Case Report

Supervised by:
dr. Rudy Alex Ticonuwu, Sp.PD, Ph.D

Presented by :
Yohannes Kurniawan Soeparno
2014.061.149

Clerckship of Internal Medicine Department

Saint Antonius Hospital , Pontianak
Period of January 9th 2017 February 4th 2017
PATIENT IDENTITY

Name : Mr. KB
Age: 49 years old
Address : Ds. Melobok , Kab. Sanggau
Religion : Protestan
Occupation : Construction Labor
Admission date : January 29th 2017
Examination date: January 30th 2017
HISTORY
Chief complaint:
Shortness of breath since 1 week ago

Additional complaint:
-Cough with phlegm since 3 weeks prior to admission.
-Fatique and decreased appetite since 3 weeks prior to
admission
-Fever (not measured) since 2 weeks prior to admission
-Swollen Limbs since 1 week prior to admission
HISTORY OF PRESENT
1
ILLNESS
1 Week
Week before
before
admission
admission
(Parindu
(Parindu
3 2
2 weeks hospital) Admissio
3 weeks
weeks weeks hospital) Admissio
before before
before n
n day
day
before Cough
Cough andand fever
fever
admission
admission admission
admission Cough
Cough and
and
still
still present
present fever (+)
fever (+)
Cough
Cough with
with Cough
Cough Fatigue
phlegm, (+).
(+). Fatigue
Fatigue andand Fatigue
phlegm, and
and
green-
green- Fatigue
Fatigue
decreased
decreased appetite
appetite decreased
decreased
yelowish
yelowish and
and worsened.
worsened. appetite
appetite
color, (+)
(+)
color, decreased
decreased Shortness
blood(-) appetite
Shortness ofof breath
breath Shortness
Shortness
blood(-) appetite (no
are (no causes,
causes, notnot of
of breath
breath
Fatigue
Fatigue all
all are still
still getting worsened
over present. getting well
well with
with worsened
over the
the present. any
Swollen
Swollen
body
body without
without Fever
Fever (not
(not
any position
position limbs
limbs
weakness changes)
changes) worsened
weakness in in measured)
measured) worsened
The
limbs. Swollen The post
post
limbs. ,, patient
patient Swollen limbs,
limbs, operation
operation
Decreased
Decreased go
go to
to patient
patient have
have wound
wound still
still
appetite, clinic
clinic and
and present
PAST MEDICAL HISTORY
Admission to Parindu Hospital in Sanggau because of the
shortness of breath 1 week ago, and got nebulizer in the
emergency unit going home
History of type II diabetes since 3 years ago (medication :
metformin 3x500 mg/ daily )
Histrory of Hypertension was denied
History of stroke was denied
History of TBC was denied
He was hospitalized in RSU Antonius around 6 months
ago before readmission, for the wound operation
(debridement) in the right limb
FAMILY HISTORY
There is no same complaints in the
family
No family member has history of type II
diabetes
PHYSICAL EXAMINATION
General condition : moderate ill
Consciousness : conscious, GCS 15
Nutritional status :
Weight : 50 kg
Height : 165 cm
BMI : 18,36 kg/m2 underweight
Vital sign
Blood pressure : 120/70 mmHg
Heart rate : 86 x/minute, reguler, full pulse
Respiratory rate : 24 x/minute, thoracoabdominal type
Temperature: 37,6C
PHYSICAL EXAMINATION
Head : normocephaly, deformity (-),
Eyes : anemic conjunctiva +/+, white sclera +/+,
pupil isochor 3mm/3mm, light reflex +/+
Ears : cerumen -/-, secret -/-, meatus akustikus
eksternus +/+
Nose : the nasal septum bone located in the middle,
crepitation -, secret -/-
Mouth : oral mucosa and lips are moist, tonsil
T1/T1,
PHYSICAL EXAMINATION
Neck: JVP 5 + 1 cmH2O impalpable thyroid,
lymph node is not palpable
Chest
Lung:
I: symmetric chest expansion, no muscle retraction,
P: symmetric chest expansion, symmetric fremitus
tactile on both lung
P: resonant on both lung. Liver dullness on ICS VI linea
midclavicularis sinistra
A: vesicular +/+, ronchi +/-, wheezing -/-
PHYSICAL EXAMINATION
Heart:
I: PMI visible (-)
P: PMI palpable (-) linea midclavicularis sinistra ICS
VI
P:
Upper border : ICS III linea parasternalis sinistra
Left border : ICS VI on linea axilaris anterior sinistra
Right border : Linea parasternalis dextra
A: Regular first and second heart sound, murmur -,
PHYSICAL EXAMINATION

Abdomen:
I: flat abdomen
A: bowel sound (+) 4-5 x/minutes, metallic
sounds -
P: tenderness (-), supple
P: tympani on all quadrant, shifting dullness -
PHYSICAL EXAMINATION
Extremities : warm extremities, CRT <2, edema (-/-/+/
+), motor strength 5/5/5/5, diabetic ulcus pedis dextra
Back :
I: normal vertebra alignment, symmetric movement
(static and dynamic)
P: symmetric, tactile fremitus symmetric
P: resonant +/+
A: vocal fremitus symmetric, vesicular +/+, ronchi +/-,
wheezing -/-,
LABORATORY TEST
CBC
Result Normal Range
(Jan 29th 2016)
Leucocyte 12,500 4,000-11,000 /uL
Erythrocyte 5,200,000/uL 4,500,000-5,500,000/uL
Hemoglobin 9.1 g/dL 13.0-17.5 g/dL
Hematocrit 27.3% 40.0-52.0%
MCV 86.4 fl 80.0-100 fl
MCH 28.8 pg 27.0-33.0 pg
MCHC 33.3 g/dL 31.0-35.0 g/dL
Thrombocyte 425.000/uL 150.000-400.000/uL
LABORATORY TEST

Jan 29th 2016 Result Normal Range

SGOT/AST 105 U/L 0 31 U/L

SGPT/ALT 34 U/L 0 32 U/L
Total Cholesterol 106 mg/dL <220 mg/dL
Trigliseride 110 mg/dL <200 mg/dL
Plasma Glucose 105 mg/dL <200 mg/dL
Ureum 34.2 mg/dL 10 50 mg/dL
Creatinine 0.68 mg/dL 0.5 1.2 mg/dL
THORAX ROENTGEN

There is Infiltrate in the

right perihillar regio

CTR 72%

Conclusion :
Pneumonia dextra
Cardiomegaly
ELECTROCARDIOGRAM
RESUME
Mr. KB, 49 years old present with:
Phlegm cough and fatigue, decreased appetite since 3 weeks prior
to admission.
Fever (not measured) since 2 weeks prior to admission
Shortness of breath and swollen limb since 1 week before
admission

From the physical examination, vital signs normal. Anemic

conjunctiva +/+.Lung and back : ronchi +/-. Cardiomegaly,
Extremities : edema -/-/+/+, diabetic ulcus pedis dextra
From the laboratory examination, there was low Hb, Ht, high
leukocyte. There was cardiomegaly with right pneumonia from
Roentgen. There was nonspecific T wave abnormality from ECG.
ASSESSMENT

Mr. KB, 49 years old with

Community Aquired Pneumonia dextra
CHF NYHA fc. 1 ec diabetic
cardiomyopathy
Type II Diabetes with complication :
Ulcus diabeticum Wagner Grade I
TREATMENT
Hospitalization
Fluid Input=output (restrict water intake)
Low salt and high protein diet 1,2 mg/kgIBW/day with total
calorie 1500 kkal/day
Cefoperazone 2x1gr/daily IV
Metronidazole 3x500 mg/daily IV
Furosemide 2x20 mg/daily IV
Pantoprazole 40 mg/daily IV
Folic Acid 5 mg/daily PO
Azithromycin 1x500 mg/daily PO
Liver Prime 3x daily PO
Check the random plasma Glucose 3 times daily, serum
albumin and sputum gram stain + culture
PROGNOSIS

Prognosis ad vitam : dubia ad bonam

Prognosis ad functionam : dubia ad bonam
Prognosis ad sanationam : dubia ad malam
LITERATURE REVIEW
COMMUNITY ACQUIRED PNEUMONIA
PATHOLOGIC CHANGES
Edema
Red hepatization
Gray hepatization
Resolution
CLINICAL FEATURES
CAP is a lower respiratory tract infection
acquired in the community within 24 hours to
less than 2 weeks.
acute cough
abnormal vital signs of tachypnea (respiratory
rate >20 breaths per minute)
tachycardia (cardiac rate >100/minute)
fever (temperature >37.8C)
with at least one abnormal chest finding of
diminished breath sounds, rhonchi, crackles, or
wheeze.
CLINICAL FEATURES
CLINICAL FEATURES
LAB EXAMS

Chest X-ray
Gram's Stain and Culture of Sputum
Blood Cultures
Antigen Tests
Polymerase Chain Reaction
Serology
TREATMENT
TREATMENT
PREVENTION

Smoking Cessation
American Diabetes Association Guideline 2015

DIABETES
STANDARDS OF MEDICAL CARE
IN DIABETES2015
CRITERIA FOR THE DIAGNOSIS OF
DIABETES
A1C 6.5%
OR
Fasting plasma glucose (FPG)
126 mg/dL (7.0 mmol/L)
OR
2-h plasma glucose 200 mg/dL
(11.1 mmol/L) during an OGTT
OR
A random plasma glucose 200 mg/dL (11.1 mmol/L)

ADA. 2. Classification and Diagnosis. Diabetes Care 2015;38(suppl 1):S9; Table 2.1
Categories of Increased Risk for Diabetes
(Prediabetes)
FPG 100125 mg/dL (5.66.9 mmol/L): IFG
OR
2-h plasma glucose in the 75-g OGTT
140199 mg/dL (7.811.0 mmol/L): IGT
OR
A1C 5.76.4%

ADA. 2. Classification and Diagnosis. Diabetes Care 2015;38(suppl 1):S10; Table 2.3
RECOMMENDATIONS:
MEDICAL NUTRITION THERAPY (MNT)
(1) Nutrition therapy is recommended for all people
with type 1 and type 2 diabetes as an effective
component of the overall treatment plan A
Individuals who have prediabetes or diabetes
should receive individualized MNT as needed to
achieve treatment goals, preferably provided
by a registered dietitian familiar with the
components of diabetes MNT A

ADA. 4. Foundations of Care. Diabetes Care 2015;38(suppl 1):S22

RECOMMENDATIONS: PHYSICAL
ACTIVITY
Adults with diabetes: at least 150 min/wk of moderate-
intensity aerobic activity
(5070% of maximum heart rate),over at least 3
days/wk with no more than 2 consecutive days without
exercise A
Evidence supports that all individuals, including those
with diabetes, should be encouraged to reduce
sedentary time, particularly by breaking up extended
amoungs of time (>90 min) spent sitting B
If not contraindicated, adults with type 2 diabetes
should perform resistance training at least twice
weekly A

ADA. 4. Foundations of Care. Diabetes Care 2015;38(suppl 1):S24

RECOMMENDATIONS:
SMOKING CESSATION
Advise all patients not to smoke or use tobacco
products A
Include smoking cessation counseling and
other forms of treatment as a routine
component of diabetes care B

ADA. 4. Foundations of Care. Diabetes Care 2015;38(suppl 1):S25

PREVENTION/DELAY OF TYPE 2
DIABETES
RECOMMENDATIONS:
PREVENTION/DELAY OF TYPE 2
DIABETES
Refer patients with IGT A, IFG E, or A1C 5.76.4% E to

ongoing support program

Targeting weight loss of 7% of body weight
Increasing physical activity to at least 150 min/week of
moderate activity (eg, walking)
Follow-up counseling appears to be important for
success B
Based on cost-effectiveness of diabetes prevention, such
programs should be covered by third-party payers B

ADA. 5. Prevention/Delay of Type 2 Diabetes. Diabetes Care 2015;38(suppl 1):S31

RECOMMENDATIONS:
PREVENTION/DELAY OF TYPE 2
DIABETES
Consider metformin for prevention of type 2 diabetes if
IGT A, IFG E, or
A1C 5.76.4% E
Especially for those with BMI >35 kg/m 2,
age <60 years, and women with prior GDM A
In those with prediabetes, monitor for development of
diabetes annually E
Screen for and treat modifiable risk factors for CVD B
DSME/DSMS programs are approparite venues for people
with prediabetes to develop and maintain behaviors that
can prevent or delay the onset of diabetes C

ADA. 5. Prevention/Delay of Type 2 Diabetes. Diabetes Care 2015;38(suppl 1):S31

GLYCEMIC TARGETS
RECOMMENDATIONS:
GLYCEMIC GOALS IN ADULTS (1)
Lowering A1C to below or around 7% has been
shown to reduce microvascular complications and,
if implemented soon after the diagnosis of
diabetes, is associated with long-term reduction in
macrovascular disease. Therefore, a reasonable
A1C goal for many nonpregnant adults is <7% B

ADA. 6. Glycemic Targets. Diabetes Care 2015;38(suppl 1):S35

GLYCEMIC RECOMMENDATIONS FOR
NONPREGNANT ADULTS WITH
DIABETES (1)
A1C <7.0%*

Preprandial capillary plasma 80130 mg/dL* (4.47.2

glucose mmol/L)

Peak postprandial capillary <180 mg/dL* (<10.0

plasma glucose mmol/L)

*Goals should be individualized.

Postprandial glucose measurements should be made 12 h after the beginning of the meal, generally
peak levels in patients with diabetes.
ADA. 6. Glycemic Targets. Diabetes Care 2015;38(suppl 1):S37; Table 6.2
GLYCEMIC RECOMMENDATIONS FOR
NONPREGNANT ADULTS WITH
DIABETES (2)
Goals should be individualized based on
Duration of diabetes
Age/life expectancy
Comorbid conditions
Known CVD or advanced microvascular complications
Hypoglycemia unawareness
Individual patient considerations

ADA. 6. Glycemic Targets. Diabetes Care 2015;38(suppl 1):S37; Table 6.2

GLYCEMIC RECOMMENDATIONS FOR
NONPREGNANT ADULTS WITH
DIABETES (3)
More or less stringent glycemic goals may be

appropriate for individual patients

Postprandial glucose may be targeted if A1C
goals are not met despite reaching preprandial
glucose goals

ADA. 6. Glycemic Targets. Diabetes Care 2015;38(suppl 1):S37; Table 6.2

 Update:
Management of Hyperglycemia in
T2DM, 2015
3. ANTI-HYPERGLYCEMIC THERAPY
Therapeutic options: Lifestyle

-Weight optimization Healthy diet

- Increased activity level

Diabetes Care 2012;35:13641379; Diabetologia 2012;55:15771596
 Update:
Management of Hyperglycemia in
3. ANTI-HYPERGLYCEMIC THERAPY
T2DM, 2015

Therapeutic options:
Oral agents & non-insulin injectables
- Metformin - Meglitinides

- Sulfonylureas - -glucosidase
inhibitors
- Thiazolidinediones
- DPP-4 inhibitors
- Colesevelam
- SGLT-2 inhibitors - Dopamine-2
Diabetesagonists
Care 2012;35:13641379; Diabetologia 2012;55:15771596
- GLP-1 receptor agonists Diabetes Care 2015;38:140-149; Diabetologia2015;58:429-442
 Update:
Management of Hyperglycemia in
T2DM, 2015
3. ANTI-HYPERGLYCEMIC THERAPY

Therapeutic options: Insulins

Human Insulins
- Neutral protamine Hagedorn (NPH)
- Regular human insulin
- Pre-mixed formulations
Insulin Analogues
- Basal analogues (glargine, detemir, degludec)
- Rapid analogues (lispro, aspart, glulisine)
Diabetes Care 2012;35:13641379; Diabetologia 2012;55:15771596
- Pre-mixed formulations Diabetes Care 2015;38:140-149; Diabetologia2015;58:429-442
 Update:
Management of Hyperglycemia in
T2DM, 2015
3. ANTI-HYPERGLYCEMIC THERAPY
Therapeutic options: Insulins
Insulin level

Rapid (Lispro, Aspart, Glulisine)

Short (Regular)

Long (Detemir) (Degludec)

Long (Glargine)

0 2 4 6 8 Hours
10 12 14 16 18
20 22 24 Hours after injection
Figure Basal Insulin
3.
(usually with metformin +/-
other non-insulin agent)

Approac Start: 10U/day or 0.1-0.2 U/kg/day

Adjust: 10-15% or 2-4 U once-twice weekly to

h to reach FBG target.

For hypo: Determine & address cause;
dose by 4 units or 10-20%.

starting
& If not

adjustin controlled after

FBG target is reached
(or if dose > 0.5 U/kg/ day),

g treat PPG excursions with

meal-time insulin.
(Consider initial

insulin Add 1 rapid insulin* injections

before largest meal
GLP-1-RA
trial.)
Change to
premixed insulin* twice daily

in T2DM Start: 4U, 0.1 U/kg, or 10% basal dose. If Start: Divide current basal dose into 2/3 AM,
A1c<8%, consider basal by same amount. 1/3 PM or 1/2 AM, 1/2 PM.
Adjust: dose by 1-2 U or 10-15% once- Adjust: dose by 1-2 U or 10-15% once-
twice weekly until SMBG target reached. twice weekly until SMBG target reached.
For hypo: Determine and address cause; For hypo: Determine and address cause;
corresponding dose by 2-4 U or 10-20%. corresponding dose by 2-4 U or 10-20%.

If not If not
controlled, Add 2 rapid insulin* injections controlled,
consider basal- consider basal-
bolus.
before meals ('basal-bolus) bolus.
Start: 4U, 0.1 U/kg, or 10% basal dose/meal. If
A1c<8%, consider basal by same amount.
Adjust: dose by 1-2 U or 10-15% once-twice
weekly to achieve SMBG target.
For hypo: Determine and address cause;
corresponding dose by 2-4 U or 10-20%.

Diabetes Care 2015;38:140-149;

Diabetologia 2015;58:429-442