Laki-laki, 21 Tahun Dengan Ketoasidosis Diabetikum,

  • View
    65

  • Download
    5

Embed Size (px)

DESCRIPTION

laki-laki,21 tahun dengan ketoasidosis diabetik dan lung infection

Text of Laki-laki, 21 Tahun Dengan Ketoasidosis Diabetikum,

  • 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)

Search related