Presentation is loading. Please wait.

Presentation is loading. Please wait.

DUTY REPORT JANUARY 5 TH 2014 Dokter jaga: dr. Rizki, dr. Dameria Koas jaga:Michael & Ayu Moderator:dr. Soroy Lardo Sp.PD Diabetic Ketoacidosis Moderate.

Similar presentations


Presentation on theme: "DUTY REPORT JANUARY 5 TH 2014 Dokter jaga: dr. Rizki, dr. Dameria Koas jaga:Michael & Ayu Moderator:dr. Soroy Lardo Sp.PD Diabetic Ketoacidosis Moderate."— Presentation transcript:

1 DUTY REPORT JANUARY 5 TH 2014 Dokter jaga: dr. Rizki, dr. Dameria Koas jaga:Michael & Ayu Moderator:dr. Soroy Lardo Sp.PD Diabetic Ketoacidosis Moderate Stage Diabetic ulcer pedis dextra Wagner I Acute on CKD

2 Duty Report Discussion Dr. Wahyu 52 year old patient with DM to exclude ACS Serial ECG, get cardiac enzymes Dr. Dermawan DKA is an acute complication of DM, ADA classification of DKA based on pH and HCO3 rehydrate patien for 1-2 hours then insulin drip and bolus prevent precipitating factors Dr. Soroy DKA improve dehydration, metabolic condition, and infection control

3 PATIENT RECAPITULATION Inpatient:7 Outpatient:2 Ward:1

4 1. Mrs. Silviani, 26 yo, , wd/ Fever day II ec Virus 2. Mr. Bonar, 52 yo, , wd/ Spontaneous Pneumothorax + bronkopleural fistula 3. Mr. Rochimin, 25 yo, , wd/ Fever day II 4. Mrs. Muntamah, 50 yo, , wd/ Dyspneu ec. CHF Grade III-IV 5. Mr. Ape, 56 yo, , wd/ DKA 6. Mrs. Titi, 60 yo, , wd/ DKA 7. Mr. Djemangin, 76 yo, , wd/ Dyspepsia

5 IDENTITY 1. Name:Mr. Ape 2. Sex:Male 3. Age:56 years old 4. Job:TNI – AD (soldier) 5. Religion:Moslem 6. Marital Status:Married 7. Address:Gang Benteng Cakur Tipar

6 ANAMNESIS Autoanamnesis on 5/2/14 at PM in the RSPAD Gatot Soebroto Emergency Room. Chief Complain: epigastric pain for 5 days before admission to ER Additional Complain: N/V, cough, loss of appetite

7 CURRENT ILLNESS Patient was admitted to ER with epigastric pain for 5 days. Intermittent pain, which worsen day by day. Pain radiated to breast bone, felt like burning sensation. Pain was not aggravated or relieved by anything. Patient also felt nausea and vomited 3-5x per day. Vomit consisted of food, liquid (>food), no blood or foam. Decrease appetite without loss of weight. Fever felt at evening, given PCT fever declined. Seizure, loss of consciousness declined. Unhealed wound was found on the right foot, pus (+), blood (+)

8 Patient denied any prolonged coughs and discomfort at throat. Patient denied any shortness of breaths. Patient denied any chest pain, sweating at night, loss of weight and coughing blood before today. Urination within normal limit, no decrease in frequency or quantity, dark urine (-) Defecation within normal limit, dark stool (-) Uncontrolled diabetes for 10 years with novorapid

9 PAST ILLNESS Heart disease, hypertension, asthma, chronic cough denied Diabetes from patient’s father Malignancy, hypertension, stroke denied FAMILY ILLNESS

10 HABITS AND LIFESTYLE Smoking, alcohol consumption denied.

11 PHYSICAL EXAMINATION VITAL SIGNS General State:Moderate Sickness Consciousness:Compos Mentis Blood Pressure:140/80 mmHg Pulse:90 x/minute Respiratory Rate:24 x/minute Temperature:37.3 o C Body Weight:68 kg Body Height:170 cm BMI:23,53 (Normoweight)

12 PHYSICAL EXAMINATION General Examination Head: Normocephal Eye: anemic conjunctiva (+/+), icteric sclera (-/-) Ears: normotia, discharge (-) Nose: septum deviation (-), discharge (-) Mouth: dry mucous, oral trush (-), leukoplakia (-) Neck : lymph nodes enlargement (-) JVP 5-2 cmH2O Thorax: symmetric, intercostal retraction (-) Cor: regular 1 st and 2 nd heart sound, murmur (-), gallop (-) Pulmo: vesicular breathing sounds, rales / crackles (-/-) ronchi (-/-) wheezing (-/-) Abdomen: distended (-), bowel sound within normal limit, tympani, hepar & lien not palpable, epigastric tenderness Extremities: warm, pitting edema (-), clubbing (-), cyanosis (-) CRT < 2 seconds, diabetic ulcer pedis dekstra

13 DIAGNOSTIC PLANS JENIS PEMERIKSAANHASILNILAI RUJUKAN Routine Hematology Hb g/dl Ht2440 – 52 % Erythrocyte mil /ul Leukocyte /ul Thrombocyte /ul MCV8280 – 96 fL MCH pg MCHC3532 – 36 g/dL LABORATORIUM

14 JENIS PEMERIKSAANHASILNILAI RUJUKAN Kimia klinik: Ureum mg/dl Creatinine – 1.5 mg/dl Random Blood Sugar879< 140 mg/dl Natrium – 147 mmol/L Potassium – 5.0 mmol/L Chloride8495 – 105 mmol/L Aceton+/positive-/Negatif

15 JENIS PEMERIKSAANHASILNILAI RUJUKAN Blood Gas Analysis pH – 7.45 pCO – 44 mg/dl pO – 104 mmHg Bicarbonate (HCO3) mmol/L Base Excess-14.8(-2)-3) mmol/L O2 Saturation %

16 ECG: Normal sinus rythm, 75 bpm, regular, normoaxis, p wave normal (upright & uniform), PR interval normal (0.14 sec), QRS complex normal (0.09 sec), ST changes (-), T-inverted (-), BBB (-), LVH/RVH (-).

17 X-RAY:

18 RESUME Patient was admitted to ER with epigastric pain for 5 days. Intermittent pain, worsen, felt like burning sensation which radiated to breast bone. Pain accompanied by nausea, vomit, anorexia, fever. History of uncontrolled DM for 10 years with insulin. On PE, patient's BP was 140/80 mmHg. Anemic conjunctiva, epigastric tenderness, organomegali (-), diabetic ulcer at the right foot with pus and blood. The Lab exam revealed anemia normocytic normochrome, leukocytosis, thrombocytosis, inc ur/creat, RBS, hyponatremia, hypochloride, acetone (+). Asidosis metabolic.

19 PROBLEMS LIST 1. Diabetic Ketoacidosis Moderate Stage 2. Diabetic ulcer pedis dextra Wagner I 3. Acute on CKD 4. Hypertension grade I

20 ASSESSMENT Diabetic Ketoacidosis Moderate Stage Anamnesis: DM uncontrolled for 10 years, epigastric pain, heart-burn like, N/V Physical examination: epigastric tenderness Additional examination: RBS: 879 mg/dL acetone (+) pH/pCO2/HCO3/O2Sat: 7.2 / 22.2 / 10 / 62.9

21 Diabetic ulcer pedis dextra Wagner I Anamnesis: unhealed wound, fever Physical exam: superficial ulcer pedis dextra, pus (+), blood (+), pain (-), Additional exam: leukocytosis RBS 879 mg/dL

22 Acute on CKD Anamnesis: nausea vomit, epigastric pain Physical exam: conjungtiva anemic, Additional exam: Hb: 8.3 MCV/H: 82/29 Ur/Creat: 125/3.2 eGFR: dd/ CKD stage IV

23 Hypertension Grade I Blood Pressure 140/80 mmHg History of high blood pressure denied

24 DIFFERENTIAL DIAGNOSIS Dyspepsia functional GERD

25 THERAPY Diagnostic Plan - CBC, ro toraks, urinalysis, albumin - Arterial Blood Gas / 8 hours - Bacterial culture mo, resistency - USG kidney, - Consult internist Therapeutic Plan - IVFD Nacl 0.9% 2L 1 st hour - RI drip 5 unit/hour 2 nd hour - Ondansentron 2 x 4 mg iv - Omeprazole 1 x 40 mg iv - Captopril 3 x 12.5 mg po - Paracetamol 3 x 500 mg po - Metronidazole 1 x 500 mg iv - Ceftriaxone 1 x 2 gr iv - Debridement Education Plan - Control to internal medicine department

26 PROGNOSIS 1. Qua ad vitam:Dubia 2. Qua ad functionam:Dubia ad malam 3. Qua ad sanationam:Dubia ad malam

27 THANK YOU


Download ppt "DUTY REPORT JANUARY 5 TH 2014 Dokter jaga: dr. Rizki, dr. Dameria Koas jaga:Michael & Ayu Moderator:dr. Soroy Lardo Sp.PD Diabetic Ketoacidosis Moderate."

Similar presentations


Ads by Google