hypoglycemia and ulcus and ck dduty report 13 jan 2016
TRANSCRIPT
HYPOGLYCEMIA E.C METFORMIN ON DIABETES MELLITUS TYPE 2
DIABETIC FOOT ULCERANEMIA MAKROSITER
CKD GRADE IVDUTY REPORT
13th January 2016Consulen : dr. Soroy Lardo Sp.PD, FINASIMResiden : dr. Yulianto
dr. DiniCo-Ass : Reza Angga Pratama, S.Ked
Febri Qurrota Aini, S.Ked
Department Of Internal Medicine, Indonesia Army Central Hosptal Gatot Soebroto
Fakultas Kedokteran UPN Veteran - Jakarta
PATIENT RECAPITULATIONTotal: 3 patients- Mrs. S, 70 yo, DM ketosis, Ulcus DM pedis
dextra sinistra- Mrs. SL. 71 yo, DM type 2, Ulcus DM pedis
dextra, anemia, CKD stage IV - Mr. S, 79 yo, anemia, dyspnea
PATIENT IDName : Mrs. SAge : 71 y.o.Religion : IslamMarital Status : MarriedOccupation : HousewifeAddress : Jakarta PusatMed Record : 257137
ANAMNESISChief ComplaintWeakness for 2 days.
History of Present Illness• 3 days before admission, the patient
complained of headache, fatigue (-), Fever (-), nausea (-), vomiting (-), diarrhea (-), constipation (-), frequency of urine increased. The patient checked GDS (random blood sugar) at home and it was 426 g / dL. Then the patients take half metformin tablet and then the patient checked GDS (random blood sugar) and it was 300 g / dL.
• 2 days before admission, the patient complained of weakness, out of breath and dizziness. Fever (-), nausea (-), vomiting (-), (-), diarrhea (-), constipation (-), frequency of urine increased. The Patient checked GDS (random blood sugar) at home and it was 81 g / dL.
History of Present Illness (Continued)• The patient was admitted to emergency room with
weakness and dizziness for 2 days. Fever (-), vomitus (-), nausea (-), diarrhea (-), constipation (-), increased frequency of urine. She had blood transfusion 3 times in order to increase her Hb.
• The patient also complained about increased frequency to consume food and drink, and increase frequency of urine. The patient did not take the drug of diabetes melitus for 3 months because the patient complained of weakness and dizziness after take a diebetes mellitus drug. She also complained of having wound on her right foot which was hard to heal. The wound is now dark reddish-black color. She did not feel pain at the wound site and the left right foot feels numbness in fingertiip
Past Medical HistoryShe was diagnosed with diabetes mellitus since she was 46 years old. lately 4 years ago she was hemodialysis. No history of allergy, heart disease, hypertensi, and lung disease.
FamiIy HistoryHer mother and grandmother suffered diabetes mellitus.
Social HistoryShe denies past or present tobacco and alcohol use.
PHYSICAL EXAMGeneral : moderate ill, compos mentis
Vital SignsBlood pressure : 137/60 mmHgHeart rate : 88 beats/minuteRespiratory rate : 20 breaths/minuteTemperature : 36,2 oC
Weight : 45 kgHeight : 160 cmBMI : 17,5 (underweight)
Head: normocephalEye: pale conjunctiva (+/+), icteric sclera (-/-)Ears: normotia, discharge (-)Nose: septum deviation (-), discharge (-)Throat: dry mucous (-), tonsils T1-T1, hyperemic
pharynx (-)Neck: JVP 5-2 cmH2O, enlargement nodes (-)Cardiovascular: regular rate and rhythm; normal S1,
S2; murmurs (-), gallops (-) Lungs: VBS (+/+), crackles (-/-), wheezes (-/-)Abdominal: not distended, normal bowel sound,
soft, tender to palpation in epigastric region, and rebound tenderness (-), liver and spleen not palpable, palpable masses (-), normal skin turgor, tympani percussion sound
Extremities: warm, CRT < 2 seconds, edema (-), cyanosis (-); ulcer DM (+)
Description of ulcus
• Impaired Perfusion : 1. none
• Size / Extent in MM2 : 5000 MM2
• Tissue loss/Dept : 1. superficial fullthickness, not deeper than dermis
• Infection : 2. infection of skin and subcutaneous tissue only
• Impaired sensation : 1. Present
LABORATORY DATALab Tests
ResultsNormal Value20th Nov,
06:3113rdJan, 16:15
Hematology
Hemoglobin 8.0 6.9* 12 – 16 g/dlHematocrit 25 21* 37 – 47 %RBC 2.5 2.1* 4.3 – 6.0 ^106 /μLWBC 8790 6770 4,800 – 10,800 /μL
Platelets 218,000 194,000 150,000 – 400,000 /μL
MCV 97 99* 80 – 96 fLMCH 32 33* 27 – 32 pgMCHC 33 33 32 – 36 g/dL
LABORATORY DATALab Tests
ResultsNormal Value20th Nov,
06:3113rdJan, 16:15
Albumin 2.6* 3.5-5.0 g/dlUreum 70 62* 20-50 mg/dLKreatinin 1.8 1.6* 0.5-1.5 mg/dLRandom Blood Sugar 68* <140 mg /dL
Natrium 146 136 135-147 mmol/LKalium 4.4 4.7 3.5-5.0 mmol/LClorida 117 109* 95-105 mmol/L
RADIOLOGY DATA
Description of Radiology result
• Shown fracture on dextra pedis caput os metatarsal digiti V
• Shown deformity on os distal phalang digiti I dextra pedis
• Decreased dextra pedis bone density• Shown soft tissue hyperplasia on regio dextra
pedis
The image suggest Osteoporosis pedis dextra, still posible osteomyelitis
ECG
• Sinus rhythm
RESUME• The patient was admitted with weakness and dizziness for 2
days. Fever (-), vomitus (-), nausea (-), diarrhea (-), constipation (-), frequency of urine increased. The patient also complained about increased frequency to consume food and drink. The patient did not take the drug of diabetes melitus for 3 months because the patient complained of weakness and dizziness. She also complained of having wound on her right foot which was hard to heal. The wound is now dark reddish-black color. She did not feel pain at the wound site and the left right foot feels numbness in fingertiips. She had blood transfusion 3 times in order to increase her Hb
.• 3 days before admission, the patient complained of headache.
The patient checked GDS (random blood sugar) at home and it was 426 g / dL. Then the patients take half metformin tablet. And then the patient checked GDS (random blood sugar) and it was 300 g / dL.
Resume (Cont)• 2 days before admission, the patient complained of
weakness, out of breath and dizziness. The Patient checked GDS (random blood sugar) at home and it was 81 g /dL.
• Vital signs are:• BP: 137/60 mmHg, HR: 88 beats/minute, RR: 20breaths/minute, Temperature:36,2 oC
• Physical exam reveals pale conjungtiva (+/+), ulcer DM (+), and dark reddish-black color on right foot.
• Laboratory data shows anemia makrositer, hipoalbumin, hypoglikemia, increase ureum and creatinin.
PROBLEM LIST
• Hypoglycemia e.c metformin on diabetes mellitus type 2
• Diabetic foot ulcer• Anemia makrositer• CKD grade IV
ASSESSMENTHypoglycemia e.c metformin on diabetes mellitus type 2• The patient was admitted with weakness and
dizziness for 2 days. Fever (-), vomitus (-), nausea (-), diarrhea (-), constipation (-), frequency of urine increased. The patient also complained about increased frequency to consume food and drink. The patient did not take the drug of diabetes melitus for 3 months because the patient complained of weakness and dizziness after take diabetes mellitus drug. 3 days before admission, the patient complained of headache. The patient checked GDS (random blood sugar) at home and it was 426 g / dL.
• Then the patients take half metformin tablet, and then the patient checked GDS (random blood sugar) and it was 300 g / dL, and the next day she feels weakness, out of breath and dizziness and she checked her GDS is 81 gr/dL.
• The patient was admitted to emergency room with weakness and dizziness for 2 days. Fever (-), vomitus (-), nausea (-), diarrhea (-), constipation (-), increased frequency of urine. She had blood transfusion 3 times in order to increase her Hb.
PE reveals BP: 137/60 mmHg, HR: 88 beats/minute, RR: 20breaths/minute, Temperature:36,2 oC• Pale conjungtiva (+/+), random blood sugar test
shows hypoglycemic (68 g/dL), increase ureum creatinin
• Diagnostic plan: reevaluate random blood sugar• Therapy: - Infus D10% 20 tpm - GDS repeat examination.• Educational plan: modifying lifestyle
Diabetic foot ulcer• Based on patient’s complained of having dark reddish-black
wound on her right foot which hard to heal. The wound now being dark reddish-black color. She did not feel pain at the wound site and the left right foot feels numbness in fingertiips.
• PE reveals ulcer (+) in right foot. – Impaired Perfusion :
1. none– Size / Extent in MM2 : 5000 MM2
– Tissue loss/Dept : 1. superficial fullthickness, not deeper than dermis– Infection : 2. infection of skin and subcutaneous tissue only– Impaired sensation : 1. Present
• Diagnostic plan: wound Gram stain and culture• Therapeutic plan: wound care, ceftriaxone IV 1x2 gr,
metronidazole IV 3x500 mg
Anemia makrositer• Based on the patients complained
weekness and dizzyness• PE: pale conjungtiva +/+• Lab examination : decrease Hb,
increase MCV • Plan theraphy : PRC transfusion
200cc
• CKD on stage IV:• Based on anamnesa: history of HD since 4 years
ago, laboratory shows increased ureum creatinin.
• GFR = (140-age) x BB = (140-71) x 45 72x creatinin plasma 72x1,6
= 26,9 (stage IV)• Plan therapy: hemodialysis
PROGNOSISQuo ad vitam : ad bonamQuo ad functionam : ad malamQuo ad sanationam : ad malam
Diabetic - Infection
Dysfunction Of
Immune System
Must be Controlled blood Sugar
Uncontrolled
Increase of Infection and colonization
+ +Neuropathy Diabetic
Nefropathy
Ulcus Diabetic
Nefropathy Diabetic
CKDPedis
Score
Assesment severity (grade)
- Education DM Program- Insulin Initiation- Antibiotic with Culture Result- Wound Maintaince Treatment- Repair Albumin Score( Decrease Severity Infection )
THANK YOU