INTERESTING CASEFRIDAY, AGUSTUS 2ND

Marti, Dety, Herlin, Esha, Dio, Riana, Akbar, Vita, Riona, Nana, Riu

RIANA HELMI

Female, 11 yo, Bantul Decrease of consciousness (Referred from Panembahan Senopati hospital due to Diabetic ketoacidosis, IDDM, Nephritis)

Has been diagnosed as IDDM since 3,5 years old.Routinely visit RS Panembahan Senopati every month (Novomix 8-8-8)Last admission in Sardjito on Jan 13 due to Diabetic Ketoacidosis

2 days BA : Pain in right abdominal and flank regio, vomit twice.

No fever, no reddish urine1 days BA : Abdominal pain getting worse, nausea, no vomit, no fever, iritable, can not sleepRS PS : GAR 278, Hb 16,7 AL 15310, AT 391000, Hct 54,1%, Seg 85%, Lim 8%, BUN 20, Crea 0,56, Na 141, K 2,4, GOT 11, GPT 11Urinalysis: cloudy urine, reduction +2, Ket+1, Bil+1, BJ 1.020, Bld+, Prot+3, Nit-, Leu est 15, granule cylinder 3-5. Dx? Tx: Novomix 8-8-8, Cefotaxime Inj 3x1 gram

Female, 11 yo, Bantul Decrease of consciousness (Referred from Panembahan Senopati hospital due to Diabetic ketoacidosis, IDDM, Nephritis)

Day of admission: Right abdominal and flank pain still persistedNo feverPrefer to sleep, lying in right side.GDS: 379Dx: Diabetic KetoacidosisTx: Nacl 0,9% 10 cc/kg/12 hour, Novorapid 2U/2 hour Referred to Sardjito

DATA LIST History of IDDM since 3,5 years old History of Diabetic Ketoacidosis on Jan 13 Abdominal pain, nausea, vomit. No fever. Decrease of consciousness Kussmaul respiration GAR : 259 Urinalysis : keton +3, glu+4 pH: 7.092, HCO3 3,3, BE -26,5 Anion gap : 27,4

Ass :Diabetic KetoacidosisType 1 Diabetes MellitusSevere Metabolic Acidosis

DATA LIST History of IDDM since 3,5 years old Decrease of consciousness Hyponatraemia (Na 126)

Ass :Cerebral oedema susp

DATA LIST History of IDDM since 3,5 years old Right flank pain, Abdominal pain, nausea, vomit. Urinalysis : proteinuria (pro+2), hematuria

(bld+2) granuler cylinder + USG : Renal diffuse disease bilateral, cystitis LFG : 78 (116,7 ±20,2)

Ass :Nephritis susp ec Nephropathy Diabeticum dd

Pyelonephritis

DATA LIST BP : 160/100 (P95 118/78, P99 125/86)

Ass :Stage 2 Hypertension

ANTHROPOMETRIC STATUS Body Weight 29 kg Body Height 135,0 cm Ideal body weight 30 kg

Waterlow 96%

Ass : Good nutritional status

LAB FINDING

CBC Result Normal valueHemoglobin (g/dL) 15,6 11,5-15,5Hematokrit (%) 46,3 35,0-45,0Jumlah leukosit (/μL) 20800 4500-11.000Hitung jenis leukositNetrofil (%) 93,4 54,0-62,0Limfosit (%) 3,7 25,0-33,0Monosit (%) 2 3,0-7,0Eosinofil (%) 0,5 1,0-3,0Basofil (%) 0,4 0-0,75Jumlah trombosit (/μL) 312000 150000-450000

LAB FINDING16.49 23.47 Nilai rujukan

Natrium 126 127 137 - 145 mmol/LKalium 3,7 6,5 3,4 - 5,4 mmol/LClorida 99 102 94 - 108 mmol/LGlucose 259 74-140 mg/dL

LAB FINDINGUrinalyis Result

Glu +4Pro +2Bil -pH 5,5Blood +2Keton +3Nit -Leu est -BJ 1,020Lp 0-1lg 1-2eri 4-5Granuler cylinder +

WORKING DIAGNOSIS Diabetic Ketoacidosis Type 1 Diabetes Mellitus Severe Metabolic Acidosis Cerebral oedema susp Nephritis susp ec Nephropathy

Diabeticum dd Pyelonephritis Stage 2 hypertension Hyponatremia, Hyperkalemia

INTEGRATED PLANNINGNo

Problem Patient’s Need

Plan Supv sign

1 Diabetic ketoacidosis

DKA resolve

•Closed monitoring VS/consiousness/GAR/2hrs, BGA & elecrolyte/4hrs •Fluid management (KaEN 3B, D51/2S) based on monitoring•Insulin 1U/kg/day ≈ 2U/2hrs s.c

2 Hypertension

Normal BP

•Captopril 0,3mg/kg/x•Target organ involvement investigation

INTEGRATED PLANNINGNo

Problem Patient’s Need

Plan Supvsign

3 Etiology of Nephritis (nephropathy diabeticum dd. Pyelonephritis)

-Confirrmed etiology

•Check UCT/CCT/Esbach

-Therapy •Ampicilin inj 100 mg/kg/day

4 Hyperglycemia

Controlled GAR

•Diet management•Maintenance insulin with mixed insulin (70/30)

5 Cerebral oedema

Prevention of worsening raised ICP

•Fluid,glucose & electrolyte monitoring•Mannitol 0,25-1g/kg or salin hypertonic if needed

INTEGRATED PLANNINGNo Problem Patien

t’s Need

Plan Supvsign

6 Electrolyte imbalance (hyponatremia, hyperkalemia)

Normal sodium and potassium level

•Electrolyte monitoring•iv fluid adjustment (KaEN or D51/2S or normal salin)

Hypertension Normal BP

•Captopril 0,3mg/kg/x•Target organ involvement investigation

Monitoring in the wardTime HR R

RBP Sign of Shock GAR

00.30 132 38 130/80

Warm acral, strong pulse, CRT< 2”

281

01.30 126 34 Warm acral, strong pulse, CRT< 2”

02.30 126 34 160/100

Warm acral, strong pulse, CRT< 2”

224

03.30 124 36 Warm acral, strong pulse, CRT< 2”

04.30 120 38 150/100

Warm acral, strong pulse, CRT< 2”

232

Blood Gas Analysis 16.49 23.47 04.07pH 7,043 7,106 7,183pO2 154,2 50,6 56,6pCO2 11 14 13,1BE -26,3 -22,9 -20HCO3 3,3 4,3 4,8

CONDITION THIS MORNINGS : No fever,O : E1V2M, Kussmaul type respiration

VS : HR 120 RR 38 BP 150/100Diuresis 4,5, BC-346Natrium 135 K4,0 Cl 105

Ass : Diabetic Ketoacidosis Type 1 Diabetes Mellitus

Severe Metabolic AcidosisCerebral oedema suspNephritis susp ec Nephropathy Diabeticum dd

PyelonephritisStage 2 hypetensionPlan : Continue plan

THANK YOU

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