Case Dm Type II + Gangrene Diabeticum +Anemia

7/29/2019 Case Dm Type II + Gangrene Diabeticum +Anemia

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DIABETES MELLITUS TYPE II

with GANGRENE DIABETICUMPEDIS DEXTRA and ANEMIA

Annisa Juwita

030.07.027


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Identity Mrs. A

Name

46 y.oAge

femaleSex

Pisang Sambo, KarawangAdress

LabourOccupation

Elementary schoolEducation

SundaneseEthnic

MarriedMarital status

MoeslimReligion

February 8th 2012Date of admission

Teluk JambeTaken from


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Anamnesis

painful wound on herright foot since 10days before admitted

to the hospital

Maincomplaint

Faint, fatigue and

slight headache Numbness on her

foot

Additionalcomplaint


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History of present disease

Mrs. A, 46-years-old woman, came to emergency department ofRSUD Karawang after experiencing painful wound on her right footsince 10 days before admitted to the hospital.

1 monthbefore hospitalized, she had her right foot prick by a wood.At that time, because it wasnt a big wound or painful, she didnt doanything for the wound, like applying the betadyne or putting on theband-aid.

2 weekbefore hospitalized, she began to feel pain on herwoundandit got worsen day by day. The wound also gotbigger,swollen andproduce some pus.

2 daysbefore hospitalized, the wound was getting bigger even

more,the swelling and pus got worsen as well. It also began black(necrotic) around the ulcer.

1 daybefore hospitalized, the wound still produced some pus and alittle bit of blood. Patient also complained slight feverbut its alreadyrecovered by now.


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Patient also admitted that she ate and drink more allthis time. She also urinated more often, 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 developed wounds, itwould take longer time to heal.

But, despite from her eating more often, she still felt

faint 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

when walking 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 2009.

At first, she frequently went to Puskesmas to take

some medicine to control the disease. But lately,

she hadnt go to the Puskesmas anymore since shedidnt have complaint about her disease.

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 : Mildly ill

Consciousness : Compos

mentis Nutrient Status : Sufficient

Weight : 53 kg

Height : 155 cm

BMI : 22,06 kg/m2


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BP:

110/70 mmHg

Pulse :

88

times/minute

RR :20 times/minute

Temp:

36,8 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, mucosanot hyperemic

Mouth dirty mouth (+), dry mouth (-), normal papil, mucosa

hyperemic (-) Throat

Tonsils T1/T1 calm, pharynx hyperemic (-)

Neck Lymph nodules enlargement (-), tiroid gland enlagement (-),

JVP 5+1 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 (-)

Palpation

Tenderness (+)

Distension (-)

No liver and spleen enlargement

Murphy sign (-)

Percussion

Tympanic No pain present on abdominal percussion

Auscultation

Bowel sound (+) normal, arterial bruit (-), venous hum (-)


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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 (+), multiple cicatrix (+)


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Laboratory Examination

February 8th 2012

Result Normal range

Hemoglobin 9,8 (12 17) g%

Leucocytes 30.000 (5.000 10.000)/LThrombocytes 294.000 (150.000 450.000)/L

Ht 29 (37 48) %

Random Blood Glucose 343 (80 140) mg/dl

Ureum 28,9 (10 45) mg/dl

Creatinine 0,95 (0,4 1,5) mg/dl


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Resume

Symptoms

Painful wound on her right footsince 10 days before admitted tohospital.

1 month before

right foot gotpricked by wood small wound(+)

2 week before painful,swelling wound (+), and producesome pus.

2 days before began necroticaround the ulcer

Polyphagy (+), polydipsia (+),polyuria (+), faint, fatigue, slightheadache, numbness on the feet.

History of Past Disease : DM since 2009

Signs

Eye conjunctiva anemic (+/+)

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

Hb 9,8 % AnemiaHt 29 %RBG 343 mg/dlHyperglycemia


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Differential Diagnosis

Diabetes Mellitus type 2 with Gangrene

Diabeticum and Anemia

Diabetes Mellitus type 2 with Cellulitis Diabetes Mellitus type 2 with

Arteriosclerosis obliterans

Diabetes Mellitus type 2 with Erycipelas


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Working Diagnosis

DIABETES MELLITUS TYPE II withGANGRENE DIABETICUM PEDIS DEXTRA

and ANEMIA


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Suggested Examination

Lipid profile

ECG

Pus culture

Rontgen thorax and pedis


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Treatment

Bed rest

Diet DM 1581 calories

IVFD NaCl 20 tpm

Regular Insulin 3 x 10 IU

Ranitidin 2 x 1 gr amp.

Ceftriaxon 1 x 2 gr fl.

Ketorolac 3 x 30 mg amp.

Metronidazol 3 x 500 mg amp.

Debridement


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Prognosis

Ad Vitam : Ad bonam

Ad Functionam : Dubia ad malam

Ad Sanationam : Dubia ad malam


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Case Dm Type II + Gangrene Diabeticum +Anemia

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