DUTY REPORT
TH
JANUARY 5 2014
Diabetic Ketoacidosis Moderate Stage
Diabetic ulcer pedis dextra Wagner I
Acute on CKD
Dokter jaga
Koas jaga
Moderator
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dr. Rizki, dr. Dameria
Michael & Ayu
dr. Soroy Lardo Sp.PD
Duty Report Discussion
• Dr. Wahyu
• 52 year old patient with DM to exclude ACS
• Serial ECG, get cardiac enzymes
• Dr. Dermawan
• DKA is an acute complication of DM,
• ADA classification of DKA based on pH and HCO3
• rehydrate patien for 1-2 hours then insulin drip and bolus
• prevent precipitating factors
• Dr. Soroy
• DKA improve dehydration, metabolic condition, and infection
control
PATIENT RECAPITULATION
Inpatient
Outpatient
Ward
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7
2
1
1. Mrs. Silviani, 26 yo, 430562, wd/ Fever day II ec Virus
2. Mr. Bonar, 52 yo, 430548, wd/ Spontaneous
3.
4.
5.
6.
7.
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Pneumothorax + bronkopleural fistula
Mr. Rochimin, 25 yo, 370987, wd/ Fever day II
Mrs. Muntamah, 50 yo, 030804, wd/ Dyspneu ec. CHF
Grade III-IV
Mr. Ape, 56 yo, 430567, wd/ DKA
Mrs. Titi, 60 yo, 430566, wd/ DKA
Mr. Djemangin, 76 yo, 430568, wd/ Dyspepsia
IDENTITY
1. Name
2. Sex
3. Age
4. Job
5. Religion
6. Marital Status
7. Address
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Mr. Ape
Male
56 years old
TNI – AD (soldier)
Moslem
Married
Gang Benteng Cakur Tipar
ANAMNESIS
• Autoanamnesis on 5/2/14 at 20.00 PM in the RSPAD
Gatot Soebroto Emergency Room.
• Chief Complain:
epigastric pain for 5 days before admission to ER
• Additional Complain:
N/V, cough, loss of appetite
CURRENT ILLNESS
• Patient was admitted to ER with epigastric pain for 5
days. Intermittent pain, which worsen day by day. Pain
radiated to breast bone, felt like burning sensation. Pain
was not aggravated or relieved by anything.
• Patient also felt nausea and vomited 3-5x per day. Vomit
consisted of food, liquid (>food), no blood or foam.
Decrease appetite without loss of weight.
• Fever felt at evening, given PCT fever declined. Seizure,
loss of consciousness declined.
• Unhealed wound was found on the right foot, pus (+),
blood (+)
• Patient denied any prolonged coughs and discomfort at
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throat. Patient denied any shortness of breaths.
Patient denied any chest pain, sweating at night, loss of
weight and coughing blood before today.
Urination within normal limit, no decrease in frequency or
quantity, dark urine (-)
Defecation within normal limit, dark stool (-)
Uncontrolled diabetes for 10 years with novorapid 10-0-10
PAST ILLNESS
• Heart disease, hypertension, asthma, chronic cough
denied
FAMILY ILLNESS
• Diabetes from patient’s father
• Malignancy, hypertension, stroke denied
HABITS AND LIFESTYLE
• Smoking, alcohol consumption denied.
PHYSICAL EXAMINATION
VITAL SIGNS
• General State
• Consciousness
• Blood Pressure
• Pulse
• Respiratory Rate
• Temperature
• Body Weight
• Body Height
• BMI
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Moderate Sickness
Compos Mentis
140/80 mmHg
90 x/minute
24 x/minute
37.3oC
68 kg
170 cm
23,53 (Normoweight)
PHYSICAL EXAMINATION
General Examination
• Head
• Eye
• Ears
• Nose
• Mouth
• Neck
• Thorax
• Cor
• Pulmo
• Abdomen
• Extremities
: Normocephal
: anemic conjunctiva (+/+), icteric sclera (-/-)
: normotia, discharge (-)
: septum deviation (-), discharge (-)
: dry mucous, oral trush (-), leukoplakia (-)
: lymph nodes enlargement (-) JVP 5-2 cmH2O
: symmetric, intercostal retraction (-)
: regular 1st and 2nd heart sound, murmur (-), gallop (-)
: vesicular breathing sounds, rales / crackles (-/-)
ronchi (-/-) wheezing (-/-)
: distended (-), bowel sound within normal limit,
tympani, hepar & lien not palpable, epigastric
tenderness
: warm, pitting edema (-), clubbing (-), cyanosis (-)
CRT < 2 seconds, diabetic ulcer pedis dekstra
DIAGNOSTIC PLANS
LABORATORIUM
JENIS PEMERIKSAAN
HASIL
NILAI RUJUKAN
Hb
8.3
13 - 18 g/dl
Ht
24
40 – 52 %
Erythrocyte
2.9
4.3 - 6.0 mil /ul
Leukocyte
24.700
4800 - 10800/ul
Thrombocyte
490.000
150000 - 400000/ul
MCV
82
80 – 96 fL
MCH
29
27 - 32 pg
MCHC
35
32 – 36 g/dL
Routine Hematology
JENIS PEMERIKSAAN
HASIL
NILAI RUJUKAN
Ureum
125
20 - 50 mg/dl
Creatinine
3.2
0.5 – 1.5 mg/dl
Random Blood Sugar
879
< 140 mg/dl
Natrium
120
135 – 147 mmol/L
Potassium
3.9
3.5 – 5.0 mmol/L
Chloride
84
95 – 105 mmol/L
Aceton
+/positive
-/Negatif
Kimia klinik:
JENIS PEMERIKSAAN
HASIL
NILAI RUJUKAN
pH
7.258
7.37 – 7.45
pCO2
22.2
33 – 44 mg/dl
pO2
36.7
71 – 104 mmHg
Bicarbonate (HCO3)
10.0
22-29 mmol/L
Base Excess
-14.8
(-2)-3) mmol/L
O2 Saturation
62.9
94-98%
Blood Gas Analysis
ECG: Normal sinus rythm, 75 bpm, regular, normoaxis, p wave normal
(upright & uniform), PR interval normal (0.14 sec), QRS complex
normal (0.09 sec), ST changes (-), T-inverted (-), BBB (-), LVH/RVH (-).
X-RAY:
RESUME
Patient was admitted to ER with epigastric pain for 5 days.
Intermittent pain, worsen, felt like burning sensation which radiated to
breast bone. Pain accompanied by nausea, vomit, anorexia, fever.
History of uncontrolled DM for 10 years with insulin.
On PE, patient's BP was 140/80 mmHg. Anemic conjunctiva,
epigastric tenderness, organomegali (-), diabetic ulcer at the right foot
with pus and blood.
The Lab exam revealed anemia normocytic normochrome,
leukocytosis, thrombocytosis, inc ur/creat, RBS, hyponatremia,
hypochloride, acetone (+). Asidosis metabolic.
PROBLEMS LIST
1. Diabetic Ketoacidosis Moderate Stage
2. Diabetic ulcer pedis dextra Wagner I
3. Acute on CKD
4. Hypertension grade I
ASSESSMENT
Diabetic Ketoacidosis Moderate Stage
• Anamnesis: DM uncontrolled for 10 years, epigastric pain,
heart-burn like, N/V
• Physical examination: epigastric tenderness
• Additional examination:
RBS: 879 mg/dL
acetone (+)
pH/pCO2/HCO3/O2Sat: 7.2 / 22.2 / 10 / 62.9
Diabetic ulcer pedis dextra Wagner I
• Anamnesis: unhealed wound, fever
• Physical exam: superficial ulcer pedis dextra, pus (+),
blood (+), pain (-),
• Additional exam:
leukocytosis
RBS 879 mg/dL
Acute on CKD
• Anamnesis: nausea vomit, epigastric pain
• Physical exam: conjungtiva anemic,
• Additional exam:
Hb: 8.3
MCV/H: 82/29
Ur/Creat: 125/3.2
eGFR: 24.79
dd/ CKD stage IV
Hypertension Grade I
• Blood Pressure 140/80 mmHg
• History of high blood pressure denied
DIFFERENTIAL DIAGNOSIS
• Dyspepsia functional
• GERD
THERAPY
• Diagnostic Plan
- CBC, ro toraks, urinalysis, albumin
- Arterial Blood Gas / 8 hours
- Bacterial culture mo, resistency
- USG kidney,
- Consult internist
• Therapeutic Plan
- IVFD Nacl 0.9% 2L 1st hour
- RI drip 5 unit/hour 2nd hour
- Ondansentron 2 x 4 mg iv
- Omeprazole 1 x 40 mg iv
- Captopril 3 x 12.5 mg po
- Paracetamol 3 x 500 mg po
- Metronidazole 1 x 500 mg iv
- Ceftriaxone 1 x 2 gr iv
- Debridement
• Education Plan
- Control to internal medicine department
PROGNOSIS
1. Qua ad vitam
2. Qua ad functionam
3. Qua ad sanationam
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Dubia
Dubia ad malam
Dubia ad malam
THANK YOU