DM Type 2 With Gangrene-Agustania

7/29/2019 DM Type 2 With Gangrene-Agustania

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DIABETES MELLITUS

TYPE II with RIGHTFOOT DIABETIC

GANGRENE

AGUSTANIA BETA PRIHANTO030.07.013


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Identity

Mrs. UName

40 y.oAge

femaleSex

Pisang Sambo, KarawangAdress

HousewifeOccupation

Elementary schoolEducation

SundaneseEthnic

MarriedMarital status

MoeslimReligion

May 26th 2012Date of admission

Teluk JambeTaken from


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Anamnesis

painful wound with a slightbloody discharge on her

right foot since 1 day beforebeing admitted to thehospital

Chiefcomplaint

Fatigue and slight headache Numbness on her footAdditional

complaint


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History of present disease

Mdm. U, 40-years-old woman, came to emergency of RSUD Karawangafter experiencing painful wound with a slight bloody discharge on herright foot since 1 day before admitted to the hospital.

1 monthbefore hospitalized, she had her right foot pricked by a brokenglass. At that time, because it wasnt a big wound or painful, she didnt doanything for the wound, like applying the betadyne or putting on thebandage.

2 weekbefore hospitalized, she began to feel pain on herwoundand it gotworsen day by day. The wound also gotbigger,swollen and produce somepus.

2 daysbefore hospitalized, the wound was getting bigger even more,theswelling and pus got worsen as well. The skin turn s black (necrotic)around the ulcer.

1 daybefore hospitalized, the wound still produced some pus and a little

bit of blood. Patient also complained slight feverbut its already recoveredby now.


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Patient also admitted that she ate and drink frequently all this

time. She also urinated more , 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 developedwounds, it would take longer time to heal.

But, despite from her eating more often, she still felt tired 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 whenwalking 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 2010. At first,

she frequently went to Puskesmas to take some medicine to

control the disease. But lately, she hadnt go to the Puskesmasanymore since she didnt have complaint about her disease.

She undergo amputation the the 4th finger of the right foot 1

year ago because of the same current illness.

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 : Slightly ill

Consciousness : Conscious

Nutrient Status : Sufficient

Weight : 53 kg

Height : 155 cm

BMI : 22,06 kg/m2


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BP:

120/70 mmHg

Pulse :

88

times/minute

RR :

20 times/minuteTemp:

36,5 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, mucosa not

hyperemic

Mouth Dirty mouth (+), dry mouth (-), normal papil, mucosa hyperemic

(-)

Throat Tonsils T1/T1 calm, pharynx hyperemic (-)

Neck Lymph nodules enlargement (-), tiroid gland enlagement (-), JVP5+2 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 (-)

Auscultation Bowel sound (+) normal

Palpation

Tenderness (+)

Distension (-)

No liver and spleen enlargement

Murphy sign (-)

Percussion

Tympanic

No pain present on abdominal percussion


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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 (+)


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Laboratory ExaminationMei 26th 2012

Result Normal range

Hemoglobin 12.2 (12 17) g%

Leucocytes 16.100 (5.000 10.000)/L

Platelet 268.000 (150.000 450.000)/L

Ht 38 (37 48) %

Random Blood Glucose 255 (80 140) mg/dl

Ureum 28,9 (10 45) mg/dl

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


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Laboratory ExaminationMei 27th 2012

Result Normal range

Hemoglobin 12.4 (12 17) g%

Leucocytes 9.700 (5.000 10.000)/L

Platelet 252.000 (150.000 450.000)/L

Ht 39 (37 48) %

Random Blood Glucose 151 (80 140) mg/dl

Ureum 30.2 (10 45) mg/dl

Creatinine 0,8 (0,4 1,5) mg/dl


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Differential Diagnosis

Diabetes Mellitus type 2 with Gangrene

Diabeticum Diabetes Mellitus type 2 with Cellulitis

Diabetes Mellitus type 2 with Erycipelas


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Resume

Symptoms

Painful wound with a slight bloody dischargeon her right foot since 1 day before admitted tohospital.

1 month before right foot got wounded bya broken glass small wound (+)

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

2 days before began necrotic around theulcer

Polyphagy (+), polydipsia (+), polyuria (+),fatigue, slight headache, numbness on the feet.

History of Past Disease : DM since 2010Amputation of the 4th finger of the right foot 1year ago.

Signs

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

RBG >200 mg/dl Hyperglycemia


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Working Diagnosis

DIABETES MELLITUS TYPE II withRIGHT FOOT DIABETIC GANGRENE


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Suggested Examination

Lipid profile

ECG Pus culture

Rontgen thorax and pedis


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Treatment

Bed rest

Diet DM 1723 calories

IVFD NaCl 20 tpm Ranitidin 2 x 1 gr amp.

Ceftriaxon 1 x 2 gr fl.

Ketorolac 3 x 30 mg amp.

Metronidazol 3 x 500 mg amp.

Metformin 3 x 500 mg tab.

Debridement


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Prognosis

Ad Vitam : Ad bonam

Ad Functionam : Dubia ad malam

Ad Sanationam : Dubia ad malam


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DM Type 2 With Gangrene-Agustania

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