DERMATOVENEROLOGY DEPARTMENT

MEDICAL FACULTY
HASANUDDIN UNIVERSITY

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Marlon Soselisa
Jurika Kakisina
Milka Margareta
Yohanes F. Simanjuntak
Nurul Fajriah Afiatunnisa

201083034
200983021
200983047
200983039
201083045

PATIENT IDENTITY

Name
Gender
D.O.B
Age
Medical Record
Marrital Status
Religion
Admision Date

: Yos Welyam Ratu

: Male
: 5 December 1983
: 32 years old
: 734715
: Married
: Christian
: 28 November 2015

HISTORY TAKING
Anamnesis : (Autoanamnesis)
Chief complaint
: wound on buttocks area
Further Anamnesis :
Patient, man, 32 y.o consulted from internal department with
decubitus wound on his buttock since 3 months ago. Firstly, it was
just a small wound seems the shape of pins head, then within 2
months it grew wider every time he wore trousers. The patient
complain the pain on it. The patient had went to the Surgeon, he
was given the medicine for five days however nothing changed.
Next, He was hospitalized in RS Samarinda for 14 days, there was
improvement, then he continued to be hospitalized in RS WS
Makassar to continue the treatment. Lay on the back was hard for
him, so by changing the position (turn the body left to right or
vice versa) when laying on the bed made him feel easier.

Past illness

Family History
Allergic History
Social History

: The patient was diagnosed with B20

and had been treated using ARV since
five years ago and stopped by six
months ago.
: (-)
: (-)
: The patients occupation was music
player in the hotel. He was narcotics
user (syringe) approximately 10 years
ago. Free-sex history is denied by the
patient

PHYSICAL EXAMINATION
General condition
Vital sign
Blood pressure
Pulse
Respiratory Rate
Temperature
Height
Weight
BMI

: Moderate illness / Compos Mentis

: 110/70 mmHg
: 84 x/m
: 24 x/m
: 36,5 C
: 167 cm
: 50 kg
: 17,9

Head : no abnormality
Eyes : anemic conjunctiva (+), icteric sclera (-)
ENT: no abnormality
Thorax :
Pulmo

Inspection : symetris dextra et sinistra

Palpation: no significant finding
Percussion: sonor
Auscultation: vesiculer

COR :

Inspection : ictus cordis (+)

Palpation: thrill (-)
Percussion: deaf
Auscultation: S1/S2 reguler

Abdomen:
Inspection : flat
Palpation: tenderness(-)
Percussion: tympani
Auscultation: peristaltic (+) normal

Genitals : Catheterized
Extremities: No abnormality

DERMATOLOGICAL STATUS
: Regio gluteus dextra et sinistra,
scrotum
Efflorescence : Ulcus, pus, erosion, excoriation

Location

LABORATORY
Hematology
RBC
HGB
HCT
MCV
MCH
MCHC
PLT
WBC
PT
aPTT

: 2,55
: 8,7
: 25,5
: 100
: 34,1
: 34,1
: 228
: 2,28
: 10,7
: 22,6

4,0 6,0 x 106 / mm3

12,0 16,0 g/dL
37,0 48,0 %
80-97 m3
26,5-33,5 Pg
31,5-35,0 g/dL
150-400 x 103 / mm3
4,0 10,0 x 103 / mm3
10-14 detik
22,0-30,0 detik

LABORATORY
Chemistry
Blood glucose: 103
Ureum
: 16
Creatinin
: 0,60
SGOT
: 93
SGPT
: 229
Albumin
: 3,0
Electrolyte
:
Natrium
: 126
Pottasium
: 2,9
Chlorida
: 87

140 mg/dL
10-50 mg/dL
M (<1,3) F (<1,1) mg/dL
< 38 U/L
< 41 U/L
3,5-5,0 gr/dL
136-145 mmol/L
3,5-5,1 mmol/L
97-111 mmol/L

Immunoserology
HbsAg
: Non reactive
Non reactive
Anti-HCV
: Reactive Non reactive

ASSESSMENT

Decubitus ulcer
B20
Chronic hepatitis C
Anemia
Electrolyte imbalance

PATIENTS FOTO

DAY 1
01 -12-2015

PATIENTS FOTO

DAY 1
01 -12-2015

PATIENTS FOTO

DAY 3
03 -12-2015

PATIENTS FOTO

DAY 3
03 -12-2015

THERAPY
Dermato therapy :
Cefixime tab 100 mg/12 h/oral
Fuson cream (fusidic acid 2%) apply after compress
NaCl 0,9% compress 3x/day, 10 minutes
Internal department therapy :
IVFD Asering/D5% 1:1 28 tpm
Maxiliv 0-1-1 (alpha lipoic acid) Liver protector
KSR 2x1 tab
Cotrimoxazole 960 mg 2x1
Novalgin 1 ampule/8 h/IV
Ceftazidime 1 vial/12 h/IV
PRC transfusion 2 bags
CD4+ count
TKTP diet

DIFFERENTIAL
DIAGNOSIS

Pyoderma gangrenosum
Ecthyma gangrenosum

RESUME

Patient, man, 32 y.o consulted from internal department with decubitus

wound on his buttock since 3 months ago. Firstly, it was just a small wound
seems the shape of pins head, then within 2 months it grew wider every
time he wore trousers. The patient complain the pain on it. The patient was
diagnosed with B20 and had been treated using ARV since 5 years ago and
stopped by 6 months ago. He was narcotics user (syringe) approximately 10
years ago.
Patient was moderate illness, compos mentis. vital signs are normal, BMI:
underweight. General status : anemic conjunctiva (+). Dermatology status:
location at egio gluteus dextra et sinistra, scrotum with efflorescence ulcus,
pus, erosion, excoriation.
From laboratory data : anemia, liver function abnormality, electrolyte
imbalance, chronic hepatitis C
Therapy :Cefixime tab 100 mg/12 h/oral, Fuson cream (fusidic acid 2%)
apply after compress, NaCl 0,9% compress 3x/day, 10 minutes

DECUBITUS ULCER

DEFINITION

A decubitus ulcer is a localized injury to the skin or

underlying tissue, usually over a bony prominence,
that is a result of pressure or of pressure or combined
with sher or friction

EPIDEMIOLOGY

Its estimated that between 1,5 and 3 million people

in the US have decubitus ulcers.
Most predevelop during the first few weeks of
hospitalization.
More common in the elderly, especially those over
the age of 70
The majority of pressure ulcers occur on the lower
part of the body, 65% in the pelvic area and 30% o
the lower limbs

RISK FACTORS

Comorbid conditions
Drug that may effect ulcer healing (e.g steroids)
History of a healed stage III or IV decubitus ulcer
Impaired diffuse or localized blood flow
Impaired or decreased mobility and functional ability
Increase in friction or shear
Moderate to severe cognitive impairment
Undernutrition, malnutrition, and hydration deficits

ETIOLOGY & PATHOGENESIS

The main etiologic factors contributing to decubitus

ulcer development include pressure, shearing forces,
friction, and moisture.
Pressure or force per unit area is considered to be the
most important factor in decubitus ulcer formation.
Normal tissue pressure : 12-32 mmHg. Pressures higher
than this upper limit can compromise tissue circulation
and oxygenation.

Pressure ulcer stage III complicated by fecal

incontinence (left) and IV (right)

CLINICAL FINDINGS
History
Should assess the following risk factors: mobility, activity
level, nutritional status, mental status,
incontinence/moisture conditions, general physical
condition, skin appearance, medication use, friction &
shear, weight, age, predisposing disease & prolonged
pressure.

CLINICAL FINDINGS

Cutaneus lesion

CLINICAL FINDINGS

CLINICAL FINDINGS
Related physical findings
Tenderness, erythema, oedema, & warmth of
surrounding skin, exudate, & foul odor symptoms &
signs of infection.
Fever & declining mental or physical status should
raise suspicion of bacteremia or osteomyelitis.
Spasticity secondary to inflammation & infection may
trigger muscle contractures & joint deformity that can
limit motion.
Weakness & sign of anemia & dehydration can be
found secondary to profound loss of fluid & protein.

CLINICAL FINDINGS
Lab tests : Anemia, leukocytosis, hypoproteinemia,
hypoalbuminemia, elevated ESR, or reduced serum
iron levels may be present
Special tests : biopsy and imaging studies.
Plain radiographs identify ectopic bone, air in the
ulcer cavity, & sclerotic or destructive changes in the
underlying bony prominence
CT scanning determine the extent of a decubitus
ulcer & its anatomic relation to surrounding structure.
MRI determining the depth & extent of soft-tissue
involvement underlying decubitus ulcers.

COMPLICATION

Local infections
Bacteremia
Osteomyelitis
Malignancies
Necrotizing fasciitis
Myonecrosis
Metabolic alterations: hypercalcemia, hypoproteinemia, anemia
Death

TREATMENT
Use of basic support surfaces, repositioning the patient,
optimizing nutritional status, & moisturizing sacral skin
with expectations of some improvement within 2 weeks.
Relief of pressure, shear, & frictional forces
Wound management: cleansing, debridement, dressing
products
Bacterial colonization & infection management:
Systemic ab therapy if there is bacteremia, cellulitis,
osteomyelitis
Topical ab to prevent/treat wound infection, reduce
bacterial load or odor & sign of inflammation

TREATMENT
Pain management
Muscle relaxants & physical & occupational therapy
muscle spasm in the area of ulcer.
TENS
Topical anesthetics
Non-opioid analgesics first line systemic therapy
Surgery for deep ulcer, grade 3 or 4, with flaps or skin
graft.

PREVENTION

DISCUSSION

THANK YOU