This document describes a case report of a 40-year-old female patient with diabetic foot. She noticed a wound on her left foot that was painful and spreading. Her medical history includes type 2 diabetes for 10 years that is uncontrolled, as well as amputations of her left little finger and right heel due to ischemia. Examination found gangrene on her left fourth and little toes. Laboratory tests showed anemia and hyperglycemia. She was assessed with diabetic foot Wagner stage IV and diabetic gastropathy. Her treatment included antibiotics, insulin, and wound care with the goal of controlling her blood glucose and healing the wound.

1. +
DIABETIC FOOT - CASE REPORT
DIVISI ENDOKRIN METABOLIK
BAGIAN ILMU PENYAKIT DALAM
UNIVERSITAS HASANUDDIN

2. +
Case
 Name : Ny. M
 Date of birth : 12-04-1969 / 40 years old
 Gender : Female
 Marital status : Married
 Religion : Muslim
 Address : Benteng, Wara
Timur
 Medical Record Number : 010430
 Date of Admission : 28-10-
2019

3. + History Taking
The patient notice a spontaneous small opening and redness without any external
injury on the dorsal and plantar aspect of left foot 2 weeks prior to admission.
Wound was painfull, swelling and spreading. Currently there is mild discharge on
the wound without foul smell. History of intermittent fever, nausea, vomiting, cough,
difficulty in breathing and sleeplessness was present.
There was history of amputation of little finger of the left hand a year ago due to
ischemic and heel of right foot in 2012.
Chief complaint: Injury of left foot

4. + History Taking
 She was diagnosed with Type 2 Diabetes Mellitus 10 years ago,
uncontrol.
 There’s no history and current impaired vision,
 She was diagnosed with hyperurecemia, uncontrol.
 The patient denied any history of heart disease, hypertention,
hypercholestrolemia.
 There is no history of cigarette smoking.

5. +
Patient Status
General condition : Moderate Illness/Compos Mentis (E4M6V5)
Height : 159 cm
Weight : 53 kg
BMI : 23.34 kg/m2
Vital Sign
Blood pressure : 120/70 mmHg Heart rate : 75 x/minutes
Respiratory rate : 18 x/minutes Temperature : 37,3 ‘C
Physical Examination

6. +
Physical Examination
Head
• Shape : Normocephal
•Face : Symmetrical left = right
•Deformity : -
Eye
• Eksoptalmus/Enoptalmus : (-)
• Movement : In normal range
• Eyelid : Edema palpebra (-)
• Conjungtiva : anemis
• Sclera : Ikterik (-)
• Cornea : Clear
• Pupil : Isochore Φ2,5
mm/2,5 mm
Ear
• Hearing : In normal range
• hemorrhage (-), Otorrhea (-)
 Nose
• Epistaxis : (-)
• Nasal Discharge : (-)
Mouth
• Lip : Cyanosis (-), Dry (-)
• Teeth : Dental caries (-)
• Gumes : Bleeding gum (-)
• Tonsil : T1 – T1, hyperemia (-)
• Pharynx : Hiperemis (-)
• Tongue : Dirty (-), Tremor(-), Hyperemia(-)

7. +
Physical Examination
Neck
Lymph nodes : Enlargement (-)
Thyroid Gland : Enlargement (-)
JVP : R+ 2 cm H2O
Blood Vessels : In normal Range
Nuchal Rigidity : Negatif
Tumor : Negatif
Trachea : Deviation (-)
Toraks
Inspection : Symetrical left = right
Palpation : mass (-), vocal fremitus is
normal
Percussion: Sonor
Auscultation: breath sound : vesicular. Ronchi and
wheezing (-)

8. +
Physical Examination
Cor
Inspection: Ictus cordis isn’t visible
Palpation : Ictus cordis isn’t palpable, Thrill (-),
Tenderness (-)
Percussion :
Right Upper border 2nd ICS linea parasternalis dextra
Left Upper border 3th ICS llinea parasternalis sinistra
Right lower border 4th ICS linea parasternalis dextra
Left lower border 6th ICS linea axillaris anterior sinistra
Auscultation: Heart sound I/II pure regular, murmur (-
)
Abdomen
Inspection : convex, following breath
movement
Auscultation: Peristaltic sound (+),
normal
Palpation : Mass (-), tenderness (-),
there are no palpable
Percussion : Timpani (+), ascites (-)

9. +
Physical Examination
Lower extremities
Inspection : Ulcer on the left little toe 1x1cm.
Gangrene on the left fourth and little toes
(plantar pedis). Pus (-) , blood (-).
Palpation : Tenderness
Upper extremities
Inspection : Amputated left little finger.
Palpation : Tenderness (-)

10. +

11. + Laboratorium (08/05/2019)
Examination Result Normal value
RBC 2,28 (106/ mm3) F: 4.00 - 5.50 106/ mm3
M: 5.00 - 5.80 106/ mm3
HGB 6.9 (g/dL) 12.0 - 16.0 g/dL
MCV 87.3 fL 80,0 – 97,0 Fl
MCH 30.3 Pg 26.5 – 33,5 pg
MCHC 34.7 (g/dL) 31.5 - 35.0 g/dL
WBC 19.60 (103/uL) 4.00 - 10.0 103/uL
NEUT 86.6 % 52.0 - 75.0 %
LYMP 8.8 % 20.0 - 40.0 %
PLT 375 (103/uL) 150 - 450 103/uL
GDS 523 <140 mg/dL

12. + Laboratorium (08/05/2019)
Examination Result Normal Value
RBC 2.66 (106/ mm3) F: 4.00 - 5.50 106/ mm3
M: 5.00 - 5.80 106/ mm3
HGB 8.1 (g/dL) 12.0 - 16.0 g/dL
MCV 88.7 fL 80,0 – 97,0 fL
MCH 30.5 Pg 26.5 – 33,5 pg
MCHC 34.3 (g/dL) 31.5 - 35.0 g/dL
WBC 22.16 (103/uL) 4.00 - 10.0 103/uL
NEUT 84.1 % 52.0 - 75.0 %
LYMP 8.8 % 20.0 - 40.0 %
MONO 6.2 % 2.0 - 8.0 %
EOS 0.8 % 1,00– 3.00%
BASO 0.1 % 0.0 - 0.10 %
HCT 23.6 % 37.0 - 48.0 %
PLT 357 (103/uL) 150 - 450 103/uL

13. +
Examination Result Normal value
GDS 350 <140 mg/dL
SGPT 21 <41
SGOT 15 <38 U/L
Albumin - 3,5-5,0 gr/dl
Kreatinin 1.5 M<1,3; F<1,1
Ureum 33 10-50 mg/dl
Natrium 136 136-145
Kalium 4.3 3,5-5,1
Klorida 106 97-111
PT 15.5 10-14 Second
INR 1.3 --
APTT 26.4 22,0-30,0 Second

14. Assesment
1. Diabetic Foot wagner IV Pedis Sinistra
2. Diabetes Militus Type 2 Non Obest
3. Anemia Normocytic Normochrome
4. Diabetic Gastropathy

15. Therapy
• Infusion NaCl 0,9% 30 TPM
• Novorapid 18-18-18 sc
• Levemir 0-0-20 sc
• Paracetamol 1g/8 Hour/Intravena
• Ciprofloxacin 500mg/8 Hour/Intraven
• Metronidazole 500g/8 Hour/ Intraven
• Ceftriaxon 2gr/24hour/Intraven
• Transfusion PRC 1 Bag
• Omeprazole 20mg /12 Hour/Oral
• Domperidone 10mg/8 hours/oral

16. Planning
• Blood Glucose Monitoring
• Diet (Diet DM 1700 kkal)
• Wound control
• Radiology : X-ray pedis

17. DISCUSSION

18. Definition
• Diabetic foot is one of the most significant and devastating complications of
diabetes, and is defined as a foot affected by ulceration that is associated with
neuropathy and/or peripheral arterial disease of the lower limb in a patient with
diabetes.

19. Epidemiology
• Systematic review included a large sample of studies involving more than 800,000 global participants from
67 studies in the past three decades. These studies included patients from five continents.suggested that
the pooled prevalence of diabetic foot ulceration was about 6.3% worldwide
• The results suggested that the highest prevalence of diabetic foot ulceration was reported in North Americ
(13.0%), and the lowest prevalence was reported in Oceania (3.0%). The prevalence of diabetic foot ulcer
was relatively higher in Africa (7.2%) than in Asia (5.5%) and Europe (5.1%).
Zhang, P., 2017. Global epidemiology of diabetic foot ulceration: a systematic review and meta-analysis. Annals of Medicine, 1, 1.

20. Clinical Manifestasions
Clinical manifestations of DM are associated
with the metabolic consequences of insulin
deficiency:
• Fasting sugar levels are not normal.
• Poliuria
• Polidipsia
• Polifagia
• Weight Loss
• Tired and sleepy
• Other symptoms that are complained of are tingling,
itching, blurred eyes, impotence in men, and prurity vulva
in women.

21. In addition, there are other
clinical symptoms that show
more signs of ulcers due to
microangiopathy in people with
diabetes mellitus, which is 5P
which means:
a. Pain(nyeri)
b. Paleness(kepucatan)
c. Paresthesia (kesemutan)
d. Pulselessness (denyut nadi
hilang)
e. Paralysis (kelumpuhan)
Clinical Symptoms

22. Etiology &
Pathophysiology

23. Diagnosis

24. Diagnosis

25. Diagnosis

26. The nylon monofilament test is a
simply performed office test to
diagnose patients at risk for
ulcer formation due to
peripheral sensory neuropathy.
The test is abnormal if the patient
cannot sense the touch of the
monofilament when it is pressed
against the foot with just enough
pressure to bend the filament

27. DM Therapy: Non Pharmacology
•The course of the disease, the need for ongoing control and monitoring
DM complications, risk factors, non-pharmacological interventions,
pharmacological, and treatment targets
How to monitor blood glucose and interpret the results, recognize early
symptoms and manage hypoglycemia
The importance of foot care and regular physical exercise
Education
•Cannot walk barefoot
Check the foot every day, report to the doctor for skin peeling, redness, or
sores
Check footwear from foreign objects before use
Keep feet clean
Cut nails regularly
Dry regularly after the bathroom
Use cotton socks
Thin the callus regularly
Use custom made footwear
Feet Care

28. DM Therapy: Non Pharmacology
KARBOHIDRAT
•Karbohidrat: 45-
65%, berserat
tinggi, tidak boleh
& 130 g
•Glukosa dalam
bumbu masih
diperbolehkan
•Sukrosa &amp;lt;
5%
•Pemanis alternatif
•Makan tiga kali
sehari + selingan
LEMAK
•20-25% (Lemak
jenuh & 7%; lemak
tidak jenuh ganda
&amp;lt; 10%;
selebihnya lemak
tidak jenuh
tunggal)
•Batasi daging
berlemak dan
susu fullcream
(lemak trans)
•Konsumsi
kolesterol &200
mg/hari
PROTEIN
•10-20%
•Nefropati diabetik:
10% atau 0.8
g/kgBB dengan
65% diantaranya
bernilai biologik
tinggi
•Penderita DM
yang menjalani
HD: 1-1.2
g/kgBB/hari
NATRIUM
•2300 mg/hari
SERAT
•20-35 g/hari
•Kacang-kacangan,
buah, dan
sayuran,
karbohidrat tinggi
serat
PEMANIS
ALTERNATIF
•Berkalori: Hitung
kandungan
kalorinya (isomalt,
lactitol, maltitol,
mannitol, sorbitol,
xylitol)
•Fruktosa tidak
dianjurkan
Meningkatkan
kadar LDL.
Namun tidak ada
alasan
menghindari
makanan seperti
buah/sayur karena
mengandung
fruktosa alami
•Tak berkalori:
Aspartam, sakarin,
acesulfame
potassium,
sukralose,
neotame

29. DM Therapy: Non Pharmacology
• 3-5 kali per minggu
• 30-45 menit (total 150 menit per minggu)
• Jeda antar latihan tidak lebih dari 2 hari berturut-turut
• GDS &amp;lt; 100 mg/dl Konsumsi karbohidrat terlebih
dahulu
• GDS &amp;gt; 250 mg/dl Tunda olahraga
• Latihan jasmani bersifat aerobik
• Intensitas sedang
• Jalan cepat
• Bersepeda santai
• Jogging
• Berenang
• DM tanpa kontraindikasi (OA, HT tidak terkontrol,
retinopati, nefropati)
• Resistance training (latihan beban) 2-3 kali/minggu
Exercise

30. DM Therapy

31. DM Therapy
Dosis insulin
(0.5
mg/kgBB/hari)
Insulin Basal
Insulin
Prandial

32. Yale Protocol (Insulin Drips)
Initial insulin
therapy (GDS 423):
Rapid-acting
insulin 5U / hour /
Syringe Pump
GDS 450-549 = 5 Units / hour / drips
GDS 350-449 = 4 Units / hour / drips
GDS 250-349 = 3 Units / hour / drips
GDS 150-249 = 2 Units / hour / drips
GDS 100-149 = 1 unit / hour / drips
-Target reduction in GDS from 50 to 100 mg / dL / hour
- If it does not reach the target, the dose is increased
50% from the initial dose.
- If the reduction in GDS is more than 100 mg / dL,
decrease the dose by 50% from the start.
- If GDS <80 stops insulin + bolus dextrose 40% 2
flacon (50 cc) in a 0.9% NACL infusion.
- If GDS 80-99 stops insulin + bolus dextrose 40%
25cc

33. Parameter Target
BMI (kg/m2) 18.5 - < 23*
Systolic Pressure (mmHg) < 140
Diastolic Pressure (mmHg) < 90
GDP (mg/dl) 80-130**
GD2PP (mg/dl) < 180**
HbA1c (%) < 7
LDL Cholesterol (mg/dl) < 100 or < 70 if
high risk for CVD
HDL Cholesterol (mg/dl) Men : > 40
Women: > 50
Trigliseride (mg/dl) < 150
*The Asia-Pacific Perspective: Redefining Obesity and Its
Treatment, 2000
**Standards of Medical Care in Diabetes, ADA 2015
Therapy
Goals

35. DM Complications

36. THANKYOU 