5 agustus 2014 - dmt2 with diabetic foot.ppt
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MORNING CASE MORNING CASE REPORTREPORTAugust 5th, 2014
By: Ayu Trisna Dewi, Widi Mas Gunanthi, Angga Pradana, Bagus Anggaraditya, Prayoga Ariguna, Rozan Fikri
PATIENT IDENTITY• Name : SA• Gender : Male• Age : 46 yo• Religion : Hindu• Address : Pedungan, Denpasar• Status : Married• ToA : August 5th 2014 / 14.30 WITA• No. MR : 14045957
ANAMNESISChief Complaint: wound and swelling at left footPresent HistoryPatient came to hospital with chief complaint wound and swelling at his left foot since 1 week ago. The complaint become worsen. The wound appeared when he use foot reflexion tools.He felt pain on his left right and the wound discharged pus. He also feel numbness on his footHe has no complaint of blurred visionHe has diabetes since 4 year ago and the diabetes was uncontrolled. History of nausea, vomiting, cough, dyspnea was denied
Past HistoryHe has history of DM type 2 since 4 years ago. He takes Glibenclamide and Metformin Family HistoryHis brother has history of diabetesHistory of hypertension, heart disease, and kidney disease was denied Social HistoryAlcoholic and smoking was denied
PHYSICAL EXAMINATION• General app. : Moderately ill• Consc. : Compos mentis• GCS : E4V5M6• BP : 160/100 mmHg• Pulse rate : 140x / minute• Respi. Rate : 29x/ minute• Axillary temp. : 38.5 ̊C
Status Present
•Eyes : anemis (-/-), icterus (-/-),pupil reflex (+/+) isochoric, Oedem palpebrae (-/-)
•ENT : Tonsil, Pharynx, tongue WNL•Neck : JVP + 0 cmH2O, gland enlargement (-)•Thorax : symmetry
COR– Insp : ictus cordis not visible– Palp : ictus cordis not palpable– Perc : UB : ICS II
LB : MCL S ICS V RB : PSL D
– Ausc : S1S2 single regular murmur (-)
PULMO– Insp : symmetrical– Palp : tactile fremitus N/N– Perc : sonor/sonor– Ausc : vesicular +/+ ; ronchi -/- ; wheezing -/-
• Abdomen- Inspection : distension (-)- Auscultation : bowel sound (+) normal- Percussion : tympani- Palpation : hepar and spleen unpalpable,
tenderness (-)Extremities : warm +/+ edeme -/-
+/+ -/-
LABORATORY EXAMINATION
Parameter Result Unit Normal Range Remarks WBC 11,4 103µL 4,10-11,00Ne % 74,6 % 47,00-80,00
Lym% 15,4 % 13,00-40,00
Mo % 7,49 % 2,00-11,00
Eo % 1,40 % 0,00-5,00
Ba % 1,11 % 0,00-2,00
Ne# 11,4 x10^3/µL 2,50-7,50 High
Ly# 1,77 x10^3/µL 1,00-4,00
Mo# 0,857 x10^3/µL 0,10-1,20
Eo# 0,160 x10^3/µL 0,00-0,50
Ba# 0,125 x10^3/µL 0,00-0,80
Complete Blood Count
Parameter Result Unit Normal Range Remarks
RBC 2,91 x10^6/µL 4,50-5,90
HGB 6,76 g/dL 12,0-16,0 Low
HCT 23,5 % 36,0-46,0
MCV 80,5 fL 80,0-100,0
MCH 23,2 pg 26,00-34,00 Low
MCHC 28,8 g/dL 31,00-36,00 Low
RDW 14,2 % 11,60-14,80
PLT 427 x10^3/µL 140,0-440,00
MPV 5,74 fL 6,80-10,00 Low
Blood Chemistry PanelParameter Result Unit Reference
rangeRemarks
Natrium 128 mmol/L 136–145 Low
Kalium 4,3 mmol/L 3,50 –5,10
Parameter Result Unit Reference range
Remarks
SGOT 14 U/L 11- 27
SGPT 11 U/L 11-34
Albumin 1,8 mg/dL 3,4 – 4,8 Low
BUN 16 mg/dL 8,00 – 23,00
Creatinin 1,3 mg/dL 0,50 – 0,90 High
Hb A1C 13,13 < 6,5 High
Blood Gas AnalysisParameter Result Unit Remarks Reference range
pH 7,44 7,35-7,45
pCO2 45 mmHg 35,00-45,00
pO2 101 mmHg High 80,00-100,0
BEecf 6,4 mmol/L -2-2
HCO3- 30,6 mmol/L High 22,00-26,00
SO2c 98 % 95%-100%
TCO2 32 mmol/L High 24,00-30,00
Parameter Result Unit Normal Range Remarks Specific gravity 1,015 negative
pH 5 7,35 – 7,45 Low
Leucocyte Negative Leuco/uL Negative
Nitrite Negative Negative
Protein (urine) 150 (+++) Mg/dL Negative
Glucose (urine) 1000 (4+) Mg/dL Normal
KET 15 (++) Negative
Urobilinogen Normal Mg/dL Normal
Bilirubin (urine) Negative Mg/dL Negative
ERY 25 (++) Ery/uL Negative
Colour p. Yellow P yellow – yellow
Urinalysis
IMAGINGThorax photo•Cor: shape and size WNL, calsification of aortic knob•Pulmo: infiltrate ait left parahiler and both paracardial•Pleural sinus: sharp•Both diaphragma are normal
Conclusion:AortosclerosisPneumonia
ASSESSMENT• Diabetes Melitus type 2• Diabetic foot grade III pedis with ketosis
and ketoalbuminemia• Hypertension stage II• CKD ec suspect DKD• Moderate anemia ec CKD
TREATMENT• Hospitalized • IVFD NaCl 0,9% 20 dpm• Drip insulin 4 U/h if BS > 250 2 U/h if BS 200-250
1 U/h if BS < 200• Fasting during insulin drip • Cefotaxime 3 x 1 gram (IV)• Metronidazole 3 x 500mg (IV)• Captopril 2 x 20 mg per oral• Paracetamol 3 x 500 mg per oral• Transfusi PRC until Hb = 9 gr/dL
PLANNING• Check BSN, Blood sugar 2hours post
prandial, lipid profile, blood culture• Consult to surgery for debridement• Monitoring vital sign and complaints• BS every hour and Na-K every 6 hours