tidak mampu menyiapkan obat sendiri 0
a. Mengatur keuangan secara mandiri (pemasukan dan pengeluaran
uang) 1
Mengatur b. Memerlukan bantuan untuk mengatur keuangan (seperti belanja
1
keuangan seharihari)  1
0
c. Tidak mampu mengatur keuangan
 NO RISIKO SKALA

1 Gangguan gaya berjalan (diseret, menghentak, berayun) 0

2 Pusing atau pingsan pada posisi tegak 0

Kebingungan setiap saat (contoh:pasien yang mengalami

3 0
demensia)

PENILAIAN 5 Nokturia/Inkontinen 0
RISIKO JATUH
Kebingungan intermiten (contoh pasien yang mengalami
5 0
Tingkat risiko : delirium/Acute confusional state)
- Risiko rendah bila skor 1-
3 Lakukan intervensi risiko
rendah 6 Kelemahan umum 1

- Risiko tinggi bila skor ≥ 4 

Lakukan intervensi risiko
tinggi Obat-obat berisiko tinggi (diuretic, narkotik, sedative,
7 antipsikotik, laksatif, vasodilator, antiaritmia, antihipertensi, obat 2
hipoglikemik, antidepresan, neuroleptic, NSAID)

8 Riwayat jatuh dalam 2 bulan terakhir 0

9 Osteoporosis 0

10 Gangguan pendengaran dan/atau penglihatan 0

11 Usia 70 tahun ke atas 0

Jumlah 3
GERIATRIC DEPRESSION
SCALE No Pertanyaan    
1 Apakah anda pada dasarnya puas dengan YA TIDAK
kehidupan anda?
Pilihlah jawaban yang paling 2 Apakah anda sudah meninggalkan banyak YA TIDAK
tepat untuk menggambarkan kegiatan dan minat /kesenangan anda?
perasaan Anda selama dua
3 Apakah anda merasa kehidupan anda YA TIDAK
minggu terakhir. hampa?
4 Apakah anda sering merasa bosan? YA TIDAK
5 Apakah anda mempunyai semangat baik YA TIDAK
 Setelah semua pertanyaan setiap saat?
dijawab, hitunglah jumlah
6 Apakah anda takut sesuatu yang buruk YA TIDAK
jawaban yang berwarna akan terjadi pada anda?
merah. Setiap jawaban
7 Apakah anda merasa bahagia pada YA TIDAK
(ya/tidak) yang bercetak tebal sebagian besar hidup anda?
diberi nilai satu (1).
 Jumlah skor diantara 5-9 8 Apakah anda sering merasa tidak YA TIDAK
berdaya?
menunjukkan kemungkinan 9 Apakah anda lebih senang tinggal di YA TIDAK
besar ada gangguan depresi. rumah daripada pergi ke luar dan
 Jumlah skor 10 atau lebih mengerjakan sesuatu hal yang baru?
menunjukkan ada gangguan 10 Apakah anda merasa mempunyai banyak YA TIDAK
depresi masalah dengan daya ingat anda
dibandingkan kebanyakan orang?
11 Apakah anda pikir hidup anda sekarang ini YA TIDAK
menyenangkan?
12 Apakah anda merasa tidak berharga YA TIDAK
seperti perasaan anda saat kini?
13 Apakah anda merasa penuh semangat? YA TIDAK
14 Apakah anda merasa bahwa keadaan YA TIDAK
anda tidak ada harapan?
15 Apakah anda pikir bahwa orang lain YA TIDAK
lebih baik keadaannya dari anda?

1
 2

3
0

0.5
1

0
2

2
0.5

2
11
 2

0.0

20
 Performance status
Grade ECOG Pasien
0 Fully active, able to carry on all pre-disease performance
without restriction
1 Restricted in physically strenuous activity but ambulatory
and able to carry out work of a light or sedentary nature, V
e.g., light house work, office work
2 Ambulatory and capable of all self care but unable to carry
out any work activities. Up and about more than 50% of
waking hours
3 Capable of only limited selfcare, confined to bed or chair
more than 50% of waking hour
4 Completely disabled. Cannot carry on any selfcare. Totally
confined to bed or chair
5 Dead
 Comorbidity Component (Apply 1 point to each unless
otherwise noted)
Myocardial Infarction  
Congestive Heart Failure  
Peripheral Vascular Disease  
Cerebrovascular Disease  
Charlson Dementia  
COPD  
Comorbidity Connective Tissue Disease  
Index Peptic Ulcer Disease  
98-90 % Diabetes Mellitus (1 point uncomplicated, 2 points if  2
0-2 Estimated 10-year
survival end-organ damage)
77 %
2 Estimated 10-year Moderate to Severe Chronic Kidney Disease (2 points)  0
survival

53 %
4 Estimated 10-year
survival

21 %
Hemiplegia (2 points)  
5 Estimated 10-year
Leukemia (2 points)  
survival

2% Malignant Lymphoma (2 points)

6 Estimated 10-year
survival

0% Solid Tumor (2 points, 6 points if metastatic)  

>= 7 Estimated 10-year
survival

Liver Disease (1 point mild, 3 points if moderate to  

severe
AIDS (6 points)  
 NO KEADAAN PASIEN SKOR
1 KONDISI FISIK UMUM
BAIK 4
LUMAYAN 3
NORTON BURUK 2
SCALE SANGAT BURUK 1
KATEGORI SKOR: 2 KESADARAN
• 16-20: KECIL
SEKALI/ TIDAK COMPOSMENTIS 4
TERJADI RESIKO APATIS 3
DEKUBITUS
• 12-15: KONFUS/ SOPOR 2
KEMUNGKINAN STUPOR/ KOMA 1
KECIL TERJADI
RESIKO 3 AKTIVITAS
DEKUBITUS AMBULAN 4
• <12 : BESAR
TERJADI AMBULAN DENGAN BANTUAN 3
HANYA BISA DUDUK 2
TIDURAN 1
17
4 MOBILITAS
BERGERAK BEBAS 4
SEDIKIT TERBATAS 3
SANGAT TERBATAS 2
TIDAK BISA BERGERAK 1
5 INKONTINENSIA
TIDAK ADA 4
KADANG-KADANG 3
SERING INKONTINENSIA URINE 2
INKONTINENSIA ALVI DAN URINE 1
ASSESMENT FRAILTY NO
1
TINGKAT FRAILTY
Sangat Fit (Very Fit)
DESKRIPSI
Aktif, energik, fit, dan penuh motivasi
 
 

2 Baik (Well)  Tidak memiliki penyakit aktif  

 Kurang fit bila dibandingkan

dengan kategori sangat fit

3 Terkontrol Baik (Managing Well) Memiliki penayakit penyerta yang  

terkontrol dengan baik

4 Tampak Renta (Apparently  Tidak secara nyata membutuhkan  

Vulnerable) bantuan orang lain untuk

melakukan aktifitas hidup sehari-
hari
 Memiliki gejala penyakit yang
membatasi aktifitas menjadi
lamban dan / atau merasa lelah
sepanjang hari

5 Renta derajat ringan (mildly frail

Ketergantungan ringan terhadap orang  

lain dalam melakukan aktifitas hidup

(ADL)
6 Renta derajat sedang (moderately Ketergantungan terhadap orang lain  

frail) dalam melakukan sebagian besar

aktifitas hidup dasar sehari-hari
7 Renta derajat berat (severely  Ketergantungan sepenuhnya  

Frail) terhadap orang lain dalam

melakukan seluruh aktifitas hidup
dasar sehari-hari
 Kondisi keseluruhan stabil

8 Renta derajat sangat berat (very Ketergantungan sepenuhnya terhadap  

severely frail) orang lain dalam melakukan seluruh

aktifitas hidup dasar sehari-hari pada
kondisi menjelang akhir hayat
5
5
TOTAL 28
2

3
2
1
3
1
1

1
PROBLEM LIST
• 1. DFU wagner III pedis (D) PEDIS criteria moderate
• 2. DM tipe II non obese dengan komplikasi DFU
• 3. Moderate Anemia normositik
• 4. Moderate hypoalbuminemia
• 5. Hipertension on treatment
• 6. Geriatric problem (infection, imobilization, Instability, imparement
visual)
• 7. Imparement Visual
 DATABASE RESUME / CUE AND CLUE (Male, 63 yo)
• ANAMNESIS P H Y S I C A L E X A M I N AT I O N OT H E R E X A M I N AT I O N

• Weakness not reduced by rest or KU : Moderrate ill Laboratorium 3/3/2021

food intake GCS : E4M6V5 Hb 9.0
• Looked pale BP 110/70 Leukosit 7.5
HR 82x/m Trombosit 449.000
• Wound in the Right foot since 1 Rr 22 x MCV 87.8
year ago sometimes exude pus and Tax 36.5 MCH 28.8
bad smell SpO2 98% room air Neutrofil 62.5
• felt tingling on his foot , pain BW 55kg PT 12.8
radiates to calf HW 165 cm INR 1.2
• he has some blurred near sight VAS 2 APTT 31.7
• history of diabetes >5 years RBS 139
Local Status Right Foot Albumin 2.9
Look SGOT 21
Dry skin (+), Sianosis (-), Edem SGPT 25
(+), hair (-), pus (+), hiperemis Ureum 24
(+), puncta (+), port de entry Creatinin 1.4
wound (-) Blood (+) Clorida 108
Feel Calcium 8.9
Cold (-) Na 138
A. dorsalis pedis pulse (+) Kalium 3.9
A. tibialis posterior pulse (+) EKG Sinus Rythm
ABI right foot 1.2 Ro thorax (-)
Move Ro. Pedis dextra AP/Oblique 4/9/2020
Pain (+) Parasthesia (+), ROM Destruksi proximal phalank digiti 3 pedis
Limited dextra, gas gangren (+)
Summary of Database
Monofilamen test reduce sensation
(+)
 INITIAL PLAN

Planning Planning
CUE AND CLUE Problem List Initial Diagnose Planning Diagnose
Therapy monitoring

 Looked pale 1. Moderate 1.1 Blood Loss dt - Blood smear - O2 2-4 LPM nasal canule Planning
 Wound in the Right foot since Anemia wound loss - Reticulocyte count Monitoring:
one year ago sometimes exude Normocytic - FOBT - PRC transfusion • Subjective
pus and bad smell Normochromic 1.2 Chronic (10 – 9.0) x 55 kg x 4 mg • Vital Sign
disease =220ml • Bleeding sign,
Physical Examination 2 pack (@175cc) • CBC after
 BP 110/70 transfussion
 Conjuntiva pale
Laboratory Findings Planning
 Hb 9.0 Education:
 WBC 7.5
 Trombosit 449 • Explain about the
 Eritrosit 3.12 condition of her
 RDW-CV 13.8
 MCV 87.8 disesase
 MCH 28.8
 INITIAL PLAN

Planning Planning
CUE AND CLUE Problem List Initial Diagnose Planning Diagnose
Therapy monitoring

 Wound in the Right foot since one year

ago sometimes exude pus and bad smell 2. Diabetic Foot ulcer Pain management Planning Monitoring:
 felt tingling on his right foot wagner III Pedis Po. PCT 3x500 p.o • Subjective
 pain radiates to calf
 history of diabetes 1 years Dextra with criteria • VAS
 Claudocatio Intermitten (+) Metabolic control: • Lipid Profile
PEDIS Moderate Control blood glucose • BSP/BS2PP
Physical Examination
 VAS 1-2 Insulin Detemir 0-0-10 unit (sc) • Albumin
 Tax: 36.5 in ward Insulin Aspart 8-8-8 unit (sc) • Bleeding sign
Local Status Right Foot • ASCVD score
 Look Microbiological control • Repeat CBC after 3
 Dry skin (+), Sianosis (-),
Edem (+), hair (-), pus (+), Ciprofloxacin 2x500mg days antibiotic
hiperemis (+), puncta (+), port
de entry wound (-) Blood (+)
Clindamycin 3x300mg • Wound base culture
 Feel and antibiotic
 Cold (-) Wound control: sensitivity
 A. dorsalis pedis pulse (+)
 A. tibialis posterior pulse (+) Wound dressing • USG Doppler
 ABI right foot 1.2
 Move
 Pain (+) Parasthesia (+), ROM Mechanical control: Planning Education:
Limited Avoid pressure to the feet • Explain about the
 ABI D 1.2
 Monofilament test reduced on 2 area condition of her
Laboratory Findings
 Hb 9.0
Vascular Control disesase, how to
 WBC 7.5
 Trombosit 449
Atorvastitin 1x40 mg manage, and
 Albumin 2.9 Aspilet 1x80mg prognosis
Pedis AP/L (4/9/2020) • Avoid putting
 Destruksii proximal phalank digiti 3 pedis
dextra, gas gangren (-) pressure on feet
• Tell to use foorware
• ASCVD DM age HIGH RISK
 INITIAL PLAN

Initial Planning Planning Planning

CUE AND CLUE Problem List
Diagnose Diagnose Therapy monitoring

 History of diabetes >5 years

 Wound in the Right foot since one year
3. DM type II non • Diet DM 1700 kkal Planning Monitoring:
ago sometimes exude pus and bad smell obese with  Basal calorie : 55x 25 = 1375kal/day • GDP/2PP
• HbA1C if HB 10
 felt tingling on his right foot
 pain radiates to calf
complication DFU and  Total calorie : 1375 -5%+10% = 1436 • Lipid profile,
 Claudocatio Intermitten (+) neuropaty kcal/day • Funduscopy
 Carbohydrate 60 % = 825kcal/day = 206 • ASCVD score
Physical Examination • Sign of hypoglycemia
 VAS 1-2 gram/day • Mikroalbuminuri
 Tax: 36.5 in ward
 Weight 55  Protein 10%/day =137kcal/day • Urinalysis
 Height 165  Fat = 518kcal/day
 BMI 20.0 Planning Education:
Local Status Right Foot
• Educate the patient
 Look
about the disease
 Dry skin (+), Sianosis (-), • Metabolic control: Diabetes Mellitus and,
Edem (+), hair (-), pus (+),  Control blood glucose (target FPG 90-150, complication to her eye
hiperemis (+), puncta (+), port PPG/RBS 140-180) and Kidney
de entry wound (-) Blood (+)
 Feel  Hba1c Complex <8.0% • Probability of taking
medicine for rest of her
 Cold (-)
 A. dorsalis pedis pulse (+)
 Detemir injection 0-0-10 life
 A. tibialis posterior pulse (+)  Aspart injection 8-8-8 • Educate about calories
 ABI right foot 1.2 amount she should take
 Move and her diet
 Pain (+) Parasthesia (+), ROM
Limited
 ABI D 1.2
 Monofilament test reduced on 2 area
Laboratory Findings
 RBS 154
Pedis AP/L (4/9/2020)
 Destruksii proximal phalank digiti 3
pedis dextra, gas gangren (-)
 INITIAL PLAN

Planning Planning
CUE AND CLUE Problem List Initial Diagnose Planning Diagnose monitoring
Therapy

 Wound in the Right foot since 4. Hipoalbumin 6.1 wound loss UL Albumin correction : Planning
one year ago sometimes exude moderate • x BB x 0.8 = (3.5 – 2.9) x Monitoring:
pus and bad smell 6.2 hypercatabolic state 55 x 0.8 = 26.8 mg  • S, VS,
transfusion Albumin 20% • albumin check
Laboratory Findings 100cc 1 flash after transfusion
 Albumin 2.9 • Albumin sachet 3x1 sachet
Planning
Education:
• Explain about the
condition of his
disesase, how to
manage, and
prognosis
 INITIAL PLAN

Planning Planning
CUE AND CLUE Problem List Initial Diagnose Planning Diagnose
Therapy monitoring

 History of HT (+) 10 5. Hypertension on  Low salt diet < 2 gram/day Planning

years, uncontrolled treatment  Lisinopril 1x5mg Monitoring:
• Subjective,
Physical Examination  (Target BPS < • Vital sign
 Highest blood pressure 140/90mmHg) • ECG
150/80 -> in ward • Chest X-Ray
110/70 mmHg
Planning Education:
 ECG • Educate the
 ECG: sinus rhytm 84 patient about the
kali/menit disease and
complication
• Patient should
routine consume
anti hypertension
drug
 Planning Planning
CUE AND CLUE Problem List Initial Diagnose Planning Diagnose
Therapy monitoring

 Wound in the Right foot since one year ago 6. Geriatric problem  Improve quality of life Planning Monitoring:
sometimes exude pus and bad smell
 felt tingling on his right foot • Infection  Educate the patient • Subjective
 pain radiates to calf • Immobility family for family care • Vital Sign
 history of diabetes >5 years
 Claudocatio Intermitten (+) • Imparement Visual and support when the • Control infection
• he has some blurred near sight patient condition • Monitor intake oral
Physical Examination
 VAS 1-2 improve and discharge (diet recall)
 Tax: 36.5 in ward • Lipid profile
Local Status Right Foot Geriatric Assesment :
 Look  Geriatrician specialist
 Dry skin (+), Sianosis (-), Edem (+), hair
(-), pus (+), hiperemis (+), puncta (+),  Nutrition specialist Planning Education:
port de entry wound (-) Blood (+)  Physiotherapist • Educate her family to
 Feel
 Cold (-)  Pharmacist give support and care
 A. dorsalis pedis pulse (+) for her
 A. tibialis posterior pulse (+)  Consider to consul • Empathy in patient
 ABI right foot 1.2
 Move Opthalmologist care include verbal
 Pain (+) Parasthesia (+), ROM Limited communication,
 ABI D 1.2
 Monofilament test reduced on 2 area understanding
Laboratory Findings
 Hb 9.0
nonverbal cues,
 WBC 7.5 spending time with
 Trombosit 449
 Albumin 2.9 her, providing care
Pedis AP/L (4/9/2020)
 Destruksii proximal phalank digiti 3 pedis
dextra, gas gangren (-)
 Planning Planning
CUE AND CLUE Problem List Initial Diagnose Planning Diagnose
Therapy monitoring

• he has some blurred near sight 7. Imparement Visual 7.1 Retinopathy 1. Funduscopy  Confirm Diagnose Planning Monitoring:
Physical Examination
 VAS 1-2 diabetic  Consider to consul • Subjective
 Tax: 36.5 in ward 7.2 Hipertensi Opthalmologist • Vital Sign
Local Status Right Foot Retinopaty • Control infection
 Look 7.3 Presbyopia • Monitor intake oral
 Dry skin (+), Sianosis (-), Edem (+), hair
(-), pus (+), hiperemis (+), puncta (+), (diet recall)
port de entry wound (-) Blood (+) • Lipid profile
 Feel
 Cold (-)
 A. dorsalis pedis pulse (+)
 A. tibialis posterior pulse (+)
 ABI right foot 1.2 Planning Education:
 Move • Educate her family to
 Pain (+) Parasthesia (+), ROM Limited
 ABI D 1.2 give support and care
 Monofilament test reduced on 2 area for her
Laboratory Findings
 Hb 9.0 • Empathy in patient
 WBC 7.5
 Trombosit 449
care include verbal
 Albumin 2.9 communication,
Pedis AP/L (4/9/2020) understanding
 Destruksii proximal phalank digiti 3 pedis
dextra, gas gangren (-) nonverbal cues,
spending time with
her, providing care
PROBLEM ANALYSIS

Controlled
hypertension

Microvascular
compication Neuropathy Diabetic Foot Hipoalbumin
Sensoric
Ulcer
Motoric
Type 2
Autonom
Diabetes
Mellitus Infection Anemia

history of
Trauma

Macrovascular
compication

Geriatric
Problem
 • S : pain at pedis sinistra (+), fever (-)

• O : GCS E4V5M6
• BP: 120/70 mmHg
• RR : 20 x/minute
• HR: 92x/m

Progress Note • T 36,9 C

• SpO2 98% room air
• vas 1-2
• H/N : pale conjunctiva (-/-),
(4/03/2020 06.00 )
• Thorax: Rh ---/---
• Extremities: oedem (-/-),
urin output: 1000 cc/24hours = 0.65
cc/kgbw/h
RBS: 154 mg/dl
 Assessment :

• 1. DFU wagner III pedis (D) PEDIS

criteria moderate
• 2. DM tipe II non obese dengan
komplikasi DFU

Progress Note • 3. Moderate Anemia normositik

• 4. Moderate hypoalbuminemia
• 5. Hipertension on treatment
(4/03/2020 06.00 )
• 6. Geriatric problem (infection,
imobilization, Instability,
imparement visual)
• 7. Imparement Visual
 Therapy :
Diet DM 1700kkal/hr
IVFD Nacl 0.9% 1500cc/24hour
Inj. Albumin 20% 1 fls
PRC 2 kolf , 1 kolf/12 Hours

PO Ciprofloxacin 2x500mg
PO Clindamycin 3x300mg
PO Lisinopril 1x5mg
PO Atorvastatin 1x40 mg
PO Aspilet 1x80mg

Progress Note PO PCT 3x500

Po Albumin 3x1 sachet
Detemir injection 0-0-10 sc
Aspart injection 8-8-8 sc
(04/03/2020 06.00 )
plan:
GDP/GD2PP
Lipid Profile
Wound culture
USG dopler both leg
Control to Poli Kaki
THEORY AND
GUIDELINES
Monofilame
nt testing
• Patient reduce
feel the
monofilament
at all points.
Stratification for Diabetic Foot
 Management Diabetic Foot

Alwi I, et al. Pentalaksanaan di Bidang Ilmu Penyakit Dalam: Panduan Praktik Klinis. Jakarta: Interna Publishing, 2015
JNC VIII BP Target
 • People with diabetes have a higher
chance of getting certain infections
and decrease of organ function
because nerve damage and blood
vessel so the wound will slow on
Key healing, so patient and family need
to understand that it takes a long
Messages time and regularly to check up and
clean any wound of Diabetes
Social • Patient need to control his blood
sugar level. And treat his diabetic
wound regularly, avoid wetting the
wound and not put lot pressure on
wound
• Support from family is important for
better quality life