5/23/2018 Laki-laki, 21 Tahun Dengan Ketoasidosis Diabetikum,
1/66
CPC
Laki-laki, 21 tahun dengan Ketoasidosis
Diabetikum, DM Tipe 1 dan Pneumonia
dr. Lia Sasmithae*
Dr. Laksmi Sasiarini, Sp.PD**
*Resident of Internal Medicine, Medical Faculty of Brawijaya University - Saiful Anwar GeneralHospital Malang
** Supervisor, Endocrine & Metabolic Disease, Internal Medicine Department BrawijayaUniversity- Saiful Anwar General hospital Malang
5/23/2018 Laki-laki, 21 Tahun Dengan Ketoasidosis Diabetikum,
2/66
KAD
Manifestasi awal dari DM tipe 1
infeksi, trauma, infark miokard, atau kelainan lainnya
hiperglikemia, asidosis metabolik, dan ketosis
Ketoasidosis diabetikum
5/23/2018 Laki-laki, 21 Tahun Dengan Ketoasidosis Diabetikum,
3/66
Kriteria KAD
5/23/2018 Laki-laki, 21 Tahun Dengan Ketoasidosis Diabetikum,
4/66
Patofisologi KAD
5/23/2018 Laki-laki, 21 Tahun Dengan Ketoasidosis Diabetikum,
5/66
DM tipe 1
5/23/2018 Laki-laki, 21 Tahun Dengan Ketoasidosis Diabetikum,
6/66
5/23/2018 Laki-laki, 21 Tahun Dengan Ketoasidosis Diabetikum,
7/66
DM tipe 1
5/23/2018 Laki-laki, 21 Tahun Dengan Ketoasidosis Diabetikum,
8/66
5/23/2018 Laki-laki, 21 Tahun Dengan Ketoasidosis Diabetikum,
9/66
Pneumonia
5/23/2018 Laki-laki, 21 Tahun Dengan Ketoasidosis Diabetikum,
10/66
5/23/2018 Laki-laki, 21 Tahun Dengan Ketoasidosis Diabetikum,
11/66
Summary of Database
Mr. Supriadi, 21 years old, W. 26ward 27
Chief complaint : decrease of conciousness
Anamnesis : auto and heteroanamnesis (his older sister)
Patient suffered from decreased of consciousness, since 4 days before admission
and worsened a day before admission, gradually. He was found in weak condition
and couldnt be able to communicate well. Because of this complaint, he was
brought to Tumpang public health centre and his random blood sugar was about
600. That was the first time his family knew about the high blood sugar in the
patient.
Patient never knew that he had diabetes. But around 2 months before admission,
he started to feel thirsty easily. He drank a lot and his appetite increased. Patient also suffered from nausea and vomiting since 10 days before admission. He
vomit 2-3x/day, - glass/vomit, contained of fluid and food residual. At home, it
wasnt accompanied with blood nor mucous. But at ER, there was blood in his
vomiting.
5/23/2018 Laki-laki, 21 Tahun Dengan Ketoasidosis Diabetikum,
12/66
He also suffered from low grade fever since 20 days before admission,
intermittently, and relieved by drug that be given from a midwife. The fever
worsen at night and made him sweat a lot. His tongue was formed white plague
that painless. It was removed easily. Patient consumed Adem Sarito relieve it, but
there was no improvement.
Sometimes he had cough with whitish sputum. It was started since about a month
before admission.
His body weight decreased about 7 Kg in a month.
Family history:
Patients father died 15 years ago and he had diabetes.
Social history:
Patient was an employee in cassava factory, hasnt married yet. He denied about
multi partner sexual, alcohol consumption, nor intravenous drug usage.
5/23/2018 Laki-laki, 21 Tahun Dengan Ketoasidosis Diabetikum,
13/66
Physical ExaminationGeneral appearance : looked severely ill
GCS: 224 (ER)
At ward: 456
Patient looks underweight
Height: 165 cm
Weight: 50 KG BMI: 18.36 m2
BP : 110/70 mmHg PR : 96 bpm, strong,
regular
RR : 20 tpm Tax : 37 0C
Head Anemic (-) , icteric (-)
White plague at tongue, removed easily
Neck JVP R+0 cm H2O, 30 degree
Lymph node englargement (-)
Thorax : Cor Ictus invisible and palpable at ICS V MCL sinistra
LHM ~ ictus, heart waist + RHM: SL D
S1, S2 single with no murmur
Pulmo Symmetric, SF D = S, v v Rh - - Wh - -
v v - - - -
v v - - - -
Abdomen Flat, soefl, bowel sound N, liver span 8 cm, traubesspace tymphani
Extremities Warm acrals, CRT< 2, edema (-)
5/23/2018 Laki-laki, 21 Tahun Dengan Ketoasidosis Diabetikum,
14/66
b f d
5/23/2018 Laki-laki, 21 Tahun Dengan Ketoasidosis Diabetikum,
15/66
Laboratory finding
Lab Value Lab ValueLeukocyte 15,050 3.500-10.000/L Natrium
Osmolality
Na
Corrected
125
300
131
136-145 mmol / L
280-295 mOsm/kg
Haemoglobine
MCV
12.7
78.8
11,0-16,5 g/dl
80-97
Kalium 4.26 3,5-5,0 mmol / L
MCH 29.6 26,5-33,5 Chlorida 110 98-106 mmol / L
PCV
Trombocyte
Eo/Ba/Neu/Ly/
MoSGOT
SGPT
33.8
215,000
0.1/0.1/80.
0/12.0/7.248
25
35-50%
146.000-
390.000/L
0.4/0.1/51-67/
25-33/2-50-40 U/L
0-40 U/L
RBS 682
442
16998
171
< 200 mg/dL
Ureum 66.7 10-50 mg/dL BUN/Cr 22.26
Creatinine 1.40 0,7-1,5 mg/dL eGFR 67.99 mL/min/1.73 m2
5/23/2018 Laki-laki, 21 Tahun Dengan Ketoasidosis Diabetikum,
16/66
LAB VALUE LAB VALUE
Urinalysis Yellow, clear 10 x
PH 6.0 Epithelia 2.2
SG 1.015 Cylinder -
Glucose 3+ Hyaline -
Protein trace Granular -
Keton 2+ Leukocyte -
Bilirubin - Erythrocyte -
Urobilinogen - 40 xNitrite - Erythrocyte 10.2
Leucocyte - Leukocyte 3.0
Erythrocyte 3+ Crystal -
Bacteria 36.3 x 103
URINALYSIS
5/23/2018 Laki-laki, 21 Tahun Dengan Ketoasidosis Diabetikum,
17/66
BGA
O2 10 lpm via NRBM
PH 6.99 7.35-7.45PCO2 20.3 3545 mmHgPO2 163.4 80100 mmHgHCO3 5.0 2128 m mol/LO2 sat Art 97.5 > 95 %BE -26.8 (-3) - (+3) m mol/LTrue O2 38.1
Anion Gap 10.0 mEq/L
Conclusion: Severe acidosis metabolic partially
compensated with alkalosis respiratory and severe
hypoxemia
5/23/2018 Laki-laki, 21 Tahun Dengan Ketoasidosis Diabetikum,
18/66
5/23/2018 Laki-laki, 21 Tahun Dengan Ketoasidosis Diabetikum,
19/66
ECG
5/23/2018 Laki-laki, 21 Tahun Dengan Ketoasidosis Diabetikum,
20/66
ECG
Sinus rhythm, Heart rate 100 bpm
Frontal Axis : normal
Horizontal Axis : normal
PR interval : 0.12
QRS complex : 0.08
QT interval : 0.36
Conclusion: Sinus rhythm with HR 100 bpm.
5/23/2018 Laki-laki, 21 Tahun Dengan Ketoasidosis Diabetikum,
21/66
CHEST X RAY
5/23/2018 Laki-laki, 21 Tahun Dengan Ketoasidosis Diabetikum,
22/66
CXR
AP position, symmetric, enough KV, enoughinspiration
Soft tissue and bone were normal
Trachea was in the middlle
Hemidiaphragm D/S were in domeshaped
Phrenicocostalis angle D/S were sharp
Cor: site was normal, size CTR 45%, shape was normal
Pulmo: bronchovascular pattern was normal
Conclusion : normal chest X-ray
5/23/2018 Laki-laki, 21 Tahun Dengan Ketoasidosis Diabetikum,
23/66
Dari anamnesa, pemeriksaan fisik dan
pemeriksaan penunjang, didiagnosa :1. Ketoasidosis diabetikum
2. DM tipe 1
3. hiponatremia hipoosmolar hypovolemia
3.1 dt no 1
3.2 GI loss
4. dyspepsia syndrome4.1 DM Gastroparese
4.2 SMRD
5. Lung infection
5.1 pneumonia
5.2 lung TB with secondary infection
6. Azotemia prerenal6.1 dt no 1
6.2 azotemia renal
6.2.1 Diabetic kidney disease
5/23/2018 Laki-laki, 21 Tahun Dengan Ketoasidosis Diabetikum,
24/66
20/04/2014; 01:00
RBS: High (lab: 682)Na/K/Cl: 125/4.26/110
BGA:
Ph: 6.99
HCO3: 5.0
Anion Gap: 10.0
Planning therapyRehydration 1L of NS
0,9% over first 1 h
Insulin short acting 0.1U/kg5iu (iv)
Line I: drip Insulin shortacting 0.1U/kg/hour (5
iu/hour)Line II: drip KCl 25 mEq
in 500 cc NaCl 0.9%
20/04/2014; 05:30
RBS: 442
Planning therapy
Line I: drip Insulin
short acting
0.1U/kg/hour (5
iu/hour)
Line II: drip KCl 25
mEq in 500 cc NaCl
0.9%
20/04/2014; 11:00
RBS: 98
Na/K/Cl: 133/3.11/119
BGA:
Ph: 7.24
HCO3: 8.8
Anion Gap: 5.2
Planning therapy
drip insulin was
stopped
5/23/2018 Laki-laki, 21 Tahun Dengan Ketoasidosis Diabetikum,
25/66
20/04/2014; 12:00RBS: 169
Na/K/Cl: 133/3.11/119
BGA:
Ph: 7.24
HCO3: 8.8
Anion Gap: 5.2
Planning therapy
Line I: drip Insulin short
acting 0.05U/kg/hour
(1 iu/hour)
Line II: drip KCl 25 mEq
in 500 cc NaCl 0.9%
20/04/2014; 15:00
RBS: 176
Na/K/Cl: 132/3.2/124
BGA:
Ph: 7.25
HCO3: 9.5
Anion Gap: 1.7
Planning therapy
Line I: drip Insulinshort acting0.05U/kg/hour (1iu/hour)
Line II: drip KCl 25mEq in 500 cc NaCl0.9%
20/04/2014; 21:00RBS: 179
Na/K/Cl: 134/4.30/122
BGA:
Ph: 7.28
HCO3: 9.8
Anion gap: 6.5
Planning therapy
Line I: drip Insulin shortacting 0.05U/kg/hour (1iu/hour)
Line II: drip KCl 25
mEq in 500 cc NaCl0.9%
5/23/2018 Laki-laki, 21 Tahun Dengan Ketoasidosis Diabetikum,
26/66
Diskusi
Pada pasien ini didiagnosa KAD karena:
Keton urin :+2 (ketosis)
