A MAN 58 YEARS OLD WITH NON-PRESSURE CHRONIC ULCER OF

SKIN DD MALIGNANT NEOPLASMA UNSPECIFIED SITE OF SKIN DD

INFECTION OF SKIN

By:
Winda Atika Sari
G991902060

Supervisor:
Dr. dr. KristantoYuliYarsa, Sp. B (K) Onk.

DEPARTMENT OF SURGERY
FACULTY OF MEDICINE UNS/ RSUD DR. MOEWARDI
SURAKARTA
2019
 Medical Record

Anamnesis
1. Patient Identity
Name : Mr.S
Age : 58 years old
Sex : Male
Religion : Islam
Address : Boyolali
Job : Farmer
Date of hospitalized : 20 Mei 2019
Date of examination : 22 Mei 2019
Medical Record Number : 0145xxxx

2. Chief Complain
Scars that didn't heal

3. Present Illness

Patient came to Moewardi Hospital presented with scars that

didn't heal and widened in his left hand since 9 months ago. The patient
also complained of the appearance of a lump of scar with an uneven and
reddish surface. The patient said the scar was a burn scar that occurred
in 1970 that hit the patient's entire body. Burns gradually heal, but there
are a small number of scars that didn't heal in the left hand as big as 100
rupiah coins. The scar was located in the follar part of the antebrachium
region, 1/3 proximal. Initially the scar did not enlarge, but the scar
continued to grow progressively in size and now the scar is as big as two
goose eggs. Its did not feel itchy and it was not hot, but 2-3 months ago
the wound became itchy, hot, and liquid bullae containing clear liquid
appeared. The patient says there are a number of bullae with varying
sizes and missing bullae that arise on their own without being broken
 down by the patient. Bullae appears accompanied by itching and
sometimes pus around the bullae. Itching feels better if patient take a
break. The scar was not painful and patient stated that she wasn’t
bothered by the scar for daily activities. Patient also said that the scar
has sign of discoloration, but has no history of bleeding. Initially, the
scars yellowish white colour but now become reddish and appear red-
black spots.

There were no other symptoms such as nausea, vomiting, fever

or cough. The patient also denied any sensory or motoric disturbances
in his left hand. Patients say that sometimes it feels tingling in the area
of the wound that is missing. Patients eat 2-3 times a day, there was no
decrease in appetite, but for the past 1 month patients have said that they
have lost weight about 3-4 kg. The urinate of the patient was smooth, 2-
3 times a day, the volume every time urinate was about 2 cups of mineral
water. Urine was clear yellow and there were no sand and blood in his
urine . History of urinate is sore and hot is denied. Defecate 1-2x a day
with soft consistency and brown color, blood and mucus were denied.

One month ago, the patient went to nearest Puskesmas and

gotten some drugs and medication but also didn't work for her
symptoms, so he went to Dr. Moewardi Hospital. Initially the patient
was directed to a plastic surgery clinic, but after being examined at a
plastic surgery clinic the patient then advised to go to the oncology
surgical polyclinic.

4. Past Illness History

History of same illness : (-)
History of allergic : (-)
History of hypertension : (-)
History of diabetes mellitus : (-)
 History of heart disease : (-)
History of operation procedure : (-)
History of tumor : (-)

5. Family’s Illness History

History of same illness : (-)
History of allergic : (-)
History of hypertension : (-)
History of diabetes mellitus : (-)
History of heart disease : (-)
History of tumor : (-)

6. Economic and Social History

The patient is a building employe. The patient is currently treated in
Moewardi Hospital with National Health Insurance.

7. History of Nutrition and Habitual

Smoking : positive, one day one pack of cigarettes

but the patient has stopped smoking since 2
months ago

Alcohol consumption : denied

Regular exercise : denied

B. PHYSICAL EXAMINATION
I. General Circumstance
1. General circumstance : compos mentis GCS E4V5M6.
2. Vital sign :
Blood pressure : 110/80 mmHg
Heart rate : 90x/minute
 Respiration rate : 18x/minute
Temperature : 36,50 C

II. General Survey

1. Skin : icterus (-), dry (-)
2. Head : other lump (-), ulcer (-), inflammation (-), facial
nerve paralysis (-/-)
3. Eyes : anemic conjunctiva (-/-), scleral icterus (-/-).
4. Nose : Symmetric, inflammation (-/-), secretions (-/-).
5. Ears : Normotia, lump (-), inflammation (-/-),
6. Mouth : wet mucosa (+), cyanosis (-).
7. Neck : enlargement of lymph nodes (-), lump (-)
8. Cor
I: ictus cordis not visible
P: ictus cordis not strong lift
P: the heart border impression is not widen
A: heart sound I-II normal intensity, regular, noisy (-)
9. Pulmo
I: symmetrical chest development (+), retraction (-)
P: fremitus right = left
P: sonor/sonor
A: vesicular base sound (+/+), additional sound (-/-)
10. Abdomen
I: abdominal wall parallel to the chest wall, distension (-)
A: bowel sound (+) normal
P: tympanic
P: tenderness (+), pain (-), mass (-)
11. Extremity: CRT < 2 seconds
 Oedema

- -

- -

Scar and tumor : in the follar, Regio of antebrachii sinistra 1/3

proksimal *look localized status

III. Localized Status

Antebrachii Region (S)
a. Inspection: scar (+), ulceration (+), erythema (+), smooth surface (-
), skin color change (+), post op scars (-)
b. Palpation: scar palpable with the solid and soft consistency, the size
is as big as two goose eggs, with oval shape about 7x24 cm. The
wound surface is flat but not smooth, the borders is irregular, pain
(-), temperature change (-), ulcer (+), pus (+), bleeding (-)

III. Assessment I
Diagnosis:
Non-pressure chronic ulcer of the skin (L98.499)
Differential Diagnosis:
1. Malignant Neoplasm unspecified site of skin (C44.90)
2. Infection of skin (L08.9)

IV. Plan I
1. Clinical laboratory blood test
2. MRI
3. Consultation with department of surgical oncology
V. Attachment