CASE BASED DISCUSSION

Advisor : dr. HM. Saugi Abduh, Sp.PD, KKV, Finasim

Cintya Dunihapsari
012116354

Patient Identity

Name
Age
Sex
Religion
Address
No CM
Room
Date in
Date out

: Mrs. W
: 47 years old
: Female
: Islam
: Dukuh Kiringan 03/05 Samirejo Kudus
: 01289876
: Baitul Izzah 1 (410.3)
: 3/7/2016
: 10/7/2016

Anamnesis
Kronologi

Patient come to RSISA complained with a left knee injury that

doesnt heal and felt so weak. The wound doesnt heal since 10
days ago. She felt pain and there is a pus in her wound. Previously
the patients admitted there were a bricks fell on her knee when she
tried to help her husband renovate their house. Patients already
clean the wound but the wound are not getting any better. Patients
didnt complain of fever (-), and claimed she had wounds that are
also difficult to recover on the thumb of her left leg. The wound is
present but she cant feel anything, there is no pain (-). Patients feel
numb of her soles and couldnt feel any touch or pressure.

History of previous illness

DM history since 5 years ago (+) (diabetes mellitus
uncontrolled since 2 years ago)
Hypertension history (+)
Hiperlipidemi history (-)
Heart disease history (-)
Familys History of Disease
DM history (-)
Hypertension history (-)
hiperlipidemi history (-)
Sosio-Economic History :
Hospital cost certified by her Family (UMUM)
Economic Impression : middle

Physical Examination
General : Patient look better
Skin
: itching (-), wound (+) knee and left thumbs of her leg,
jaundice (-), pale (-).
Head
: mesocephal, headache (-)
Eyes
: blurred vision (-) / (-), red eyes (-), icteric sclera (-/-) (-/-)
Ears
: hearing loss (-), ring (-), discharge (-)
Nose
: nosebleed (-), discharge (-)
Mouth : cyanosis (-), thrush (-), bleeding gums (-)
Throat : pain swallow (-), hoarseness (-), difficult in
swallowing (-)
Neck
: trachea deviation (-), enlargement of the gland (-)
Chest : dyspneu (-), chest pain (-)
GI tract : abdominal pain (-)

Physical Examination
Vital Sign
Tekanan darah
: 145/95 mmHg
Nadi
: 104 x/menit
Suhu
: 36,2oc
RR
: 21 x/menit
Kesan: hipertensi grade 1

Status Gizi
BB : 65 kg
TB : 160 cm (1.6 m)
BMI : 65/2.56 = 25,34
Kesan : Overweight

Thorax

Interpretasi : Normal

Cardiac

Interpretasi : Normal

Abdomen

Interpretasi : Normal

Ekstremities

P E D I S Criteria
The Knee Injury

Perfution : Pulsation (+)

Exposure : diameter 2 cm
Deep
: superfisial
Infection : Pus with redness
outskirts
Sensibility : (+) pain

The Thumb Injury

Perfution : Pulsaion (+)

Exposure : diameter 1 cm
Deep
: superfisial
Infection : pus (-) , looks dry
without redness
Sensibility
: (-) numb

ABPI Examination

Laboratory Result July 3rd 2016

Pemeriksaan

Hasil

Nilai Normal

Hb

12.1g/dl

11.7 -15,5 g/dl

Ht

38.7%

33-45%

Leukosit

28.71 ribu/Ul

3,6-11,0 ribu/uL

Trombosit

586 ribu/uL

150-440 ribu/uL

GDS

647

Ureum

64(H)

10-50 mg/dl

Creatinin Darah

1.45 (H)

0.5-0.9 mg/dl

HBsAg kualitatif

Non reaktif

Hematologi rutin

Kimia :

Interpretasi : Leukositosis,
Trombositosis, Hiperglikemi,
Azotemia

Interpretation
1. Hiperglikemia
2. Azotemia
GFR

= (140-Age) x BB/72 x creatinin serum

= (140-47)x65/72x1,45x0.815
= 57 ml/min/1,73m2

Abnormalitas Data
ANAMNESIS
1.Weakness
2.Pain in left knee
3.Numbness at the soles of the feet
PHYSICAL EXAMINATION
4. Wound on left knee
5. Wound at the soles of the feet
ADDITIONAL EXAMINATION
6. Sensibility of feet solesi -/7. ABPI 0,91 [borderline]
Lab :
8. Hiperglikemia
9. Azotemia
10. Leukositosis
11. Trombositosis

 Problem List

DM type 2
Ulkus DM (3, 5, 6, 7, 9)
Hipertensi stage 1
Nefropati diabetikum

1. Diabetic Mellitus Type II

Ass :
Status Glicemic
1.
Acute complication
KAD
HHNK
2.
Cronic Complication :
makrovaskuler
brain
Heart : Coronary areterial disseass
PAD

Mikrovaskuler
retinopati diabetika
nefropati diabetika
neuropati diabetik
4. funduskopi
Ip Dx :
5. urinary examination (keton bodies,
1.fasting Glucose,
mikroalbuminuria)
2.Post prandial Glucose,
6. EKG
3.HbA1c,
7. ABPI

 Ip Tx :
Insulin 3x15 UI
rehidration

Non Farmacology
o Caloric adjusted to the needs of the patients
o Diet DM 2100calori
Ip.Mx :
o general condition,
o Vital sign
o On-time Glocuse, Glukose 2 hours Post prandial
o hba1c
o Profil lipid
o Ureum kreatinin
Ip. Ex :
o Diet low sugar
o limitation consumption of fat

 High = 160 cm , weight = 65 kg

Ideal body weight : 90%x (160-100) = 90% x 60 = 54 kg
BMI = BB(kg)/TB(m)

= 65 kg/(1,60
m)
kg
= 65/2.56 = 25,34
= 25,34

Kalori basal need = 54 kg x 30 kalori = 1620 calory

Age 47 years old

: (-5%) 1539 calory

Activity

: + 10%, 1636,3 calory

Fever

: (+ 13%) 1830,6 calory

Total calory
calory/day

: 1830,6 kalori = 1800

2. Ulkus DM

Ass : DM II
IP Dx : IpTx:
Farmakologi
- Infus Nacl 0,9 % 20 tpm
- Metronidazole 3x 500mg
- Asam Mefenamat 2x 500mg
- Ceftriaxone 2 x
- Gabapentin 2 x 300 mg
Non farmakologi

Debridement

IpMx:
Monitoring luka, wound cultur, GDS
IpEx :

Makan rendah gula

Melakukan aktifitas fisik cukup , olahraga teratur 3x seminggu, memakai sandal
Senam kaki diabetes
Minum obat seara rutin
Rutin membersihkan luka

3. Hipertension grade I

Ass : retinopati hipertensi , faktor dislipidemi yang lain

IP Dx
: funduskopi, profil lipid
Ip Tx :
Non farmakologi :
Lower salt diet

Avoid fatty food and junk food.

Farmakologi
infus RL 20 tpm
Po:
Captopril 12.5mg 1x1
IpMx : Vital sign,
IpEx :
Explain to the patient family about disisease.
Enough rest time
Low salt diet and high kalium
Drink drug regulary to control blood preassure.

4. Nefropati diabeticum
Ass :
Insufisiensi renal
- CKD stage 1 / 2
IP. Diagnosis :
1. Urinary laboratorium (proteinuri
2. Usg

Ip. Therapy :
non farmakologis
low protein intake 0,6 0,8 / kgbb
Farmakologis
caco3 3x1
IP. Monitoring :
urin product
darah rutin
ureum kreatinin
GFR
chemical blood axamination (na, k, cl)
Ip edukasi : batasi aktifitas, mengurangi konsumsi garam,
mengurangi konsumsi minum , l , mengurangi asupan kalium,
diit