Hypoglycemia on antidiabetic treatment with ulcus diabetic and CKD showed importance of comprehensive approach diabetes with infection and severity condition

1. HYPOGLYCEMIA E.C METFORMIN ON DIABETES
MELLITUS TYPE 2
DIABETIC FOOT ULCER
ANEMIA MAKROSITER
CKD GRADE IV
DUTY REPORT
13th January 2016
Consulen : dr. Soroy Lardo Sp.PD, FINASIM
Residen : dr. Yulianto
dr. Dini
Co-Ass : Reza Angga Pratama, S.Ked
Febri Qurrota Aini, S.Ked
Department Of Internal Medicine, Indonesia Army Central Hosptal Gatot Soebroto
Fakultas Kedokteran UPN Veteran - Jakarta

2. PATIENT RECAPITULATION
Total: 3 patients
- Mrs. S, 70 yo, DM ketosis, Ulcus DM pedis
dextra sinistra
- Mrs. SL. 71 yo, DM type 2, Ulcus DM pedis
dextra, anemia, CKD stage IV
- Mr. S, 79 yo, anemia, dyspnea

3. PATIENT ID
Name : Mrs. S
Age : 71 y.o.
Religion : Islam
Marital Status : Married
Occupation : Housewife
Address : Jakarta Pusat
Med Record : 257137

4. ANAMNESIS
Chief Complaint
Weakness for 2 days.

5. History of Present Illness
• 3 days before admission, the patient complained
of headache, fatigue (-), Fever (-), nausea (-),
vomiting (-), diarrhea (-), constipation (-),
frequency of urine increased. The patient
checked GDS (random blood sugar) at home
and it was 426 g / dL. Then the patients take half
metformin tablet and then the patient checked
GDS (random blood sugar) and it was 300 g /
dL.
• 2 days before admission, the patient complained
of weakness, out of breath and dizziness. Fever
(-), nausea (-), vomiting (-), (-), diarrhea (-),
constipation (-), frequency of urine increased.
The Patient checked GDS (random blood sugar)
at home and it was 81 g / dL.

6. History of Present Illness (Continued)
• The patient was admitted to emergency room with
weakness and dizziness for 2 days. Fever (-), vomitus
(-), nausea (-), diarrhea (-), constipation (-), increased
frequency of urine. She had blood transfusion 3 times
in order to increase her Hb.
• The patient also complained about increased
frequency to consume food and drink, and increase
frequency of urine. The patient did not take the drug of
diabetes melitus for 3 months because the patient
complained of weakness and dizziness after take a
diebetes mellitus drug. She also complained of having
wound on her right foot which was hard to heal. The
wound is now dark reddish-black color. She did not
feel pain at the wound site and the left right foot feels
numbness in fingertiip

7. Past Medical History
She was diagnosed with diabetes mellitus since
she was 46 years old. lately 4 years ago she was
hemodialysis.
No history of allergy, heart disease, hypertensi,
and lung disease.
FamiIy History
Her mother and grandmother suffered diabetes
mellitus.
Social History
She denies past or present tobacco and alcohol
use.

8. PHYSICAL EXAM
General : moderate ill, compos mentis
Vital Signs
Blood pressure : 137/60 mmHg
Heart rate : 88 beats/minute
Respiratory rate : 20 breaths/minute
Temperature : 36,2 oC
Weight : 45 kg
Height : 160 cm
BMI : 17,5 (underweight)

9. Head: normocephal
Eye: pale conjunctiva (+/+), icteric sclera (-/-)
Ears: normotia, discharge (-)
Nose: septum deviation (-), discharge (-)
Throat: dry mucous (-), tonsils T1-T1, hyperemic pharynx (-
)
Neck: JVP 5-2 cmH2O, enlargement nodes (-)
Cardiovascular: regular rate and rhythm; normal S1, S2;
murmurs (-), gallops (-)
Lungs: VBS (+/+), crackles (-/-), wheezes (-/-)
Abdominal: not distended, normal bowel sound, soft, tender
to palpation in epigastric region, and rebound
tenderness (-), liver and spleen not palpable,
palpable masses (-), normal skin turgor,
tympani percussion sound
Extremities: warm, CRT < 2 seconds, edema (-), cyanosis
(-); ulcer DM (+)

10. Description of ulcus
• Impaired Perfusion :
1. none
• Size / Extent in MM2 :
5000 MM2
• Tissue loss/Dept :
1. superficial fullthickness, not deeper than dermis
• Infection :
2. infection of skin and subcutaneous tissue only
• Impaired sensation :
1. Present

11. LABORATORY DATA
Lab Tests
Results
Normal Value
20th Nov, 06:31 13rdJan, 16:15
Hematology
Hemoglobin 8.0 6.9* 12 – 16 g/dl
Hematocrit 25 21* 37 – 47 %
RBC 2.5 2.1* 4.3 – 6.0 ^106 /μL
WBC 8790 6770 4,800 – 10,800 /μL
Platelets 218,000 194,000 150,000 – 400,000 /μL
MCV 97 99* 80 – 96 fL
MCH 32 33* 27 – 32 pg
MCHC 33 33 32 – 36 g/dL

12. LABORATORY DATA
Lab Tests
Results
Normal Value
20th Nov, 06:31 13rdJan, 16:15
Albumin 2.6* 3.5-5.0 g/dl
Ureum 70 62* 20-50 mg/dL
Kreatinin 1.8 1.6* 0.5-1.5 mg/dL
Random Blood
Sugar
68* <140 mg /dL
Natrium 146 136 135-147 mmol/L
Kalium 4.4 4.7 3.5-5.0 mmol/L
Clorida 117 109* 95-105 mmol/L

13. RADIOLOGY DATA

14. Description of Radiology result
• Shown fracture on dextra pedis caput os metatarsal digiti
V
• Shown deformity on os distal phalang digiti I dextra pedis
• Decreased dextra pedis bone density
• Shown soft tissue hyperplasia on regio dextra pedis
The image suggest Osteoporosis pedis dextra, still posible
osteomyelitis

15. ECG
• Sinus rhythm

16. RESUME
• The patient was admitted with weakness and dizziness for 2
days. Fever (-), vomitus (-), nausea (-), diarrhea (-),
constipation (-), frequency of urine increased. The patient also
complained about increased frequency to consume food and
drink. The patient did not take the drug of diabetes melitus for
3 months because the patient complained of weakness and
dizziness. She also complained of having wound on her right
foot which was hard to heal. The wound is now dark reddish-
black color. She did not feel pain at the wound site and the left
right foot feels numbness in fingertiips. She had blood
transfusion 3 times in order to increase her Hb
.
• 3 days before admission, the patient complained of headache.
The patient checked GDS (random blood sugar) at home and
it was 426 g / dL. Then the patients take half metformin tablet.
And then the patient checked GDS (random blood sugar) and
it was 300 g / dL.

17. Resume (Cont)
• 2 days before admission, the patient complained of
weakness, out of breath and dizziness. The Patient
checked GDS (random blood sugar) at home and it was
81 g /dL.
• Vital signs are:
• BP: 137/60 mmHg, HR: 88 beats/minute,
RR: 20breaths/minute, Temperature:36,2 oC
• Physical exam reveals pale conjungtiva (+/+), ulcer DM
(+), and dark reddish-black color on right foot.
• Laboratory data shows anemia makrositer, hipoalbumin,
hypoglikemia, increase ureum and creatinin.

18. PROBLEM LIST
• Hypoglycemia e.c metformin on diabetes
mellitus type 2
• Diabetic foot ulcer
• Anemia makrositer
• CKD grade IV

19. ASSESSMENT
Hypoglycemia e.c metformin on diabetes mellitus type 2
• The patient was admitted with weakness and dizziness
for 2 days. Fever (-), vomitus (-), nausea (-), diarrhea (-),
constipation (-), frequency of urine increased. The
patient also complained about increased frequency to
consume food and drink. The patient did not take the
drug of diabetes melitus for 3 months because the
patient complained of weakness and dizziness after take
diabetes mellitus drug. 3 days before admission, the
patient complained of headache. The patient checked
GDS (random blood sugar) at home and it was 426 g /
dL.

20. • Then the patients take half metformin tablet, and
then the patient checked GDS (random blood
sugar) and it was 300 g / dL, and the next day she
feels weakness, out of breath and dizziness and
she checked her GDS is 81 gr/dL.
• The patient was admitted to emergency room with
weakness and dizziness for 2 days. Fever (-),
vomitus (-), nausea (-), diarrhea (-), constipation (-
), increased frequency of urine. She had blood
transfusion 3 times in order to increase her Hb.

21. PE reveals BP:
137/60 mmHg, HR: 88 beats/minute,
RR: 20breaths/minute, Temperature:36,2 oC
• Pale conjungtiva (+/+), random blood sugar test shows
hypoglycemic (68 g/dL), increase ureum creatinin
• Diagnostic plan: reevaluate random blood sugar
• Therapy:
- Infus D10% 20 tpm
- GDS repeat examination.
• Educational plan: modifying lifestyle

22. Diabetic foot ulcer
• Based on patient’s complained of having dark reddish-black
wound on her right foot which hard to heal. The wound now
being dark reddish-black color. She did not feel pain at the
wound site and the left right foot feels numbness in fingertiips.
• PE reveals ulcer (+) in right foot.
– Impaired Perfusion :
1. none
– Size / Extent in MM2 :
5000 MM2
– Tissue loss/Dept :
1. superficial fullthickness, not deeper than dermis
– Infection :
2. infection of skin and subcutaneous tissue only
– Impaired sensation :
1. Present
• Diagnostic plan: wound Gram stain and culture
• Therapeutic plan: wound care, ceftriaxone IV 1x2 gr,
metronidazole IV 3x500 mg

23. Anemia makrositer
• Based on the patients complained
weekness and dizzyness
• PE: pale conjungtiva +/+
• Lab examination : decrease Hb, increase
MCV
• Plan theraphy : PRC transfusion 200cc

24. • CKD on stage IV:
• Based on anamnesa: history of HD since 4 years ago,
laboratory shows increased ureum creatinin.
• GFR = (140-age) x BB = (140-71) x 45
72x creatinin plasma 72x1,6
= 26,9 (stage IV)
• Plan therapy: hemodialysis

25. PROGNOSIS
Quo ad vitam : ad bonam
Quo ad functionam : ad malam
Quo ad sanationam : ad malam

26. Diabetic - Infection
Dysfunction
Of
Immune System
Must be
Controlled blood
Sugar
Uncontrolled
Increase of Infection
and colonization
+ +
Neuropathy
Diabetic
Nefropathy
Ulcus Diabetic
Nefropathy
Diabetic
CKDPedis
Score
Assesment
severity
(grade)
- Education DM Program
- Insulin Initiation
- Antibiotic with Culture Result
- Wound Maintaince Treatment
- Repair Albumin Score
( Decrease Severity Infection )

27. THANK YOU