Case

Report

DM TYPE 2

NUR SYAHIDATUL NADIA BT MOHD ITA C014172202

DESMY FADILLAH C014172104

Subdivision of Endocrine
Department of Internal Medicine
Medical Faculty of Hasanuddin University
2018
 PATIENT IDENTITY

Name : Mr. HDN

Date of Birth : 26-02-1975 (43 years old)
Sex : Male
Address : Dusun Tamalate
Religion : Moslem
MR : 845241
Ward : L1AB/Bed 2/Class III
Date of Admission : 08-06-2018
 HISTORY TAKING

Chief Complaint : Diarrhea

Present History :
A patient comes with diarrhea 2 weeks long. He also
suffered abdominal pain in right hyperchondrium region and feels
his stomach slightly bigger day by day. This problem has been
experienced since 1 month ago and is treated by
Gastroenterohepatology subdivision. He also suffered DM Type 2
for 7 years.
 Regarding to patient history of DM, he told that he feels too
tired, eat too much food, and always thirsty in the early phase. So he
took a blood glucose test recommended by his neighbour (which is
nurse) and the result is 400mg/dl. Starting from there he consume
Metformin and Glibenclamide regularly and control diet.
In January 2017, he was admitted in RSUH with diagnosis
Hyperglicemia (700mg/dl). He got Insulin Novorapid 14-14-14 and
Levemir 0-0-18 and his blood glucose level is under controlled.
He stop taking insulin from March 2017 due to long entry in
RSUH and now admitted in RSWS with Liver abscess and uncontrolled
DM type 2.
Patient works as a driver and he love to drink Coca cola or teh
kotak while driving to avoid sleepy. There were history of the same
complaints in the family.
 PHYSICAL EXAMINATION
General Description
General condition: Mild illness
Nutrition:
 Height : 176 cm
 Weight : 38 kg
 BMI: 20.30 kg/m2
Vital Signs
 Awareness : Conscious (GCS 15)
 Blood pressure : 110/80 mmHg
 Heart rate : 80x/ min, regular, strong
 Respiratory rate : 20 x/min
 Temperature : 36°C (axilla)
 VAS : 5/10
 Head : Normocephal, hair not easily removed

 Face : Normal

 Eyes : Pupils isochoric, anemic (+), icteric (-)

 Ear : No abnormalities, otorrhea (-)

 Nose : No abnormalities, secret (-)

 Oral cavity : No abnormalities

 Throat : No abnormalities, pharyngeal hyperemia (-),T1-T1

 Neck : No lymphadenopathy, no deviation of the trachea.

 Lung
 Inspection : Symmetrical left and right
 Palpation : Focal fremitus normal
 Percussion : Sonor
 Auscultation : Vesicular breathing sounds, wheezing (-), ronchi (-)

 Cor
 Inspection : Ictus cordis is not visible
 Palpation : Ictus cordis is not palpable
 Percussion : Dull, left heart border linea midclavicularis
 Auscultation : Bruit (-)
 Abdomen
 Inspection : slightly distended
 Auscultation : bowel peristalsis (+), normal
 Palpation : pain with low pressure given in right hyperchondrium. Liver and
spleen not palpable
 Percussion : Tympani
 Extremity
 Upper extremity : warm, edema (-)
 Lower extremity : edema (-)
LABORATORY
Result Normal value Unit

WBC 15.3 4.00-10.00 10^3 U/L

Haemoglobin 13.4 14.00-18.00 g/dL

MCV 87.5 80.0-100.0 µm3

MCH 29.3 27.0-32.0 Pg

MCHC 33.5 32-36 g/dL

Trombocyte 321 150-400 10^3 u/L

Eritrocyte 4.57 3.5-5.8 10^6 u/L

ESR 56 <20 mm
 Result Normal value Unit
SGOT 20 <38 u/l
SGPT 20 <41 u/L
Ureum 18 10-50 Mg/dl
Creatinine 0.7 <1.1 Mg/dl
Total Cholesterol 243 200 mg/dL
HDL 89 >65 mg/dL
LDL 154 <130 Mg/dl
TG 185 200 mg/dL
Uric acid 3.5 2.4-5.7 mm

HbsAg 0 <0.13 COI

Anti-HCV 0.24 <1 COI

 DATE TIME Premeal Blood Glucose Instruction by DPJP
(mg/dl)
8/7/2018 Morning 110 -Novorapid 16-16-14
Afternoon 180 -Levemir 0-0-12 (stop)
Evening/night 61
9/7/2018 Morning 327 -Novorapid 16-16-16
Afternoon 323 -Levemir 0-0-10
Evening/night 307
10/7/2018 Morning 242 -Novorapid 16-16-16
Afternoon 178 -Levemir 0-0-10
Evening/night 189
11/7/2018 Morning 182 -Novorapid 16-16-16
Afternoon 180 -Levemir 0-0-10
Evening/night 245
12/7/2018 Morning 143 -Novorapid 16-16-16
Afternoon - -Levemir 0-0-10
Evening/night 264
Radiology
Abdominal USG:
• Kesan Massa lobus kanan hepar sugestif (Tampak lesi
hipoisoechoic dengan tepi anechoic, bentuk relatif bulat,
tepi ireguler, tanpa kalsifikasi, ukuran sekitar
6.96x7.96x6.15 cm pada lobus kanan)
Radiology

Hasil Pemeriksaan CT Scan Abdomen:

• Kesan Sesuai gambaran abses hepar lobus kanan
(Tampak lesi soliter hipodens, bentuk bulat, batas tegas,
tepi reguler, dinding tebal dengan gambaran double
target sign, tanpa klasifikasi dengan ukuran +/- 69x68
mm, kesan berasal dari lobus kanan hepar)
 PROBLEM LIST
ASSESSMENT PLANNING MANAGEMENT
1. Colitis pseudo membrane • LGIE (13/7/2018) -

2. Post laparascopy Liver abscess (right lobe) • Control of abdominal • Infuse Ringer
USG Lactate/20tpm/IV
• Meropenem 1gr/8hours/IV
• Metamizole 1gr/8 hours/IV

3. Diabetes Mellitus Type 2 non obese • Control of Premeal • Diet DM 1700 kcal
Blood Glucose • Novorapid 16-16-14
• Levemir 0-0-10
4. Infected Bronchiectasis • Consult to Pulmonology -
subdivision

5. Chronic HBV CTP B • HBeAg, Anti HBc • Diet Hepar 2

• UDCA 250mg/12 hours/ oral

6. Hypoalbuminemia • Check albumin • Aminolebun 500ml/24 hours/

IV
• Protein intake 110gr
Discussion
Introduction
 Diabetes mellitus (DM) is a group of diseases characterized by
high levels of blood glucose resulting from defects in insulin
production, insulin action, or both.

 The term diabetes mellitus describes a metabolic disorder of

multiple aetiology characterized by chronic hyperglycaemia with
disturbances of carbohydrate, fat and protein metabolism
resulting from defects in insulin secretion, insulin action, or both.

 The effects of diabetes mellitus include long–term damage,

dysfunction and failure of various organs.
Type 2 diabetes
 Was previously called non-insulin-dependent diabetes mellitus
(NIDDM) or adult-onset diabetes.
 Type 2 diabetes may account for about 90% to 95% of all
diagnosed cases of diabetes. It usually begins as insulin
resistance, a disorder in which the cells do not use insulin
properly. As the need for insulin rises, the pancreas gradually
loses its ability to produce insulin.
 This type of diabetes is associated with older age, obesity,
family history of diabetes, history of gestational diabetes,
impaired glucose metabolism, physical inactivity, and
race/ethnicity.
Risk Factors
 Family History of DM
 Obesity
 Habitual physical inactivity
 Previously identified impaired glucose tolerance (IGT) or
impaired fasting glucose (IFG)
 Hypertension
 Hyperlipidemia
 History of gestational diabetes or gave birth to a baby weighing
9 pounds or more.
Etiology
• Any one test should be confirmed with a second test, most often
fasting plasma glucose (FPG).
• This criteria for diagnosis should be confirmed by repeating the
test on a different day.
Treatment
Desired Outcomes:
 Relieve symptoms
 Reduce mortality
 Improve quality of life
 Reduce the risk of microvascular and macrovascular disease complications:
 Macrovascular complications:
Coronary heart disease, stroke and peripheral vascular disease
 Microvascular complications:
Retinopathy, nephropathy and neuropathy
Clinical Manifestation
 Polyarthritis
 Carditis
 Fever
 Chorea
 Erythema marginatum and subcutaneous nodules (rare)
How to Diagnose?
JONES’ CRITERIA FOR DIAGNOSIS OF ACUTE RHEUMATIC FEVER

Major Minor
 Joint involvement  CRP increased
 O looks like heart (carditis)  Atralgia
 Nodules subcutaneous  Fever
 Erythema marginatum  Elevated ESR
 Sydenham chorea  Prolonged PR interval
 Anamnesis of Rheumatism
 Leukocytosis
Treatment
 Primary Prophylaxis
1) Benzathine penicillin 1,2 million units IM (for child
with body weight <27 kg: 600.000 units)
2) Amoxicillin 2-3 times each day (25-50 mg/kg)

 Secondary Prophylaxis
1) Penicillin V 250 mg twice a day
2) Eritromycin 250 mg twice a day
Thank You