Duty Report24 February 2016

Resident`on Duty: dr.Dini & dr. RenaldyCoass on Duty: Elsa & DimazSupervisor : dr Soroy Lardo SpPD FINASIMFaculty of Medicinet UPN Veteran JakartaDepartment of Internal Medicine Indonesia Army Central Hospital Gatot Soebroto

Ketoacidosis Diabeticum Cough for 1 week e.c dd/ lung oedem, acute upper respiratory tractDyspepsia syndromeHyponatremia hypoosmolar hypovolemiaOD CataractCHF fc I

Patient Recapitulation• Mr.H, 48 y.o, Dyspepsia• Mrs, 47 y.o, chronic diseases anemia e.c Ca mammae• Mrs R, 57 y.o, DM ketosis, Hypertension grade I, Dyslipidemia• Mr.B, 76 y.o, DM ketosis, hyponatremia hypoosmolar

hypovolemia, dyspepsia syndrome

Patient’s Identity• Name: B• Sex: Male• Age: 76 y.o• Occupation: Retired• Address: Jakarta• Date of Admission: 24 February 2016

Anamnesis• Autoanamnesis on 24 February 2016 at 8.30 pm

• Chief complaint: Weakness for 1 week

Present Ilness History• Patient came to the ward with chief complaint weakness for 1

week, it was getting worse and made patient prefer to lay in bed, he also complained of nausea and vomitus for 1 week. He vomited everytime when he took the meal. , lost of appetite (+), thirst increased (+), headache (-), deep and shortness of breath (-) no defecation for 1 week, urination within normal limit color yellowish. He also complained of cough for 1 week, sputum (+) colour yellowish, blood (-), his family complained that he had a fever but never checked the temperature, fainted (-), cold sweat (-), palpitation (-), dyspneu at night (-), dyspneu d’effort (-), orthopneu (-), foot swollen(-) hypertension (-), paralysis or weakness on half body (-), sensibility loss (+), decrease of right eye sight (+) worsen for 1 week. The patient had diabetic melitus controlled for 10 years.

Past illness history • Controlled diabetes mellitus + 10 years• Pedic ulcer + 5 years• Hypertension (-)• Heart disease (-)• Kidney disease (-)• Stroke (-)• Cataract (+) in right eye• Hypoglicemia (-)

Family illness history• The patient complains about a family member living together

with him who coughs

Social history• Smoke (-)• Alcohol (-)• The patient already changed his diet for diabetes

Medication history:Metformin 3 x 500 mg

Physical examination• General state : moderate ill• Conciousness : Compos mentis• Vital sign: BP: 150/80 mmHg HB: 76 bpm RR: 20x/m T:36,3⁰C• Head: Normocephal• Eye: Pale conjungtiva -/-, icteric sclera -/-, cilliary injection +/-,

sunken eyes -/-• ENT: normal, hyperemis pharyng (-)• Mouth: dry tongue mucosa, oral thrush (+)• Neck: JVP 5 +2 cmH2O, lymph not palpable

• Thorax-LungI: normochest, both hemisphere movement symetricPal: VF simetric, chest wall movement symetricPer: sonor on both lungA: vesicular +/+, rales -/-, wheezing -/-

HeartI: IC not seenPal: IC not palpablePer: Right border: ICS IV lin parasternal dextra Left border : ICS V one finger lateral lin mid clavicula sinistra Heart waist: ICS III lin. Parasternal sinistraA: Regular I/II heart sound, murmur (-), gallop (-)

• Abdomen:I: concaveA: bowel sound normalPal: hepar & spleen not palpable, tenderness (+) epigastric Balotement -/-, turgor decreasedPer: tymphani, shifting dullness (-)• Extremities: CRT < 2 second foot edema +/+, pale nail -/-

Laboratory ResultBlood routine Result

Hb 13.0 mg/dl

Ht 36 %

RBC 4,4 M/uL

WBC 5910 /uL

Platelet 224000 /uL

MCV 83 fl

MCH 30 pg

MCHC 36 g/dl

Biochemical blood Result

SGOT 15 U/L

SGPT 16 U/L

Ureum 29 mg/dl

Kreatinin 0,8 mg/dl

RBS 292 mg/dl

Natrium 124 mmol/L

Kalium 4,7 mmol/L

Clorida 88 mmol/L

Aseton +

Blood gas analysis Result

pH 7,395

pCO2 32,0

pO2 89

HCO3 19,8

BE -3,6

Sp O2 96,8

Anion Gap = Na – (Cl + HCO3) = 124 – (88 + 19,8) = 16,2 (increased)

Resume• Patient come to the ward with chief complaint weakness for 1

week and getting worse, nausea (+) vomitus (+) everytime he took a meal, thirst increased, headache (-), deep and shortness of breath (-), defecation and urination within normal limit. Cough for 1 week, sputum (+), yellowish, blood (-), fever (-), dyspneu d effort (-), dyspneu at night (-), orthopneu (-), sight decreased on right eye worsen for 1 week. Patient had histories of controlled diabetic mellitus + 10 years, pedic ulcer 5 years ago, cataract (+) right eye, there is family member that had a cough, BP: 150/80 HB: 76 bpm RR:20 x/m T:36.3⁰C, cilliary injection +/- , JVP 5+2 cm H2O, heart border wider, abdominal shape concave, turgor decreased, epigastric pain (+) , foot edema +/+, hyperglicemia (292 mg/dl), hyponatremia (124 mmol/l), hypochloride (88 mmol/L), aseton (+) pH (7,395), normal value of leucocyte (5910)

• Decrease of PCO2 (32 and HCO3 (19,8), with increased value of anion gap (16,2)

Problem list• Ketoacidosis Diabeticum • Cough for 1 week e.c dd/ lung oedem, acute upper respiratory

tract• Dyspepsia syndrome• Hyponatremia hypoosmolar hypovolemia• OD Cataract• CHF fc I

Discussion• Mild Ketoacidosis DiabeticumA(x) : weakness for 1 week, nausea (+) vomit (+) everytime he took a meal, deep and short of breath (-), cough (+) 1 week, sputum (+) collor yellowish, fever (-), defecation and urination within normal. He had histories of controlled diabetic + 10 years, pedic ulcer 5 years ago, cataract (+) right eyeP(x) : BP 150/80 HB: 76 bpm RR: 20 x/m T:36.3⁰C, abdominal shape concave, turgor decreased, epigastric pain, hyperglicemia (292 mg/dl), aseton (+), compensated metabolic asidosis (pH N, PCO 2 ↓ HCO3 ↓) eventhough the pH value was normal, but there was incresed value of anion gap (16,2)Planning Diagnostic : random blood sugar, electrolyte, aseton, blood gas analyse (every 6 hour)

Several Condition Clinical Symptom of Chronic Inflammation

Diabetes Melitus with pedic ulcer (10 years uncontrolled)

Gastropathy Nephropathy Neuropathy

Retinopathy Miocardiopathy

Weakness, nausea & vomitus

Electrolyte imbalance

Acute hyperglicemia Diabetic Ketosis

Aseton (+)

Diabetic Ketosis Dehydration (caution with CHF)

Metabolic Intermediate Management (insulin management)

Treatment etiology of disease (infection and MCI)

Warning approach of :Another complication like sepsis and MODS

• Planning therapy: -NaCL 0,9% loading 1-2l in 1st hr, 1 L 2nd hr, 500 ml 3rd & 4th hr, 250 ml 5th &6th hr

-rapid insulin IV 210 U sliding scale 5U NaCl 0,9% at 2nd hr and blood sugar < 200 stop - KCl 25 mEq/ 6 hr

• Cough for 1 week e.c dd/ acute upper respiratory tract, lung oedem

A(x) : cough (+) 1 week, sputum (+) collor yellowish, fever (-), deep and shortness of breath (-), dyspneu at night (-) dyspneu d effort (-) orthopneu (-) history of DM 10 years

P(x) : RR within normal limit, lung examination show no abnormality, hyperemis pharyng (-), cardiomegali and foot edema +/+ , WBC 5910 /ul

Planning Diagnostic : chest x-ray, sputum culturPlanning therapy : Inj. Ceftriaxone 1x2 gr IV

• Dyspepsia syndromeA(x) : nausea + vomitus everytime he took a meal for 1 weekP(x): epigastric pain Planning diagnostik: ureabreath testPlanning therapy: inj omeprazole 1 x 40 mg P.O sucralfat 1 x 15 cc

• Hyponatremia hypoosmolar hypovolemia• A(x): nausea + vomitus everytime he took a meal for 1 week, loss

of apetite (+), thirst increased urination within normal limit• P(x): BP: 150/90 HB:76 bpm, sunken eyes -/-. JVP 5+2 cm H2O,

abdominal shape concave, turgor decreased, hyponatremia (124 mmol/L) with osmolarity value 274,5

• Planning diagnostik: electrolyte serial• Planning therapy : decreased sodium value maybe cause of

delucional condition in diabetic ketosis state (hyperglicemic condition), so for this problem the planning therapy is correction the diabetic ketosis state by rehydration (NaCL 0,9% loading 1-2l in 1st hr, 1 L 2nd hr, 500 ml 3rd & 4th hr, 250 ml 5th &6th hr)

• OD Cataract dd/ acute glaucoma• A(x) : decreased of right eye sight, worsen for 1 week, diabetes

mellitus type 2 (+), catarcat hystory (+)• P(x): cilliary injection +/-• Planning diagnostic: funduscopy, slit lense examination, retina

imaging• Planning therapy: -

• CHF fc I• A(x): dyspneu at night (-) dyspneu d effort (-) orthopneu (-)

history of DM 10 years• P (x): cardiomegali and foot edema +/+• Planning diagnostic : ECG and Echo• Planning therapy: central venous pressure monitoring• monitoring fluid balance =0

Prognosis• Quo ad vitam : dubia ad bonam• Quo ad santionam: dubia ad bonam• Quo ad functionam: dubia ad bonam

Thank you