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A WOMAN 40 YO WITH DIABETIC MELLITUS
TYPE 2 AND DIABETIC FOOT
D E L L A P U T R I A R I Y A N I
0 3 0 . 0 9 . 0 6 1
D O K T E R P E M B I M B I N G : D R . S U P R I S S P.
P D
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IDENTITY
Mrs. NardiahName
40 years oldAge
FemaleSex
Krajan KarawangAddress
High schoolEducation
-Occupation
MoeslemReligion
MarriedMarital status
June 20th 2012Admitted
SundaneseEthnic
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Main Complaint Additional Complaint
Pain in the right leg since
1 month agoNausea
dizziness
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HISTORY OF THE DISEASE
patients came to the hospital with complaints of pain
in the right foot. The perceived grievances 1 monthago.
Patient has a wound on the right leg since 3months ago. The injuries arise suddenly without
realizing patients, initial small wound extends long.
The wound was in surgery at one hospital.however, the wound is still oozing pus and smell.
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5 years ago patient cames to the clinic anddiagnosed with diabetes melitus. But she
didnt control regularly for her illness
3 month ago : patient has a wound on theright leg
2 month ago:The wound was in surgery atone hospital
1 months ago : the wound is still oozing pusand smell. And patien felt pain in her right foot.
June 20 2012, patient come to emergency unitof karawang hospital
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HISTORY OF THE PAST DISEASE
Diabetesmelitus (+)
Hipertension(-)
Asthma (-)
Allergy (-)
High uricacid (-)
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FAMILY HISTORY
Diabetesmelitus (+)her parent
Kidneydisease (-)
Allergy (-)Asthma (-)
Hypertension(-)
Heart disease(-)
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HABIT HISTORY
Alcohol consumption (-)
Smoking (-)
Routine exercise (-) Injected drugs (-)
Traditional beverages(-)
Coffe 1 cup/days
Patient are likely to eat sweet food
Patient are likely to eat a largeportion
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GENERAL CONDITION
Moderately illGeneralcondition
ComposMentis
Consciousness
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VITAL SIGN
VitalSigns
Blood Pressure
110/70 mmHg
RespirationRate
36X/minute
Pulse Rate
86x/minute,weak pulse
Temperature
38 C
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PHYSICAL EXAMINATIONHead
Normocephali
Eyes Anemic conjunctiva -/-,
Icteric sclera -/-
Mouth
Lip: cyanosis(-) dryness (-)
Pharynx: hyperemic (-), symmetrical, uvula at midline
Thypoid tounge -
Neck
Lymph gland & Thyroid gland is not palpable
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THORAX EXAMINATION
LungExamination
Inspection: Symmetrical
Palpation: Equal vocal fremitus
Percussion: Sonor
Auscultation: Vesicular breathsound in both lung, no ronchi andwheezing
HeartExamination
Inspection: Ictus cordis is available
Palpation: Ictus cordis is palpableat 5th ICS LMCS
Percussion :Right heart border: ICS III-V LSD
Left heart border: ICS V 1cm medial LMCS
Upper heart border: ICS III LPSS
Auscultation: Regular I - II heartsound no murmur and gallop
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ABDOMINAL EXAMINATION
Inspection:
Brown skin
Skinabnormality (-)
Palpation:
Sociable
Defensemuscular (-),mass (-)
Noenlargementof liver andspleen
Percussion:
No painpresent onabdominalpercussion
Sounds dull Shifting
dullness (-)
CVA (-)
Auscultation:
Bowel sound(+)
Arterial bruit (-)
Venous hum (-)
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EXTREMITY EXAMINATION
Warm acrals (+)Oedem (-)
Wound +/-
Range of Motion arelimited due to the pain
(numbness)
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LABORATORY EXAMINATIONJune 20,2013
RESULT Normal Range
Hemoglobin 9,2 (12 17) g%
Leucocytes 18.510 (5.000 10.000)/L
Thrombocytes 517.000 (150.000 450.000)/L
Ht 27 (37 43) %
Differential Count
Basophil 0 (0 1) %
Eosinophil 0 (1 3) %
Rod Neutrophil 0 (2 6) %
Segment Neutrophil
88
(50 70) %
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June 21, 2013
GDS : 357
RESULT Normal Range
Lymphocyte 8 (20 40) %
Monocyte 4 (2 8) %
Random Blood Glucose 311 (80 140) mg/dl
Ureum 51,5 (10 45) mg/dl
Creatinine 0,65 (0,4 1,5) mg/dl
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PHOTO RO
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RADIOLOGI OSTEOMIELITIS
7-10 days infectionsoft tissueswelling
10-14 days infection periostealreaction, sclerosis, involucrum
and scewstrum
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DIABETES MELITUS
Definition
A metabolic disorder of multiple etiology
characterized by chronic hyperglycemia with
disturbances of carbohydrate, fat and protein
metabolism resulting from defects in insulin
secretion, insulin action, or both.
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CHARACTERISTIC SYMPTOMS
1. Poliuria,
2. Polidipsi,
3. Polifagia,
4. Weight loss
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ATYPICAL SYMPTOMS
1. Fatigue and weakness
2. dizziness
3. Skin infections
4. Chronic itching
5. Poor healing of skin wounds6. Numbness of fingers and toes
7. Blurred vision
8. etc
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CRITERIA DIAGNOSA DM
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Hemoconcentration
trombosis
Aterosklerosi
s
Makrovaskul
er
Mikrovaskule
r
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Mikro
1.Diabeticcardiomyophaty
2.Diabeticnephrophaty
3.Diabeticneurophaty
4.Diabeticretinophaty
Makro
1.Coronary arterydisease
2.Diabeticmyonecrosis
3.Peripheralvascular disease
4.Stroke
COMPLICATION
Diabetic foot
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VASCULAR, INFECTION OR NEUROPHATY?
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EDMONDS 2004-2005
Stage 1: Normal Foot
Stage 2: High Risk Foot
Stage 3: Ulcerated Foot
Stage 4: Infected Foot
Stage 5: Necrotic Foot
Stage 6: Unsalvable Foot
Primary prevention
Care and
specialist
services
Hospitalization
and surgeon
Secondary
prevention
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MANAGEMENT OF DIABETIC FOOT
PRIMARY PREVENTIONbased on the magnitude of risk and the
risk of problems that may occur.
Classification based on the risk of diabetic foot
problems (Frykberg):a) Normal Sensation Without Deformityb) Normal sensation with deformities or HighPlantar Pressure
c) insensitivity Without Deformityd) Ischemia Without Deformitye) Combination / complicated
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SECONDARY PREVENTION
1. Metabolic control
2. Vascular control
3. Wound control
4. Microbiological control
5. Pressure control
6. Education control
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Metabolic:
control of blood sugar levels,
serum albumin level, hemoglobin
level and the degree of tissue
oxygenation and kidney function. All
of these factors will be poor healing
wounds if left unchecked and not
repaired.
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Vaskular
peripheral vascular abnormalities can
be identified simply as: color and
temperature of the skin, palpation of the
dorsalis pedis artery and posterior tibialarteries and added blood pressure
measurement. Management can be a risk
factor modification (atherosclerosis risk
factors and improve walking program),pharmacological therapy (improve patency
in vascular disease legs with DM) and
revascularisation (surgical therapy).
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Wound
adequate debridement and
topical therapy (saline for cleaning
wounds, or yodine watery liquid,
silver compounds as part of the
dressing).
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Microbacterial
antibiotics with a broad spectrum,
including Gram positive and negative
bacteria, combined with useful drugs
against anaerobic bacteria (such asmetronidazole).
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Pressure
if the fixed leg is used for walking,
which is always under pressure sores will
not have time to heal, if the wound is
located on the plantar as Charcot footulcers. To achieve non weight-bearing can
be done include: removable cast walker,
temporary shoes, wheelchair, total contact
casting.
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Education
With a good education, people with
diabetes or ulcer / gangrene diabetic and
his family are expected to be able to help
and support the actions necessary foroptimal wound healing.
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WORKING DIAGNOSIS
DM Type 2 with diabetic foot grade III
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THERAPY
Insulin Humalog (20-0-20)
Ceftriaxone 2x1
Metronidazole 3x500
Ketorolac 3x500
OMZ 2x1
PCT p.r.n
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PROGNOSIS
AdVitam:Bonam
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