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