1

Syafrudin, Male, 58 yo, MW 11

Chief Complaint: (autoanamnesis and alloanamnesis)
• Breathlessness increased since 3 days ago

Present Illness History :

• Breathlessness increased since 3 days ago, affected by activity, increased with supine.
Sleep comfortable with 2 pilllow. History wake-up at midnight because of breathlessness
(+)
• Contact in adekuat, patient look sleepy
• Decreased of appetite since 2 weeks ago, only 3-4 spoons each meal
• Cough since 5 dayss ago, pleghm (+), no bleed
• Hystorical fever since 1 weeks ago, up and go for 3 days no high, no chill, but not felt now
• Micturition was normally
• Defecation was normally
• Patient has known DM type 2 since 5 years ago, not routine control, only free consumpt
glimepiride 1x2mg po
• Patient reffered from Sijunjung district hospital, hospitalitation 5 days cb KAD
Past illness history

• Diabetes Mellitus (+) since 5 years ago

• Hypertension (-)
• Tuberculosis (-)

Family illness history

No history of tuberculosis
No history of Diabetes Mellitus
• No history of Hypertension
Physical Examination
VII

• General Appearance : Severe

• Consciousness level : Apatis

• BP : 110/70 mmHg

• HR : 90 bpm

• RR : 28 rpm

• T : 36,5 º C

• SaO2 : 96 % with NRM Oxygen 15 lpm

• Head, Eye, Mouth & Neck
 Head : Normocephalic VII
 Conjunctiva Palpebra are anemic (-/-), icteric (-/-)
 Mouth : Oral ulcer (-)
 Neck : Jugular Vein Dystention 5+2 cmH2O
lymph node enlargement (-)
• Lung:
 Inspection : Symmetric
 Palpation : Fremitus normal on the left and right
 Percussion : Sonor in both lung
 Auscultation : bronchovesicular, rhales (+/+), wheezing (-/-)
• Cor: VII
 Inspection : ictus is not seen.
 Palpation : ictus is palpated at 2 finger lateral LMCS ICS VI
 Percussion :
• Left border : 2 finger lateral LMCS ICS VI
• Right border : linea sternalis dextra
• Upper border : ICS II
 Auscultation : regular, murmur (-), gallop (-)
• Abdomen: VII
– Inspection : Scapoid (-)
– Palpation : hepar and lien not palpable
– Percussion : thympani, Shiffting dullness (-)
– Auscultation : bowel sound (+) N

• CVA : flank pain (-/-)

• Extremities :
– Oedema pretibia -/-
– Physiologic Reflex +/+
– Pathologic Reflex -/-
 Laboratory
Items Value VII
Hb : 13,5 gr/dl
Ht : 40 %
WBC : 13.990 /mm3
Platelet : 226.000 /mm3
Diff. Count. : 0/0/85/11/4
RBG : 391 (district hospital)  198 Mg/dl
Ur/Cr : 37/1,1 mg/dL
Na/K/Cl : 131/3,8/97 Mmol/L
Alb/glo : 2,6/3,1 g/dL
ph/pco2/po2/hco3-/be/so : 7,533/21,3/76,2/18,1/-1,6/96,5
HBSAg/ anti HCV : non reaktif/ non reaktif/ non reaktif
Keton Urine (+1)
Chest X-Ray VII
ECG
Problems

• Dyspnea
• Heart failure
• Pneumonia
• Hypoalbumine
• Hyperglycemia
Working Diagnosis

• Ketoacidosis Diabetikum (improvement)

• Heart failure stg C nyha fc II
• Communnity Acquired Pneumonia with hypoxemia
• Hypoalbumin cb low intake
• Uncontrolled DM type 2 normoweight
Differential Diagnosis

• DM with ketosis
 Therapy
• Bed Rest/ Diabetic Diet 1500kcal
• O2 15 lpm via NRM
• IVFD Nacl 0,9% 500 cc/8 hours
• Drip Insulin 50 unit in Nacl 0,9% 50cc via syringe pump, up titration
• Inj. Furosemide 2 x 20mg iv
• Inj. Ceftriaxon 2 x 1 gr iv
• Inf levofloxacin 1 x 750 mg iv
• Asetilsistein 3 x 200mg po
• Concor 1 x 2,5mg po
• Used Folley Catether
• Fluid Balance
Plan

• Check keton urine/ days

• Culture sputume
• Check fasting blood glucose, 2 hours post prandial blood glucose, HbA1C, profile
lipid