DIABETES MELLITUS TYPE II with GANGRENE DIABETICUM PEDIS DEXTRA and ANEMIA

Annisa Juwita 030.07.027

Identity
Name Age Sex Adress
Mrs. A 46 y.o female Pisang Sambo, Karawang

Occupation
Education Ethnic Marital status Religion
Date of admission

Labour
Elementary school Sundanese Married Moeslim
February 8th 2012

Taken from

Teluk Jambe

Anamnesis
Main complaint
painful wound on her right foot since 10 days before admitted to the hospital

Additional complaint

Faint, fatigue and slight headache Numbness on her foot

History of present disease

Mrs. A, 46-years-old woman, came to emergency department of RSUD Karawang after experiencing painful wound on her right foot since 10 days before admitted to the hospital. 1 month before hospitalized, she had her right foot prick by a wood. At that time, because it wasnt a big wound or painful, she didnt do anything for the wound, like applying the betadyne or putting on the band-aid.

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. It also began 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 its already recovered by now.

Patient also admitted that she ate and drink more all this 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, it would 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.

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 she

didnt have complaint about her disease.

Hypertension (-) Asthma (-)

Allergy (-)

Family History

Same illness () Hypertension () Allergy () Asthma ()

Medication History

Patient never consume any medicine for a

long term

Blood transfusion ()

Surgery ()
Other medication ()

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

General Condition

General Appearance

: Mildly ill

Consciousness Nutrient Status

Weight

: Compos
mentis

: Sufficient
: 53 kg

Height
BMI

: 155 cm
: 22,06 kg/m2

BP: 110/70 mmHg

Pulse : 88 times/minute
Vital Sign

RR : 20 times/minute

Temp: 36,8 C

General Status

Head

Normocephali, hair distribution is good, not easy to revoked Pupil isokor, CA +/+ , SI -/ Normotia, secrete -/-, serumen -/-, intact timpany membrane septum deviation (-), secrete -/-, concha is normal, mucosa not hyperemic dirty mouth (+), dry mouth (-), normal papil, mucosa hyperemic (-) Tonsils T1/T1 calm, pharynx hyperemic (-) Lymph nodules enlargement (-), tiroid gland enlagement (-),

Eyes
Ears

+/+ Nose

Mouth

Throat
Neck

JVP 5+1 cm H20

Thorax Examination

Thorax Examination

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 (-)

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 (+)

Laboratory Examination February 8th 2012

Result Hemoglobin 9,8 Normal range (12 17) g%

Leucocytes Thrombocytes
Ht Random Blood Glucose Ureum Creatinine

30.000 294.000
29 343 28,9 0,95

(5.000 10.000)/L (150.000 450.000)/L

(37 48) % (80 140) mg/dl (10 45) mg/dl (0,4 1,5) mg/dl

Resume
Symptoms
Painful wound on her right foot since 10 days before admitted to hospital. 1 month before right foot got pricked by wood small wound (+) 2 week before painful, swelling wound (+), and produce some pus. 2 days before began necrotic around the ulcer Polyphagy (+), polydipsia (+), polyuria (+), faint, fatigue, slight headache, 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 % Anemia Ht 29 % RBG 343 mg/dl Hyperglycemia

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

Working Diagnosis

DIABETES MELLITUS TYPE II with GANGRENE DIABETICUM PEDIS DEXTRA and ANEMIA

Suggested Examination

Lipid profile ECG Pus culture Rontgen thorax and pedis

Treatment

Bed rest

Diet DM
IVFD NaCl

1581 calories
20 tpm

Regular Insulin 3 x 10 IU

Ranitidin
Ceftriaxon Ketorolac Metronidazol Debridement

2 x 1 gr amp.
1 x 2 gr fl. 3 x 30 mg amp. 3 x 500 mg amp.

Prognosis

Ad Vitam Ad Functionam

: Ad bonam : Dubia ad malam

Ad Sanationam

: Dubia ad malam