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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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