CASE REPORT

DIABETES MELLITUS AND

DYSPEPSIA
Perceptors : dr. Hj. Ihsanil Husna, SP.PD
By : Jihanita Diansabila (2015730066)

Medical Profession Programme Department of Internal Medicine

Faculty of Medicine University of Muhammadiyah Jakarta - Jakarta Islamic Hospital Cempaka Putih
PATIENT STATUS
 PATIENT’S
3 IDENTITTY
▹ Name : Mrs. S
▹ Age : 62 years old
▹ Address : Pamendangan, North Jakarta
▹ Marital Status : Married
▹ Religion : Islam
▹ Race : Betawi
▹ Medical Record : 0047xxxx
▹ Date of Admission : February, 18 2020
▹ Date of Examination : February, 20 2020
4 ANAMNESIS
CHIEF COMPLAINT :
Nausea and vomiting since 1 day before being admitted to the hospital.

ANOTHER COMPLAINT :
Fatigue
5 ANAMNESIS
HISTORY OF PRESENT ILLNESS:

The patient complained of nausea and vomiting since 1 day before being admitted
to the hospital. Patient threw up 3 times/day. Patient got an intermittent epigastric
pain since 2 months ago. Patients felt so weak 3 days before he came to the hospital.
It happened to the whole body after doing the activity, and continuously heavier day
by day, and it showed impairment daily activities. Patient said that he has a history
of heart disease and diabetes mellitus. Flu and cough are denied. No complaint
during defecate.
6 ANAMNESIS
HISTORY OF PAST ILLNESS :

▹ History of type 2 diabetes mellitus since 5 years ago

▹ History of heart disease since 5 years ago

HISTORY OF FAMILY : No histroy of same complaint.

HISTORY OF ALERGY : No history of drugs, foods, or climate allergic.

7 ANAMNESIS
HISTORY OF TREATMENT:
▹ Medication for heart disease
▹ Metformin 500 mg tab

HABBITS :
▹ Patient smoker active 5 years ago, but not alcoholism, or drug abuse.
8 PHYSICAL EXAMINATION
General Status Moderate Ill
GCS Composmentis (E4 M6 V5)
Antropometric Weight : 50 kg, Height 158 cm, BMI : 22 (Normoweight)
Blood Pressure 120 / 70 mmHg
Heart Rate 90 x/minutes
Respiratory Rate 20 x/minutes
Temperature 36,6 °C
 GENERAL PHYSICAL
9 EXAMINATION
Head Normocephal
Eye Anemic Conjungtiva (-/-), Icteric Sclera (-/-), Light reflex (+/+)
Nose Normonasi (+), Secret (-/-), Epistaksis (-/-), Hyperemic Mucosa
(-/-)
Ear Normotia, Secret (-/-)
Mouth Oral mucose moist, Cyanosis (-), Coated Tongue (-)
Neck Lymph node enlargement (-), Tyroid enlargment (-), increase JVP
(-)
 STATUS
10 GENERALISATA
Thorax
Pulmo I : Normochest (+), chest move symmetrically (+/+)
P : Same vocal fremitus in dextra and sinistra
P : Sonor (+/+)
A : Vesicular breath sounds (+/+), Ronkhi (-/-), Wheezing (- / -)
Cor I : Ictus cordis not seen on ICS V LMCS
P : Ictus cordis not palpable on ICS V LMCS
P : Right heart margin: Sternalis line sinistra ICS-V
Left heart margin : Midclavicular line sinistra ICS -V
A : Regular 1st & 2nd heart sound (+), Murmur (-), Gallop (-)
 STATUS
11 GENERALISATA
Abdominal I : Flat, scar (-), distensi (-), darm contour (-) darm steifung (-)
A : Bowel Sound (+)
P : Suprapubic pain (+), Epigastric Pain (-), Organomegaly (-),
Skin turgor (+)
P : Bladder percusion : dull. Other region are tympanic.
Extermities Superior : Edema (-/-), Cyanosis (-/-), Warm acral (+/+), CRT <2
seconds (+/+)
Inferior : Edema (-/-), Cyanosis (-/-), Warm acral (+/+), CRT <2
seconds (+/+)
 LABORATORY
FINDINGS Tuesday, February 18 2020
12 EXAMINATION VALUE UNITS NORMAL

Hematology
Hemoglobin 12,6 g/dL 13,2 – 17,3

Hematocrit 35 % 40 – 52
3
Leukocyte 12,11 10 /uL 3.8 – 10,6
3
Thrombocyte 164 10 /µl 150 – 440
6
Erythrocytes 4,34 10 /µl 4,4 – 5,9

MCV 81 Fl 80-100

MCH 29 Pg 26-34

MCHC 36 g/dl 32-36

Kidney Function

Creatinine 4,4 mg/dL <1,4

Electrolytes

Sodium (Na) 127 mEq/L 135-147

Potassium (K) 3,8 mEq/L 3,5-5,0

Chloride (Cl) 96 mEq/L 94-111

Diabetes

Blood Glucose 236 mg/dL 70-200

 LABORATORY
FINDINGS
13
Laboratory Findings : 19/02/2020
- Blood Glucose 165 mg/dL (06.00)
- Blood Glucose 143 mg/dL (11.00)
- Blood Glucose 257 (17.00)

Laboratory Findings : 20/02/2020

- Blood Glucose 222 mg/dL (11.00)
- Blood Glucose 180 mg/dL (17.00)
14 RESUME
▹ Mr. S, 62 years old, The patient complained of nausea and vomiting since 1 day
before being admitted to the hospital. Patient threw up 3 times/day. Patients felt so
weak 3 days before he came to the hospital. It happened to the whole body after
doing the activity, and continuously heavier day by day, and it showed impairment
daily activities. Patient said that he has a history of heart disease and diabetes
mellitus. The patient is under treatment of heart disease and diabetes mellitus.

Physical Examination :
▹ Moderate ill
Laboratory Findings :
▹ Composmentis (GCS : 15) • Hematocrite : 35 (L)
▹ Epigastric pain (+) • Leucocyte : 12,11 (H)
Vital Sign : • Creatinin : 4,4 (H)
▹ Blood Pressure : 120/70 mmHg • Na : 127 (L)
▹ Heart Rate : 90 x/minute • Blood Glucose : 236 (H)
▹ Respiratory Rate : 20 x/minute
▹ Temperature : 36,6 °C
 PROBLEM
15 LIST
▹ Malaise

▹ Nausea

▹ Vomitus

▹ Leucocytosis

▹ Hyperglicemia
 ASSESSEME
NT
16 Nausea + vomitus + malaise + ASSESMENT :
▹
leukocytosis e.c Dyspepsia dd/ Nausea + vomitus + malaise + leukocytosis e.c
Dyspepsia dd/ Gastritis
Gastritis PLANNING :
SUBJECTIVE : Diagnostic
▹ The patient complained of nausea and vomiting since 1 day ▹ Urea Breath Test
before being admitted to the hospital.
▹ Oesophago-Gastro-Duodenoscopy (OGD).
OBJECTIVE :
▹
Planning Non Therapeutics
Vital Sign: BP: 120/70 mmHg, HR:90x/minute,
RR:20x/minute, Temperature: 36,6°C. ▹ Offer simple lifestyle advice, including advice on
▹ Physical Examination : Epigastric pain (+) healthy eating, weight reduction and smoking
cessation, alcohol, coffee, chocolate, fatty foods and
▹ Laboratory Findings : 18/02/20
being overweight. Raising the head of the bed and
▹ Hematocrite 35% having a main meal well before going to bed.
▹ Leukocyte 12,11 103/uL Planning Therapeutics
▹ Creatinine 4,4 mg/dL Sodium ▹ IVFD RL 500 cc / 8 hours
▹ (Na) 127 mEq/L ▹ Lansoprazole 30 mg / day
▹ Blood Glucose 236 mg/dL ▹ Ranitidin inj 1 amp
 ASSESSEME
NT
17 Hyperglicemia + malaise e.c Type 19/02/2020

2 Diabetes Mellitus ▹ Blood Glucose 165 mg/dL (06.00)

SUBJECTIVE :
▹ Blood Glucose 143 mg/dL (11.00)
▹ Patients also complained of weakness since 3 days before ▹ Blood Glucose 257 (17.00)
entered the hospital. It happened the whole body after doing 20/02/2020
the activity, and continuously heavier day by day, and it
showed impairment daily activities. ▹ Blood Glucose 222 mg/dL (11.00)
OBJECTIVE : ▹ Blood Glucose 180 mg/dL (17.00)
▹ Vital Sign: BP: 120/70 mmHg, HR:90x/minute, ASSESMENT :
RR:20x/minute, Temperature: 36,6°C.
▹ Hyperglicemia + malaise e.c type 2 diabetes mellitus
▹ Physical Examination : Epigastric pain (+)
▹ Laboratory Findings : 18/02/20 PLANNING :
▹ Hematocrite 35% Diagnostic FPG & HbA1c
▹ Leukocyte 12,11 103/uL Planning Non Therapeutics
▹ Creatinine 4,4 mg/dL Sodium ▹ Nutrition, Physical activity, tobacco use.
▹ (Na) 127 mEq/L Planning Therapeutics
▹ Blood Glucose 236 mg/dL ▹ Acarbose 30 mg tab
 FOLLOW-UP
Tuesday, February 18 2020
S Nausea and vomit. Patient felt weakness the whole body. History of type 2 diabetes
mellitus and heart disease.
18 O Vital Sign
BP : 100/70 mmHg
HR : 78 times/min
RR : 20 times/min
T : 36.7 °C
Physical Examination : Epigastric pain (+)
Laboratory Findings : 18/02/2020
- Hematocrite 35%
- Leukocyte 12,11 103/uL
- Creatinine 4,4 mg/dL Sodium
- (Na) 127 mEq/L
- Blood Glucose 236 mg/dL
A Type 2 Diabetes Mellitus and Dyspepsi
P Diagnostic
- Fasting blood glucose
- UBT
Non-therapeutic
- Lifestyle changing
Therapeutic
- IVFD RL 500 cc / 8 hours
- Ranitidine inj 1 amp
- Sucralfat 500 mg syr po 2x1
- Continue Type 2 Diabetes Mellitus therapy
 FOLLOW-UP
Wednesday, February 19 2020
S Nausea and vomit less than yesterday. No more weakness. History of type 2
diabetes mellitus and heart disease.
19 O Vital Sign
BP : 130/80 mmHg
HR : 80 times/min
RR : 20 times/min
T : 36.7 °C
Physical Examination : Epigastric pain (+)
Laboratory Findings : 19/02/2020
- Blood Glucose 165 mg/dL (06.00)
- Blood Glucose 143 mg/dL (11.00)
- Blood Glucose 257 (17.00)
A Type 2 Diabetes Mellitus and Dyspepsi
P Diagnostic
- Fasting blood glucose
- UBT
Non-therapeutic
- Lifestyle changing
Therapeutic
- IVFD RL 500 cc / 8 hours
- Sucralfat 500 mg syr po 2x1
- Continue Type 2 Diabetes Mellitus therapy
 FOLLOW-UP
Thursday, February 20 2020
S Nausea and vomit less than yesterday. No more weakness. History of type 2
diabetes mellitus and heart disease.
20 O Vital Sign
BP : 120/80 mmHg
HR : 75 times/min
RR : 20 times/min
T : 36.7 °C
Physical Examination : Epigastric pain (+)
Laboratory Findings : 19/02/2020
- Blood Glucose 222 mg/dL (11.00)
- Blood Glucose 180 mg/dL (17.00)
A Type 2 Diabetes Mellitus and Dyspepsi
P Diagnostic
- Fasting blood glucose
- UBT
Non-therapeutic
- Lifestyle changing
Therapeutic
- IVFD RL 500 cc / 8 hours
- Sucralfat 500 mg syr po 2x1
- Continue Type 2 Diabetes Mellitus therapy
 FOLLOW-UP
Thursday, February 21 2020
S Nausea and vomit (-). No more weakness. History of type 2 diabetes mellitus and
21 heart disease.
O Vital Sign
BP : 120/80 mmHg
HR : 88 times/min
RR : 20 times/min
T : 36.7 °C
Physical Examination : Epigastric pain (-)
A Type 2 Diabetes Mellitus and Dyspepsi
P Diagnostic
- Fasting blood glucose
- UBT
Non-therapeutic
- Lifestyle changing
Therapeutic
- IVFD RL 500 cc / 8 hours
- Sucralfat 500 mg syr po 2x1
- Continue Type 2 Diabetes Mellitus therapy
 CASE ANALYSIS

22
 THEORY CASE
- Type 2 diabetes (due to aprogressive loss of - Patients had history of Type 2 Diabetes
23 b-cell insulin secretion frequently on the Mellitus.
background of insulin resistance)
- Diagnostic test with - RPG Patients 236 mg/dL.
- RPG > 200 mg/dL
- FPG >126 mg/dL
- TTGO >200 mg/dL
- Risk Factors : - Patients was smoker 5 years ago.
- Obesity (especially abdominal or
visceralobesity),
- dyslipidemia with high triglycerides and/or
low HDL cholesterol,
- hypertension,
- smoker.
- Clinical Manifestation - Patients felt so weak 3 days before he came
- polidipsi to the hospital.
- polifagi
- poliuri
- Fatigue
 THEORY
- Dyspepsia is any symptom of the upper
24 gastrointestinal tract (GI), present for 4
weeks or more, including upper abdominal
pain or discomfort, heartburn, acid reflux,
nausea, or vomiting.
- More often prescribed in older people
- The following features increase the
likelihood of significant organic disease:
- family history of gastric cancer (onset age
<50 years)
- severe or persistent dyspeptic symptoms
- previous peptic ulcer disease, particularly if
CASE
- Patient got an intermittent epigastric pain
since 2 months ago.
- Patients 62 years old
- The patient complained of nausea and
vomiting since 1 day before being admitted
to the hospital.
- Patient threw up 3 times/day.

complicated
- ingestion of NSAIDs, particularly in those
at
risk
- unexplained weight loss
- GI bleeding, anaemia
- dysphagia (difficulty swallowing)
- protracted vomiting
- palpable abdominal mass.
 LITERATURE
REVIEW DIABETES
MELLITUS

25
 26 DIABETES MELLITUS
▹ Diabetes can be classified into the following general categories:
⬩ Type 1 diabetes (due to autoimmune b-cell destruction, usually leading to
absolute insulin deficiency)
⬩ Type 2 diabetes (due to aprogressive loss of b-cell insulin secretion frequently
on the background of insulin resistance)
⬩ Gestational diabetes mellitus (GDM) (diabetes diagnosed in the second or third
trimester of pregnancy that was not clearly overt diabetes prior to gestation)
⬩ Specific types of diabetes due to other causes, e.g., monogenic diabetes
syndromes (such as neonatal diabetes and maturity-onset diabetes of the young
[MODY]), diseases of the exocrine pancreas (such as cystic fibrosis and
pancreatitis), and drug or chemical-induced diabetes (such as with
glucocorticoid use, in the treatment of HIV/AIDS, or after organ
According transplantation)
to American
Diabetes
Association
2019
 compensation Hyperosmolarity Filtration of
Damage in vascular glucose in kidney
insulin’s receptor
27 Low secretion
of insulin
glucagon
Hyper
Glukoseuria
glycemic
Low insulin is
produced

Gluconeogenesis Diuresis osmotic

Glycolysis

Polyuria
As the receptor damaged, Cell B pancreas for More
pancreas works intensively production of insulin compensation hyperglycemic

Low fluid
Poly
Hyper Shock and
dipsia
trophy electrolyte

Atrophy Dehydration
1. Infarct myocardia
2. Stroke Micro vascular
3. gangrene
Hemoconcentr
Atherosclerosis Thrombosis
1. Retinopathies diabetic ation
2. Neuropathy Macro vaskular
3. gastropathy
 Damage in Fatigue
insulin’s receptor
28 Low secretion
of insulin
glucagon
Hyper
glycemic ATP
Low insulin is
produced

Gluconeogenesis
Glycolysis

As the receptor damaged, Cell B pancreas for More Lypolisis

pancreas works intensively production of insulin compensation hyperglycemic

Hyper FFA
trophy

Atrophy Ketonemia

Nausea &
Asidosis pH
fatigue
 29 DIABETES MELLITUS

According
to American
Diabetes
Association
2019
 30 DIABETES MELLITUS

According to
American Diabetes
Associatio 2019
 31 DIABETES MELLITUS

According to
PerkumpuIan
Endokrinologi
Indonesia 2015
According
to American
Diabetes
Association
2019
According
to American
Diabetes
Association
2019
 34

According
to American
Diabetes
Association
2019
 35

According
to American
Diabetes
Association
2019
According
to American
Diabetes
Association
2019
 37

According
to American
Diabetes
Association
2019
 INSULIN THERAPY
Hitung Insulin Harian (IHT)
38 = 0,5 U x BB (kg)
Contoh BB 60 kg
0,5 x 60 kg = 30 U

Insulin Prandial Total (IPT) Insulin Basal Total (IBT)

Rumus 60% IHT Rumus 40% IHT
60% x 30 = 18 U 40% x 30 = 12 U

Dosis makan Dosis makan Dosis makan Dosis sebelum tidur = IBT
pagi 1/3 IPT siang 1/3 IPT malam 1/3 IPT 40% x 30 U = 12 U
1/3 x 18 U = 1/3 x 18 U = 1/3 x 18 U =
6U 6U 6U

According to “Perkumpulan Endokrinologi Indonesia” 2011

 COMPLICATION OF DIABETES
MELLITUS
39

- According to
ADA 2019
- According to
National Institute of
Diabetes and Digestive
and Kidney Diseases.
Practice transformation
for physicians & health
care teams.
 LITERATURE
REVIEW DYSPEPSIA

40
 41 DYSPEPSIA

Dyspepsia is any symptom of the upper gastrointestinal tract (GI), present for 4 weeks or more,
including :

▹ upper abdominal pain or discomfort,

DYSPEPSI
▹ heartburn,
A
▹ acid reflux,

▹ nausea, or vomiting.
Organic
Functional
Disorders

According to Guideline Management of Dyspepsia & Heartburn

According to Guideline Dyspepsia and GORD
 42 DYSPEPSIA

The organic disorders dyspepsia, caused by : (diagnosed by OesophagoGastroDuodenoscopy)

1. Oesophagitis

2. Duodenitis

3. Gastric ulcer

4. Duodenal ulcer

5. Cancer stomach & oesophagus

According to Guideline Management of Dyspepsia & Heartburn

According to Guideline Dyspepsia and GORD
 43 DYSPEPSIA

Functional dyspepsia has been defined as

dyspepsia of at least several weeks duration
for which no focal or structural lesion can be
found using OGD, and which cannot be
explained by any other obvious structural or
biochemical abnormality on screening blood
tests or abdominal ultrasound examination
where appropriate

According to Guideline Management of Dyspepsia & Heartburn

According to Guideline Dyspepsia and GORD
 44
Classification
Functional
Gastrointestinal
Disorders
(Roma IV)

- According to Guideline
Management of Dyspepsia
& Heartburn
- According to Guideline
Dyspepsia and GORD
 45
Classification
Functional
Gastrointestinal
Disorders
(Roma IV)

- According to Guideline
Management of Dyspepsia
& Heartburn
- According to Guideline
Dyspepsia and GORD
 46

- According to Guideline
Management of Dyspepsia
& Heartburn
- According to Guideline
Dyspepsia and GORD
 47 DYSPEPSIA

Diagnostic test :

- Oesophago-Gastro-Duodenoscopy
TREATMENT
(OGD).

- UBT (Urea Breath Test).

- Barium Meal Examination.

PPI Sucralfat

H2RAS Antasida

According to Guideline Management of Dyspepsia & Heartburn

According to Guideline Dyspepsia and GORD
 48 DYSPEPSIA

Diagnostic test :

- Urea Breath Test (UBT)

- Oesophago-Gastro-Duodenoscopy (OGD).

- According to Guideline
Management of Dyspepsia
& Heartburn
- According to Guideline
Dyspepsia and GORD
 49 DYSPEPSIA

- According to Guideline
Management of Dyspepsia
& Heartburn
- According to Guideline
Dyspepsia and GORD
50

THANKYO
U
Any Question?