A WOMAN 40 YO WITH DIABETIC MELLITUS

TYPE 2 AND DIABETIC FOOT

D E L L A P U T R I A R I YA N I
030.09.061
D O K T E R P E M B I M B I N G : D R . S U P R I S S P.
PD

IDENTITY
Name

Mrs. Nardiah

Age

40 years old

Sex

Female

Address
Education

Occupation
Religion
Marital status
Admitted
Ethnic

Krajan Karawang
High school
Moeslem

Married
June 20th 2012
Sundanese

Pain in the right leg since

1 month ago

Main Complaint

Nausea
dizziness

Additional Complaint

HISTORY OF THE DISEASE

patients came to the hospital with complaints of pain
in the right foot. The perceived grievances 1 month
ago.

Patient has a wound on the right leg since 3

months ago. The injuries arise suddenly without
realizing patients, initial small wound extends long.

The wound was in surgery at one hospital.

however, the wound is still oozing pus and smell.

 5 years ago patient cames to the clinic and

diagnosed with diabetes melitus. But she
didnt control regularly for her illness
3 month ago : patient has a wound on the
right leg

2 month ago:The wound was in surgery at

one hospital

1 months ago : the wound is still oozing pus

and smell. And patien felt pain in her right foot.

June 20 2012, patient come to emergency unit

of karawang hospital

HISTORY OF THE PAST DISEASE

Diabetes
melitus (+)

Hipertension
(-)

Asthma (-)
Allergy (-)

High uric
acid (-)

FAMILY HISTORY

Diabetes
melitus (+)
her parent
Hypertension
(-)
Heart disease
(-)

Kidney
disease (-)
Allergy (-)
Asthma (-)

HABIT HISTORY
Alcohol consumption (Smoking (-)
)
Routine exercise (-)

Injected drugs (-)

Traditional beverages
Coffe 1 cup/days
(-)
Patient are likely to eat sweet food
Patient are likely to eat a large
portion

GENERAL CONDITION
General
condition

Consciousness

Moderately ill
Compos
Mentis

VITAL SIGN

Blood Pressure
110/70 mmHg

Temperature
38 C

Vital
Signs
Pulse Rate
86x/minute,
weak pulse

Respiration
Rate
36X/minute

PHYSICAL EXAMINATION
Head
Normocephali

Eyes
Anemic conjunctiva -/-,
Icteric sclera -/-

Mouth
Lip: cyanosis(-) dryness (-)
Pharynx: hyperemic (-), symmetrical, uvula at midline
Thypoid tounge -

Neck
Lymph gland & Thyroid gland is not palpable

THORAX EXAMINATION
Lung
Examination

Heart
Examination

Inspection: Symmetrical

Inspection: Ictus cordis is available

Palpation: Equal vocal fremitus

Palpation: Ictus cordis is palpable

at 5th ICS LMCS
Percussion

Percussion: Sonor

Auscultation: Vesicular breath

sound in both lung, no ronchi and
wheezing

Right heart border: ICS III-V LSD

Left heart border: ICS V 1cm medial LMCS
Upper heart border: ICS III LPSS

Auscultation: Regular I - II heart

sound no murmur and gallop

ABDOMINAL EXAMINATION

Inspection:
Brown skin
Skin
abnormality (-)

Palpation:
Sociable
Defense
muscular (-),
mass (-)
No
enlargement
of liver and
spleen

Percussion:
No pain
present on
abdominal
percussion
Sounds dull
Shifting
dullness (-)
CVA (-)

Auscultation:
Bowel sound
(+)
Arterial bruit ()
Venous hum ()

EXTREMITY EXAMINATION

Oedem (-)

Warm acrals (+)

Wound +/-

Range of Motion are

limited due to the pain
(numbness)

LABORATORY EXAMINATION
June 20,2013

RESULT

Normal Range

Hemoglobin

9,2

(12 17) g%

Leucocytes

18.510

(5.000 10.000)/L

Thrombocytes

517.000

(150.000 450.000)/L

27

(37 43) %

Basophil

(0 1) %

Eosinophil

(1 3) %

Rod Neutrophil

(2 6) %

Segment Neutrophil

88

(50 70) %

Ht
Differential Count

RESULT

Normal Range

Lymphocyte

(20 40) %

Monocyte

(2 8) %

311

(80 140) mg/dl

Ureum

51,5

(10 45) mg/dl

Creatinine

0,65

(0,4 1,5) mg/dl

Random Blood Glucose

June 21, 2013
GDS : 357

PHOTO RO

RADIOLOGI OSTEOMIELITIS

7-10 days infection soft tissue

swelling
10-14 day infection reaction
periosteal, sclerosis,
involucrum, and scwestrum

DIABETES MELITUS
Definition

A metabolic disorder of multiple etiology

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

CHARACTERISTIC SYMPTOMS
1.
2.
3.
4.

Poliuria,
Polidipsi,
Polifagia,
Weight loss

ATYPICAL SYMPTOMS
1. Fatigue and weakness

2. dizziness
3. Skin infections
4. Chronic itching

5. Poor healing of skin wounds

6. Numbness of fingers and toes
7. Blurred vision

8. etc

CRITERIA DIAGNOSA DM

Makrovaskul
er

Mikrovaskule
r

Aterosklerosi
s

trombosis

Hemoconcentration

COMPLICATION
Mikro
1.Diabetic
cardiomyophaty
2.Diabetic
nephrophaty
3.Diabetic
neurophaty
4.Diabetic
retinophaty

Makro
1.Coronary artery
disease
2.Diabetic
myonecrosis
3.Peripheral
vascular disease
4.Stroke

Diabetic foot

DIABETIC FOOT
Of the sixteen million Americans with
diabetes, 25% will develop foot problems
related to the disease. Diabetic foot
conditions develop from a combination of
causes including poor circulation and
peripheral vascular
neuropathy.
neuropathy

disease inhibits
circulation.

insensitivity or a loss
of ability to feel pain,
heat, and cold.

narrowing of the
arteries

minor cuts, scrapes,

blisters, or pressure
sores

oxygen and nutrition

supplied
Poor healing

VASCULAR, INFECTION OR NEUROPHATY?

EDMONDS 2004-2005

Stage 1: Normal Foot

Primary prevention

Stage 2: High Risk Foot

Stage 3: Ulcerated Foot
Stage 4: Infected Foot
Stage 5: Necrotic Foot
Stage 6: Unsalvable Foot

Care and
specialist
services
Secondary
prevention
Hospitalization
and surgeon

MANAGEMENT OF DIABETIC FOOT

PRIMARY PREVENTION
based on the magnitude of risk and the
risk of problems that may occur.
Classification based on the risk of diabetic foot
problems (Frykberg):
a) Normal Sensation Without Deformity
b) Normal sensation with deformities or High
Plantar Pressure
c) insensitivity Without Deformity
d) Ischemia Without Deformity
e) Combination / complicated

SECONDARY PREVENTION
1. Metabolic control
2. Vascular control
3. Wound control
4. Microbiological control
5. Pressure control
6. Education control

Metabolic:
control of blood sugar levels,
serum albumin level, hemoglobin
level and the degree of tissue
oxygenation and kidney function. All
of these factors will be poor healing
wounds if left unchecked and not
repaired.

Vaskular
peripheral vascular abnormalities can
be identified simply as: color and
temperature of the skin, palpation of the
dorsalis pedis artery and posterior tibial
arteries and added blood pressure
measurement. Management can be a risk
factor modification (atherosclerosis risk
factors and improve walking program),
pharmacological therapy (improve patency
in vascular disease legs with DM) and
revascularisation (surgical therapy).

Wound
adequate debridement and
topical therapy (saline for cleaning
wounds, or yodine watery liquid,
silver compounds as part of the
dressing).

Microbacterial
antibiotics with a broad spectrum,
including Gram positive and negative
bacteria, combined with useful drugs
against anaerobic bacteria (such as
metronidazole).

Pressure
if the fixed leg is used for walking,
which is always under pressure sores will
not have time to heal, if the wound is
located on the plantar as Charcot foot
ulcers. To achieve non weight-bearing can
be done include: removable cast walker,
temporary shoes, wheelchair, total contact
casting.

Education
With a good education, people with
diabetes or ulcer / gangrene diabetic and
his family are expected to be able to help
and support the actions necessary for
optimal wound healing.

WORKING DIAGNOSIS
DM Type 2 with diabetic foot grade III

THERAPY
Insulin Humalog (20-0-20)
Ceftriaxone 2x1
Metronidazole 3x500
Ketorolac 3x500
OMZ 2x1
PCT p.r.n

PROGNOSIS

Ad
Vitam:
Bonam