INTERESTING CASE

FRIDAY, AGUSTUS 2ND

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

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 urine
1 days BA : Abdominal pain getting worse, nausea, no vomit,
no fever, iritable, can not sleep
RS 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 11
Urinalysis: 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 persisted
No fever
Prefer to sleep, lying in right side.
GDS: 379
Dx: Diabetic Ketoacidosis
Tx: 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 Ketoacidosis
Type 1 Diabetes Mellitus
Severe 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

CBC
Hemoglobin (g/dL)
Hematokrit (%)
Jumlah leukosit (/L)
Hitung jenis leukosit
Netrofil (%)
Limfosit (%)
Monosit (%)
Eosinofil (%)
Basofil (%)
Jumlah trombosit (/L)

Result
15,6
46,3
20800

Normal value
11,5-15,5
35,0-45,0
4500-11.000

93,4
3,7
2
0,5
0,4
312000

54,0-62,0
25,0-33,0
3,0-7,0
1,0-3,0
0-0,75
150000-450000

Natrium
Kalium
Clorida
Glucose

16.49
126
3,7
99
259

23.47
127
6,5
102

Nilai rujukan
137 - 145 mmol/L
3,4 - 5,4 mmol/L
94 - 108 mmol/L
74-140 mg/dL

Urinalyis
Glu
Pro
Bil
pH
Blood
Keton
Nit
Leu est
BJ
Lp
lg
eri
Granuler cylinder

Result
+4
+2
5,5
+2
+3
1,020
0-1
1-2
4-5
+

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 PLANNING
Patient
s Need
Diabetic
DKA
ketoacidosi resolve
s

N
o
1

Problem

Hypertensi
on

Normal
BP

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

Supv
sign

INTEGRATED PLANNING
N
o

Problem

Patients
Need

Etiology of
Nephritis
(nephropathy
diabeticum
dd.
Pyelonephriti
s)
Hyperglycemi
a

-Confirrmed Check UCT/CCT/Esbach

etiology
-Therapy
Ampicilin inj 100
mg/kg/day

Cerebral

Prevention

Controlled
GAR

Plan

Diet management
Maintenance insulin with
mixed insulin (70/30)
Fluid,glucose &

Sup
vsig
n

INTEGRATED PLANNING
No

Problem

Patient Plan
s Need

Electrolyte
imbalance
(hyponatremia,
hyperkalemia)

Normal
sodium
and
potassiu
m level
Normal
BP

Hypertension

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

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

Sup
vsig
n

Monitoring in the ward

Time
00.30

01.30
02.30
03.30
04.30

HR

R BP
R
132 38 130/
80
126 34

Sign of Shock

GAR

Warm acral, strong 281

pulse, CRT< 2

Warm acral, strong

pulse, CRT< 2
126 34 160/ Warm acral, strong 224
100 pulse, CRT< 2
124 36
Warm acral, strong
pulse, CRT< 2
120 38 150/ Warm acral, strong 232
100 pulse, CRT< 2

Blood Gas Analysis

pH
pO2
pCO2
BE
HCO3

16.49
7,043
154,2
11
-26,3
3,3

23.47
7,106
50,6
14
-22,9
4,3

04.07
7,183
56,6
13,1
-20
4,8

CONDITION THIS MORNING

S : No fever,
O : E1V2M, Kussmaul type respiration
VS : HR 120 RR 38 BP 150/100
Diuresis 4,5, BC-346
Natrium 135 K4,0 Cl 105
Ass : Diabetic Ketoacidosis
Type 1 Diabetes Mellitus
Severe Metabolic Acidosis
Cerebral oedema susp
Nephritis susp ec Nephropathy Diabeticum dd Pyelonephritis
Stage 2 hypetension
Plan : Continue plan

THANK YOU