DIABETES MELLITUS TYPE II with RIGHT FOOT DIABETIC GANGRENE

AGUSTANIA BETA PRIHANTO 030.07.013

Identity
Name Age Sex
Mrs. U 40 y.o female

Adress
Occupation

Pisang Sambo, Karawang

Housewife

Education
Ethnic Religion Taken from

Elementary school
Sundanese

Marital status Married

Moeslim
Teluk Jambe

Date of admission May 26th 2012

Chief complaint Additional complaint

Anamnesis

painful wound with a slight bloody discharge on her right foot since 1 day before being admitted to the hospital

Fatigue and slight headache Numbness on her foot

Mdm. U, 40-years-old woman, came to emergency of RSUD Karawang after experiencing painful wound with a slight bloody discharge on her right foot since 1 day before admitted to the hospital. 1 month before hospitalized, she had her right foot pricked by a broken glass. 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 bandage. 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. The skin turn s 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.

History of present disease

Patient also admitted that she ate and drink frequently all this time. She also urinated more , 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 tired 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.

Patient has history of Diabetes Mellitus since 2010. 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. She undergo amputation the the 4th finger of the right foot 1 year ago because of the same current illness. Hypertension (-) Asthma (-)

Allergy (-)

History of Past Disease

Same illness ()

Hypertension ()
Allergy ()

Asthma ()

Family History

Patient never consume any medicine for a long

term

Blood transfusion () Surgery () Other medication ()

Medication 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

Personal and Social History

General Appearance : Slightly ill

Consciousness
Nutrient Status

: Conscious
: Sufficient

Weight
Height

: 53 kg
: 155 cm

BMI

: 22,06 kg/m2

General Condition

BP: 120/70 mmHg Vital Sign RR :

Pulse :

88
times/minute

20 times/minute

Temp:

36,5 C

Head

Normocephali, hair distribution is good, not easy to revoked Pupil isokor, CA -/- , SI -/ Normotia, secrete -/-, serumen -/-, intact timpany membrane

Eyes
Ears

+/+

Nose

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 (-), JVP

Mouth

Throat
Neck

5+2 cm H20

General Status

Thorax Examination

Thorax Examination

Inspection
Flat, symmetric, caput medusa (-), smiling umbilicus (-)

Auscultation
Bowel sound (+) normal

Palpation
Tenderness (+) Distension (-) No liver and spleen enlargement Murphy sign (-)

Percussion
Tympanic No pain present on abdominal percussion

Abdominal 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 (+)

Extremity Examination

Result Hemoglobin Leucocytes 12.2 16.100

Normal range (12 17) g% (5.000 10.000)/L

Platelet Ht Random Blood Glucose

Ureum Creatinine

268.000 38 255
28,9 0,95

(150.000 450.000)/L (37 48) % (80 140) mg/dl

(10 45) mg/dl (0,4 1,5) mg/dl

Laboratory Examination Mei 26th 2012

Result

Normal range

Hemoglobin
Leucocytes Platelet Ht

12.4
9.700 252.000 39

(12 17) g%
(5.000 10.000)/L (150.000 450.000)/L (37 48) %

Random Blood Glucose

Ureum Creatinine

151
30.2 0,8

(80 140) mg/dl

(10 45) mg/dl (0,4 1,5) mg/dl

Laboratory Examination Mei 27th 2012

Diabetes Mellitus type 2 with Gangrene

Diabeticum

Diabetes Mellitus type 2 with Cellulitis Diabetes Mellitus type 2 with Erycipelas

Differential Diagnosis

Symptoms
Painful wound with a slight bloody discharge on her right foot since 1 day before admitted to hospital. 1 month before right foot got wounded by a broken glass small wound (+) 2 week before painful, swelling wound (+), and produce some pus. 2 days before began necrotic around the ulcer Polyphagy (+), polydipsia (+), polyuria (+), fatigue, slight headache, numbness on the feet. History of Past Disease : DM since 2010 Amputation of the 4th finger of the right foot 1 year ago.

Signs
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

RBG >200 mg/dl Hyperglycemia

Resume

DIABETES MELLITUS TYPE II with RIGHT FOOT DIABETIC GANGRENE

Working Diagnosis

Lipid profile

ECG
Pus culture

Rontgen thorax and pedis

Suggested Examination

Bed rest Diet DM IVFD NaCl Ranitidin Ceftriaxon Ketorolac Metronidazol Metformin Debridement

1723 calories 20 tpm 2 x 1 gr amp. 1 x 2 gr fl. 3 x 30 mg amp. 3 x 500 mg amp. 3 x 500 mg tab.

Treatment

Ad Vitam Ad Functionam Ad Sanationam

: Ad bonam : Dubia ad malam : Dubia ad malam

Prognosis