dm type 2 with gangrene-agustania
TRANSCRIPT
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DIABETES MELLITUS
TYPE II with RIGHTFOOT DIABETIC
GANGRENE
AGUSTANIA BETA PRIHANTO030.07.013
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Identity
Mrs. UName
40 y.oAge
femaleSex
Pisang Sambo, KarawangAdress
HousewifeOccupation
Elementary schoolEducation
SundaneseEthnic
MarriedMarital status
MoeslimReligion
May 26th 2012Date of admission
Teluk JambeTaken from
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Anamnesis
painful wound with a slightbloody discharge on her
right foot since 1 day beforebeing admitted to thehospital
Chiefcomplaint
Fatigue and slight headache Numbness on her footAdditional
complaint
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History of present disease
Mdm. U, 40-years-old woman, came to emergency of RSUD Karawangafter experiencing painful wound with a slight bloody discharge on herright foot since 1 day before admitted to the hospital.
1 monthbefore hospitalized, she had her right foot pricked by a brokenglass. At that time, because it wasnt a big wound or painful, she didnt doanything for the wound, like applying the betadyne or putting on thebandage.
2 weekbefore hospitalized, she began to feel pain on herwoundand it gotworsen day by day. The wound also gotbigger,swollen and produce somepus.
2 daysbefore hospitalized, the wound was getting bigger even more,theswelling and pus got worsen as well. The skin turn s black (necrotic)around the ulcer.
1 daybefore hospitalized, the wound still produced some pus and a little
bit of blood. Patient also complained slight feverbut its already recoveredby now.
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Patient also admitted that she ate and drink frequently all this
time. She also urinated more , especially at night. The frequency
of her urinating is about 9 times per day, the color is yellow and
no blood. Patient also admitted that sometimes if she developedwounds, it would take longer time to heal.
But, despite from her eating more often, she still felt tired and
fatigue. And she also complained that she had slight headache
lately, and felt numb on her feet.
She denied any convulsion, loss of consciousness, pain whenwalking before trauma. She didnt have any complain about her
defecation.
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History of Past Disease
Patient has history of Diabetes Mellitus since 2010. At first,
she frequently went to Puskesmas to take some medicine to
control the disease. But lately, she hadnt go to the Puskesmasanymore since she didnt have complaint about her disease.
She undergo amputation the the 4th finger of the right foot 1
year ago because of the same current illness.
Hypertension (-)
Asthma (-)
Allergy (-)
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Family History
Same illness ()
Hypertension ()
Allergy ()
Asthma ()
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Medication History
Patient never consume any medicine for a long
term Blood transfusion ()
Surgery ()
Other medication ()
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Personal and Social History
She has a habit of eating sweet foods since she
was a child. But after she found out that she had
Diabetes Mellitus, she tried to endure it.
She didnt exercise regularly.
No smoke, no consumption of alcohol or drugs
No consumption of herbal drink
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General Condition
General Appearance : Slightly ill
Consciousness : Conscious
Nutrient Status : Sufficient
Weight : 53 kg
Height : 155 cm
BMI : 22,06 kg/m2
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BP:
120/70 mmHg
Pulse :
88
times/minute
RR :
20 times/minuteTemp:
36,5 C
Vital Sign
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General Status
Head Normocephali, hair distribution is good, not easy to revoked
Eyes
Pupil isokor, CA -/- , SI -/- Ears
Normotia, secrete -/-, serumen -/-, intact timpany membrane+/+
Nose septum deviation (-), secrete -/-, concha is normal, mucosa not
hyperemic
Mouth Dirty mouth (+), dry mouth (-), normal papil, mucosa hyperemic
(-)
Throat Tonsils T1/T1 calm, pharynx hyperemic (-)
Neck Lymph nodules enlargement (-), tiroid gland enlagement (-), JVP5+2 cm H20
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Thorax Examination
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Thorax Examination
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Abdominal Examination
Inspection
Flat, symmetric, caput medusa (-), smiling umbilicus (-)
Auscultation Bowel sound (+) normal
Palpation
Tenderness (+)
Distension (-)
No liver and spleen enlargement
Murphy sign (-)
Percussion
Tympanic
No pain present on abdominal percussion
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Extremity Examination
Upper limb : oedem (-/-), warm (+/+)
Lower limb : Right: gangrene on the right foot (+), 3 x 4
cm, hyperemic-black, tenderness (+), swollen,
warm, pus (+), necrotic area around the ulcer(+), pulse (-)
Left: oedem (-), warm (+)
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Laboratory ExaminationMei 26th 2012
Result Normal range
Hemoglobin 12.2 (12 17) g%
Leucocytes 16.100 (5.000 10.000)/L
Platelet 268.000 (150.000 450.000)/L
Ht 38 (37 48) %
Random Blood Glucose 255 (80 140) mg/dl
Ureum 28,9 (10 45) mg/dl
Creatinine 0,95 (0,4 1,5) mg/dl
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Laboratory ExaminationMei 27th 2012
Result Normal range
Hemoglobin 12.4 (12 17) g%
Leucocytes 9.700 (5.000 10.000)/L
Platelet 252.000 (150.000 450.000)/L
Ht 39 (37 48) %
Random Blood Glucose 151 (80 140) mg/dl
Ureum 30.2 (10 45) mg/dl
Creatinine 0,8 (0,4 1,5) mg/dl
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Differential Diagnosis
Diabetes Mellitus type 2 with Gangrene
Diabeticum Diabetes Mellitus type 2 with Cellulitis
Diabetes Mellitus type 2 with Erycipelas
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Resume
Symptoms
Painful wound with a slight bloody dischargeon her right foot since 1 day before admitted tohospital.
1 month before right foot got wounded bya broken glass small wound (+)
2 week before painful, swelling wound(+), and produce some pus.
2 days before began necrotic around theulcer
Polyphagy (+), polydipsia (+), polyuria (+),fatigue, slight headache, numbness on the feet.
History of Past Disease : DM since 2010Amputation of the 4th finger of the right foot 1year ago.
Signs
Extremities gangrene on the right foot (+),
3 x 4 cm, hyperemic-black, tenderness (+),
swollen, warm,pus (+) , necrotic area around
the ulcer (+),pulse (-)
Laboratories and others
RBG >200 mg/dl Hyperglycemia
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Working Diagnosis
DIABETES MELLITUS TYPE II withRIGHT FOOT DIABETIC GANGRENE
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Suggested Examination
Lipid profile
ECG Pus culture
Rontgen thorax and pedis
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Treatment
Bed rest
Diet DM 1723 calories
IVFD NaCl 20 tpm Ranitidin 2 x 1 gr amp.
Ceftriaxon 1 x 2 gr fl.
Ketorolac 3 x 30 mg amp.
Metronidazol 3 x 500 mg amp.
Metformin 3 x 500 mg tab.
Debridement
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Prognosis
Ad Vitam : Ad bonam
Ad Functionam : Dubia ad malam
Ad Sanationam : Dubia ad malam
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