DIABETES MELLITUS DIABETES MELLITUS TYPE II with TYPE II with RIGHT FOOT RIGHT FOOT

DIABETIC GANGRENEDIABETIC GANGRENE

Identity Identity

Anamnesis Anamnesis

History of present diseaseHistory of present disease

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

1 month before hospitalized, she had her right foot pricked by a broken glass. At that time, because it wasn’t a big wound or painful, she didn’t do anything for the wound, like applying the betadyne or putting on the bandage.

2 week before hospitalized, she began to feel pain on her wound and it got worsen day by day. The wound also got bigger, swollen and produce some pus.

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

1 day before hospitalized, the wound still produced some pus and a little bit of blood. Patient also complained slight fever but it’s already recovered by now.

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 developed wounds, 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 when walking before trauma. She didn’t have any complain about her defecation.

History of Past DiseaseHistory 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 hadn’t go to the Puskesmas anymore since she didn’t 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 (-)

Family History Family History

Same illness (–)

Hypertension (–)

Allergy (–)

Asthma (–)

Medication HistoryMedication History

Patient never consume any medicine for a

long term

Blood transfusion (–)

Surgery (–)

Other medication (–)

Personal and Social History 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 didn’t exercise regularly.

No smoke, no consumption of alcohol or drugs

No consumption of herbal drink

General ConditionGeneral Condition

General Appearance : Slightly ill

Consciousness : Conscious

Nutrient Status : Sufficient

Weight : 53 kg

Height : 155 cm

BMI : 22,06 kg/m2

General StatusGeneral 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 (-), JVP

5+2 cm H20

Thorax Examination Thorax Examination

Thorax Examination Thorax Examination

Abdominal ExaminationAbdominal 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

Extremity ExaminationExtremity Examination

Upper limb : oedem (-/-), warm (+/+)

Lower limb :

◦Right: gangrene on the right foot (+), ø 3 x 4 cm,

hyperemic-black, tenderness (+), swollen, warm,

pus (+), necrotic area around the ulcer (+), pulse

(-)

◦Left: oedem (-), warm (+)

Laboratory ExaminationLaboratory ExaminationMei 26Mei 26thth 2012 2012

Result Normal range

Hemoglobin 12.2 (12 – 17) g%

Leucocytes 16.100 (5.000 – 10.000)/μL

Platelet 268.000 (150.000 – 450.000)/μL

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

Laboratory ExaminationLaboratory ExaminationMei 27Mei 27thth 2012 2012

Result Normal range

Hemoglobin 12.4 (12 – 17) g%

Leucocytes 9.700 (5.000 – 10.000)/μL

Platelet 252.000 (150.000 – 450.000)/μL

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

Differential DiagnosisDifferential Diagnosis

Diabetes Mellitus type 2 with Gangrene

Diabeticum

Diabetes Mellitus type 2 with Cellulitis

Diabetes Mellitus type 2 with Erycipelas

Resume Resume

Working Diagnosis Working Diagnosis

DIABETES MELLITUS TYPE II with RIGHT FOOT DIABETIC GANGRENE

Suggested Examination Suggested Examination

Lipid profile

ECG

Pus culture

Rontgen thorax and pedis

Treatment Treatment

Bed restDiet DM 1723 calories IVFD NaCl 20 tpmRanitidin 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

Prognosis Prognosis

Ad Vitam : Ad bonam

Ad Functionam: Dubia ad malam

Ad Sanationam: Dubia ad malam