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1. Duty Report
24 February 2016
Resident`on Duty: dr.Dini & dr. Renaldy
Coass on Duty: Elsa & Dimaz
Supervisor : dr Soroy Lardo SpPD FINASIM
Faculty of Medicinet UPN Veteran Jakarta
Department of Internal Medicine Indonesia Army Central
Hospital Gatot Soebroto
Ketoacidosis Diabeticum
Cough for 1 week e.c dd/ lung oedem, acute upper respiratory tract
Dyspepsia syndrome
Hyponatremia hypoosmolar hypovolemia
OD Cataract
CHF fc I

2. Patient Recapitulation
• Mr.H, 48 y.o, Dyspepsia
• Mrs, 47 y.o, chronic diseases anemia e.c Ca mammae
• Mrs R, 57 y.o, DM ketosis, Hypertension grade I, Dyslipidemia
• Mr.B, 76 y.o, DM ketosis, hyponatremia hypoosmolar
hypovolemia, dyspepsia syndrome

3. Patient’s Identity
• Name: B
• Sex: Male
• Age: 76 y.o
• Occupation: Retired
• Address: Jakarta
• Date of Admission: 24 February 2016

4. Anamnesis
• Autoanamnesis on 24 February 2016 at 8.30 pm
• Chief complaint:
Weakness for 1 week

5. Present Ilness History
• Patient came to the ward with chief complaint weakness for 1
week, it was getting worse and made patient prefer to lay in
bed, he also complained of nausea and vomitus for 1 week. He
vomited everytime when he took the meal. , lost of appetite
(+), thirst increased (+), headache (-), deep and shortness of
breath (-) no defecation for 1 week, urination within normal
limit color yellowish. He also complained of cough for 1 week,
sputum (+) colour yellowish, blood (-), his family complained
that he had a fever but never checked the temperature,
fainted (-), cold sweat (-), palpitation (-), dyspneu at night (-),
dyspneu d’effort (-), orthopneu (-), foot swollen(-)
hypertension (-), paralysis or weakness on half body (-),
sensibility loss (+), decrease of right eye sight (+) worsen for 1
week. The patient had diabetic melitus controlled for 10 years.

6. Past illness history
• Controlled diabetes mellitus + 10 years
• Pedic ulcer + 5 years
• Hypertension (-)
• Heart disease (-)
• Kidney disease (-)
• Stroke (-)
• Cataract (+) in right eye
• Hypoglicemia (-)

7. Family illness history
• The patient complains about a family member living together
with him who coughs

8. Social history
• Smoke (-)
• Alcohol (-)
• The patient already changed his diet for diabetes
Medication history:
Metformin 3 x 500 mg

9. Physical examination
• General state : moderate ill
• Conciousness : Compos mentis
• Vital sign: BP: 150/80 mmHg HB: 76 bpm RR: 20x/m T:36,3⁰C
• Head: Normocephal
• Eye: Pale conjungtiva -/-, icteric sclera -/-, cilliary injection +/-,
sunken eyes -/-
• ENT: normal, hyperemis pharyng (-)
• Mouth: dry tongue mucosa, oral thrush (+)
• Neck: JVP 5 +2 cmH2O, lymph not palpable

10. • Thorax
-Lung
I: normochest, both hemisphere movement symetric
Pal: VF simetric, chest wall movement symetric
Per: sonor on both lung
A: vesicular +/+, rales -/-, wheezing -/-

11. Heart
I: IC not seen
Pal: IC not palpable
Per: Right border: ICS IV lin parasternal dextra
Left border : ICS V one finger lateral lin mid clavicula
sinistra
Heart waist: ICS III lin. Parasternal sinistra
A: Regular I/II heart sound, murmur (-), gallop (-)

12. • Abdomen:
I: concave
A: bowel sound normal
Pal: hepar & spleen not palpable, tenderness (+) epigastric
Balotement -/-, turgor decreased
Per: tymphani, shifting dullness (-)
• Extremities: CRT < 2 second foot edema +/+, pale nail -/-

13. Laboratory Result
Blood routine Result
Hb 13.0 mg/dl
Ht 36 %
RBC 4,4 M/uL
WBC 5910 /uL
Platelet 224000 /uL
MCV 83 fl
MCH 30 pg
MCHC 36 g/dl

14. Biochemical blood Result
SGOT 15 U/L
SGPT 16 U/L
Ureum 29 mg/dl
Kreatinin 0,8 mg/dl
RBS 292 mg/dl
Natrium 124 mmol/L
Kalium 4,7 mmol/L
Clorida 88 mmol/L
Aseton +

15. Blood gas analysis Result
pH 7,395
pCO2 32,0
pO2 89
HCO3 19,8
BE -3,6
Sp O2 96,8
Anion Gap = Na – (Cl + HCO3)
= 124 – (88 + 19,8)
= 16,2 (increased)

16. Resume
• Patient come to the ward with chief complaint weakness for 1
week and getting worse, nausea (+) vomitus (+) everytime he
took a meal, thirst increased, headache (-), deep and
shortness of breath (-), defecation and urination within
normal limit. Cough for 1 week, sputum (+), yellowish, blood (-
), fever (-), dyspneu d effort (-), dyspneu at night (-),
orthopneu (-), sight decreased on right eye worsen for 1 week.
Patient had histories of controlled diabetic mellitus + 10 years,
pedic ulcer 5 years ago, cataract (+) right eye, there is family
member that had a cough, BP: 150/80 HB: 76 bpm RR:20 x/m
T:36.3⁰C, cilliary injection +/- , JVP 5+2 cm H2O, heart border
wider, abdominal shape concave, turgor decreased, epigastric
pain (+) , foot edema +/+, hyperglicemia (292 mg/dl),
hyponatremia (124 mmol/l), hypochloride (88 mmol/L),
aseton (+) pH (7,395), normal value of leucocyte (5910)

17. • Decrease of PCO2 (32 and HCO3 (19,8), with increased value
of anion gap (16,2)

18. Problem list
• Ketoacidosis Diabeticum
• Cough for 1 week e.c dd/ lung oedem, acute upper respiratory
tract
• Dyspepsia syndrome
• Hyponatremia hypoosmolar hypovolemia
• OD Cataract
• CHF fc I

19. Discussion
• Mild Ketoacidosis Diabeticum
A(x) : weakness for 1 week, nausea (+) vomit (+) everytime he
took a meal, deep and short of breath (-), cough (+) 1 week,
sputum (+) collor yellowish, fever (-), defecation and urination
within normal. He had histories of controlled diabetic + 10 years,
pedic ulcer 5 years ago, cataract (+) right eye
P(x) : BP 150/80 HB: 76 bpm RR: 20 x/m T:36.3⁰C, abdominal
shape concave, turgor decreased, epigastric pain, hyperglicemia
(292 mg/dl), aseton (+), compensated metabolic asidosis (pH N,
PCO 2 ↓ HCO3 ↓) eventhough the pH value was normal, but
there was incresed value of anion gap (16,2)
Planning Diagnostic : random blood sugar, electrolyte, aseton,
blood gas analyse (every 6 hour)

20. Several Condition
Clinical Symptom of
Chronic Inflammation
Diabetes Melitus with pedic ulcer (10 years
uncontrolled)
Gastropathy Nephropathy
Neuropathy
Retinopathy Miocardiopathy
Weakness, nausea &
vomitus
Electrolyte
imbalance
Acute
hyperglicemia
Diabetic Ketosis
Aseton (+)

21. Diabetic Ketosis Dehydration
(caution with CHF)
Metabolic Intermediate
Management (insulin
management)
Treatment etiology of
disease (infection
and MCI)
Warning approach of :
Another complication like
sepsis and MODS

22. • Planning therapy: -NaCL 0,9% loading 1-2l in 1st hr, 1 L 2nd hr,
500 ml 3rd & 4th hr, 250 ml 5th &6th hr
-rapid insulin IV 210 U sliding scale 5U
NaCl 0,9% at 2nd hr and blood sugar < 200  stop
- KCl 25 mEq/ 6 hr

23. • Cough for 1 week e.c dd/ acute upper respiratory tract, lung
oedem
A(x) : cough (+) 1 week, sputum (+) collor yellowish, fever (-),
deep and shortness of breath (-), dyspneu at night (-) dyspneu
d effort (-) orthopneu (-) history of DM 10 years
P(x) : RR within normal limit, lung examination show no
abnormality, hyperemis pharyng (-), cardiomegali and foot
edema +/+ , WBC 5910 /ul
Planning Diagnostic : chest x-ray, sputum cultur
Planning therapy : Inj. Ceftriaxone 1x2 gr IV

24. • Dyspepsia syndrome
A(x) : nausea + vomitus everytime he took a meal for 1 week
P(x): epigastric pain
Planning diagnostik: ureabreath test
Planning therapy: inj omeprazole 1 x 40 mg
P.O sucralfat 1 x 15 cc

25. • Hyponatremia hypoosmolar hypovolemia
• A(x): nausea + vomitus everytime he took a meal for 1 week,
loss of apetite (+), thirst increased urination within normal
limit
• P(x): BP: 150/90 HB:76 bpm, sunken eyes -/-. JVP 5+2 cm H2O,
abdominal shape concave, turgor decreased, hyponatremia
(124 mmol/L) with osmolarity value 274,5
• Planning diagnostik: electrolyte serial
• Planning therapy : decreased sodium value maybe cause of
delucional condition in diabetic ketosis state (hyperglicemic
condition), so for this problem the planning therapy is
correction the diabetic ketosis state by rehydration (NaCL 0,9%
loading 1-2l in 1st hr, 1 L 2nd hr, 500 ml 3rd & 4th hr, 250 ml
5th &6th hr)

26. • OD Cataract dd/ acute glaucoma
• A(x) : decreased of right eye sight, worsen for 1 week,
diabetes mellitus type 2 (+), catarcat hystory (+)
• P(x): cilliary injection +/-
• Planning diagnostic: funduscopy, slit lense examination, retina
imaging
• Planning therapy: -

27. • CHF fc I
• A(x): dyspneu at night (-) dyspneu d effort (-) orthopneu (-)
history of DM 10 years
• P (x): cardiomegali and foot edema +/+
• Planning diagnostic : ECG and Echo
• Planning therapy: central venous pressure monitoring
• monitoring fluid balance =0

28. Prognosis
• Quo ad vitam : dubia ad bonam
• Quo ad santionam: dubia ad bonam
• Quo ad functionam: dubia ad bonam

29. Thank you