DUTY REPORT JANUARY 5 TH 2014

DUTY REPORTJANUARY 5TH 2014

Dokter jaga : dr. Rizki, dr. Dameria

Koas jaga : Michael & Ayu

Moderator : dr. Soroy Lardo Sp.PD

Diabetic Ketoacidosis Moderate Stage Diabetic ulcer pedis dextra Wagner IAcute on CKD

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 : 7

Outpatient : 2

Ward : 1

1. Mrs. Silviani, 26 yo, 430562, wd/ Fever day II ec Virus

2. Mr. Bonar, 52 yo, 430548, wd/ Spontaneous Pneumothorax + bronkopleural fistula

3. Mr. Rochimin, 25 yo, 370987, wd/ Fever day II

4. Mrs. Muntamah, 50 yo, 030804, wd/ Dyspneu ec. CHF Grade III-IV

5. Mr. Ape, 56 yo, 430567, wd/ DKA

6. Mrs. Titi, 60 yo, 430566, wd/ DKA

7. Mr. Djemangin, 76 yo, 430568, wd/ Dyspepsia•

IDENTITY

1. Name : Mr. Ape

2. Sex : Male

3. Age : 56 years old

4. Job : TNI – AD (soldier)

5. Religion : Moslem

6. Marital Status : Married

7. Address : 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 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

• Diabetes from patient’s father• Malignancy, hypertension, stroke denied

FAMILY ILLNESS

HABITS AND LIFESTYLE• Smoking, alcohol consumption denied.

PHYSICAL EXAMINATION

VITAL SIGNS•General State : Moderate Sickness•Consciousness : Compos Mentis•Blood Pressure : 140/80 mmHg•Pulse : 90 x/minute•Respiratory Rate : 24 x/minute•Temperature : 37.3oC•Body Weight : 68 kg•Body Height : 170 cm•BMI : 23,53 (Normoweight)

PHYSICAL EXAMINATIONGeneral Examination•Head : Normocephal

• Eye : anemic conjunctiva (+/+), icteric sclera (-/-)• Ears : normotia, discharge (-)• Nose : septum deviation (-), discharge (-)• Mouth : dry mucous, oral trush (-), leukoplakia (-)

•Neck : lymph nodes enlargement (-) JVP 5-2 cmH2O•Thorax : symmetric, intercostal retraction (-)

• Cor : regular 1st and 2nd heart sound, murmur (-), gallop (-) • Pulmo : vesicular breathing sounds, rales / crackles (-/-)

ronchi (-/-) wheezing (-/-)•Abdomen : distended (-), bowel sound within normal limit,

tympani, hepar & lien not palpable, epigastric tenderness

•Extremities : warm, pitting edema (-), clubbing (-), cyanosis (-) CRT < 2 seconds, diabetic ulcer pedis dekstra

DIAGNOSTIC PLANS

JENIS PEMERIKSAAN HASIL NILAI RUJUKAN

Routine Hematology

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

LABORATORIUM

JENIS PEMERIKSAAN HASIL NILAI RUJUKAN

Kimia klinik:

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

JENIS PEMERIKSAAN HASIL NILAI RUJUKAN

Blood Gas Analysis

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%

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:

RESUMEPatient 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 : Dubia

2. Qua ad functionam : Dubia ad malam

3. Qua ad sanationam : Dubia ad malam

THANK YOU