DIABETES MELLITUS TYPE 2

DIABETIC FOOT WAGNER IV PEDIS

SINISTRA

PATIENT IDENTITY
Name : IWM
Age : 47 y.o.
Gender : Male
Citizenship : Indonesia
Religion : Hindu
Study : SD
Status : Married
Job : Wiraswasta
Address : Br. Dinas Tengah Selumbung
Manggis
ATH : 24 Maret 2012
Date of examination : 3 April 2012

Main complaint : wound on left foot
Patient came councious with his family. Patient complain of having wound
on his left sole and back side of his foot. At first, the patient had high fever
for 1 week, then his foot started to be painful and swollen, and it developed
into a wound. The wound was small about 1 cm containing pus, which was
incisied by a doctor near the patients house, but the wound became bigger
in a week . Patient also felt discomfort with the wound because it was
getting bigger, wont heal, and painful. Patient also complained that the
wound smells bad, numbness was also present and decreased with rest, but
was painful when palpated.
Patient said he often feels hungry and thirsty, and urinate often. Patient
eats 4 times a day and urinates more than 6 times a day with a volume of 1
glass per time.

Past History :
About 14 years ago, patient had the same complain, which were
weakness, frequent hunger and urination. Patient didnt feel thirsty.
Patient eats more than 4 times a day and urinates more than 6 times
a day.
Thus, this brought the patient to the primary health care, and the
doctor suggested to perform a blood test. Patient is aware that he
has diabetes. Primary health care doctor also explained about the
disease and prescribed glibenclamid. Patient never followed any
diet.

Patient complains of decreasing eye-sight since 5 years
ago. Patient also complains of decreasing body weight,
his body weight used to be 80 kg and now it is 60kg.
Patient feels tired after mild exercise. No abnormality on
urination and defeacation. Eating and drinking are
normal. History of nausea, vomiting, syncope were
denied. History of drug and food allergy, heart disease,
asthma, and hypertension were denied.

History of Medication
Patient was given gibenclamid 2x5mg for diabetes but the drug was not
taken regularly and did not go for follow up to the hospital regularly.
Patient was admitted to RSUD Karangasem with chief complain of fever for
16 days (fever was gone and patient went home) before coming to Sanglah.
But 2 days BATH patient had fever again and went to RSUD Karangaasem
from where he was referred to RSUP Sanglah.
Family History
Patient said that his mother also suffered from diabetes. She also suffered
from swollen wound on foot but his mother passed away 10 years ago
because of diabetes. History of hypertension and heart disease were denied.

Social history:
Patient works in the private sector but he quit when he
was injured.
Consuming alcohol and smoking was denied by the
patient.He does not drink coffee,Patient eats more than
4 meals a day,1 portion of rice(8 spoons) and side dishes
such as pork,beef,chicken or fish and vegetables
depending on his wife mood on what to cook.
Patient likes to eat sweet and junk food. Patient never
exercises.If he has to travel a short distance he rather use
a motorcycle than taking a walk.
Physical Examination
Vital sign:
General presentation: Average
Conciousness: Compos mentis
Nutrition: Average
GCS: E4 V5 M6
Blood pressure: 110/70 mmHg
Pulse: 80 x/minute
RR : 20x/minute
Tax: 36,6
0
C
Body weight : 60 kg
Height : 160 cm
BMI : 23,4 kg/m
2


General examination
Eye : anemic +/+, Icterus -/-, Pupil Relex +/+ isokor
ENT: Head neck :
Ear : External ear N/N
Hearing normal, fluid -/-
Nose : External nose normal, fluid -/-
Throat : Tonsil T0/ T0, hyperemic -/-
Faring: Normal
Neck : kaku kuduk (-), Pembesaran kelenjar getah bening (-), kelenjar
tiroid dalam batas normal, vena jugularis dalam batas normal
Thorax : Simetri
Cor : Inspeksi : Tidak tampak pulsasi iktus cordis
Palpasi : Teraba iktus kordis pada ICS V 1cm dari MCL kiri,
irama teratur, thrill (-)
Perkusi : Batas atas jantung ICS II
Batas bawah jantung setinggi ICS V
Batas kanan jantung 1cm PSL kanan
Batas kiri jantung 1cm lateral MCL kiri
Auskultasi: S1S2 tunggal regular murmur (-)
Pulmo Inspeksi : Simetri
Palpasi : Pergerakan simetri, taktil
vokal fremitus simetri
Perkusi : Batas bawah kanan ICS V,
batas bawah kiri ICS VI,
sonor/sonor
Auskultasi : Vesikuler +/+, Ronki -/-,
Wheezing -/-
Abdomen : Inspeksi : distensi (-)
Auskultasi: bising usus (+) normal
Palpasi: hepar/lien tidak teraba, ginjal
tidak teraba, nyeri tekan (-)
Perkusi : ascites (-)
Ekstremitas : Hangat ++/++, edema: -/-/-/-

Regio dorsal pedis:
Inspection: Erythematous macule without fix boundaries which
measures about 12 cm long and width about 15cm and with 3 ulcers
with fix boundaries.
The 1st uclers measurement are 3cm long,3cm wide and 1cm deep.
The 2nd ulcers measurement is 6cm long,2cm and 1cm deep on the
left dorsal pedis.
The other ulcer is on the left plantar
pedis,swelling(+)blood(+),pus(+) on the left dorsal pedis.
On the left tibial region,there was hair fall.On the right dorsal and
plantar pedis there was no injury,the right tibia region was normal.
Palpation: Pain on pressure is + on the left dorsal pedis,right dorsal
pedis arteri pulse is regular whereas on the left is weak but still
regular.
Supporting examinations
Complete blood count , on 26 March 2012





Clinical chemistry

Test results Normal Interpretation
WBC 26,37 x 10
3
/L 4.1-11 High
RBC 3,03 x 10
6
/ L 4,50 5,90 Low
Hb 8,50 g/Dl 13.5-17.5 Low
MCV 82,10 Fl 80.0-100.0 Normal
Plt 581,0x 10
3
/L 150-440 High
Hct 24,9 % 41.0-53.0 Low
Test Results Normal Interpretation
SGOT 12,4 U/L 11.0-33.0 Normal
SGPT 8,1 U/L 11.0-50.0 Normal
BUN 5,0 mg/dL 8.0-23.0 Low
Creatinine 0,34 mg/dL 0.50-1.20 Low
Random blood glucose 95.00 mg/dL 70-140 Normal
Urinalysis
Parameter 26/03/2012 Unit Reference value
pH 6 - 5-8
Leucoyte 25 (+1) Le/mikroL Negatif
Nitrite Positif - Negatif
Protein 25 (+1) Mg/dl Negatif
Glucose 1000 (+4) Mg/dl Negatif
Ketone 150(+4) Mg/dl Negatif
Urobilinogen - Mg/dl 1 mg/dl
Bilirubin - Mg/dl Negatif
Erythrocyte 25 (+2) Ery/mikroL Negatif
Specific Gravity 1,02 1,005 1,020
Colour Amber p.yellow
Sedimen Urine - - --
Leukosit 0-1 /lp <6 /lp
Eritrosit 0-1 /lp <3 /lp
Sel epitel - /lp --
Sel gepeng 0-1 /lp --
Blood glucose, on 29 March 2012

Test Results Normal Interpretation
Fasting plasma glucose 137,00 mg/dL 80-100 High
2-hour post-prandial glucose 118,00 80-140 Normal
HbA1C 8,856% <6,5 High
Radiology
Photo Thoraks
Cor : normal with CTR 50%
Pulmo : no infiltrat or
nodul with normal
bronkovaskularization
Normal costophrenic angle
Normal right and left
diaphragm
No bone abnormalities
Conclusion : cor and pulmo
normal


Left pedis photo
Good alignment
Normal bone trabecular
Osteophyte (-), normal joint space
Soft tissue swelling (+)
Abnormal calcification (-), spur formation (-)
Conclusion : soft tissue swelling due to
inflammation

Dx
Working diagnosis
DM Tipe II
DF Wagner IV pedis sinistra post debridement +
amputation day- III
Mild normokromiknormositer anemia suspect
anemia with chronic disease

THERAPY
Admission to the hospital
IVFD NS 20 drops/minit
Diet : 1860kkal carbohidrat 60% = 1100 kkal = 275
gr/day
fat 25% = 450 kkal = 50 gr/day
protein 15%= 300 kkal = 75 gr/day
fiber 25gr/day
Cefotaxim 3x1 g
Metronidazole 3x500 mg
Humulin R 3x8 unit
Humulin N 0-0-0-10 unit
Wound care everyday
KIE

PLANNING
BS 2 hours pp
Fasting BS
HBA1C
Lipid profile
Blood gas elektrolit
ABI
Cultur pus
Control to BTKV for diabetic foot
Consult to eye department
MONITORING
vital sign
Blood sugar (fasting and 2 jam pp)


THANK YOU