Case Report Session (CRS)

DIABETIC ULCUS PEDIS SINISTRA

Maulina Analita, S.Ked

Advisor:
dr. Amran Sinaga, Sp.B
 introduce

Diabetes Mellitus (DM) is often called the great imitator because this disease can af-
fect all organs of the body such as the brain (stroke), kidneys (kidney failure), heart,
eyes, and feet (diabetic gangrene).

According to the records of (WHO), in 1996 in the world there were

120 million people with diabetes mellitus which is estimated to
double by 2025.

One of the most common complications of diabetes mellitus is dia-

betic foot, which can manifest as ulcers, infections, gangrene, and
Charcot arthropathy.
PATIENT IDENTITY
Name : Mrs.W
Age : 50 Years 
Gender : women
Address : Tanjung Jabung Barat
Nation : Indonesia
Enter the hospital : the 12th of July 2022
MAIN COMPLAINT

Pain in the wound on the left

leg since 1 day SMRS
 HISTORY OF NOW DISEASE

The patient came with complaints of pain in the wound on the

left leg since 1 day of SMRS. The pain is felt continuously and
feels like a stabbing. The patient also complained that the wound
also felt hot and pus came out of the wound. The patient can
still feel touch on the left foot, but often feels numbness in the
sole of the foot. The patient has a history of diabetes since
approximately 5 years ago and routinely uses novorapid insulin
at a dose of 3x12 units. Fever (-), nausea (-), vomiting (-), bowel
and bladder as usual
 History of similar complaints (-) • History of similar com- • Patient is BPJS class III
History of diabetes mellitus (+)
• History of hypertension (-) plaints (-)
• History of diabetes melli-
tus (-)
• History of hypertension (-)

PAST MEDICAL FAMILY HISTORY OF

SOCIOECONOMIC
HISTORY DISEASE
 PHYSICAL EXAMINATION

General condition: Moderate pain

Awareness : Compos mentis (E4M6V5)
Blood pressure : 130/70 mmHg
Pluse : 100 time per minute
RR : 20 time per minute
Temperature : 36,5 ºC
SpO2 : 99 %
 Generalized status
Head : nose
Form : symmetrical, • Deviation septum (-)
normocephal • Epistaxis (-)
Ear : • Rhinorrhea (-)
Tragus tenderness (-) eye
Otorrhoea (-) • Konjungtiva anemis (-/-)
Mouth : • Sklera ikterik (-/-)
Dry lips (-), pale (-), cyanosis (-) • Light Refleks (+/+)

Neck :
Enlargement KGB (-)
Heart
Inspection: IC nokseen
Palpation: IC palpable at ICS IV
Pulmo linea midclavicular sinistra
Inspection: symmetrical Right and left
Percussion: L imitheart DBN
Palpation:Right tactile fremitus is the same as left
Percussion : Sonors whole lung field Auscultation: heart sound I/II
Auscultation: Vesicular(+/+),rh (-/-),wh(-/-) regular, murmurs (-),gallops (-)
Abdomen
inspection: Symmetrical, surgical scars (-), scar in
inguinal regio (-), groin lump in inguinal regio
Auscultation : Bowel noise (+)
Palpation: tenderness (+)
liver : not palpable, hepatomegaly (-)
 Lien: not palpable
 Kidneys: not palpable Extremities :
Percussion : tympani Superior
Dextra:Warm acral, CRT < 2 seconds, edema (-)
Sinistra  :Warm acral, CRT < 2 seconds, edema (-)
Inferior
Dextra:Warm Akral, CRT < 2 seconds 
Sinistra : Warm accral, CRT < 2 seconds,edema(-)
 Supporting investigasion
result Reference value
Hematologi
Hemoglobin 10,6 g/dL 13,4 – 15,5
Hematokrit 31,5 % 34,5 - 54
Eritrosit 3,96 10^6/uL 12,9 – 14.2
Trombosit 461 10^3/uL 150 – 450
Leukosit 12,0 10^3/uL 4,0 – 10,0
GDS 280 Mg/dl <200
Elektrolit
Natrium (Na) 129,3 mmol/L 135 – 148
Kalium (K) 4,58 mmol/L 3,5 – 5,3
Chlorida (Cl) 94,1 mmol/L 98 – 110
Kalsium (Ka) 1,19 mmol/L 1,10-1,35
Ur 24 Mg/dl 15-39
Kr 0,77 Mg/dl 0,55-1,3
HbA1C 8,1 % <6,5
 TREAT
Physical Ex- history
amination
Non Farmakologi
1. Bed Rest
2. Wound Toilet
Supporting
investigasion Farmakologis:
1. IVFD NaCl 0,9 % 20 tpm
2. Inj Ceftriaxone 1x2gr
3. Inj Metronidazole 3x500mg
4. Inj Ketorolac 3x1
5. Inj Ranitidin 2x1
6. Inj Novorapid 3x12 IU
7. Inj Lontus 1x8 IU
Diagnosis: 8. Transfusi PRC 2 kantong
9. Pro Debridement
Ulkus Diabetikum Pedis Sinistra
-
Literatur review
 Diabetic ulcers

• Diabetic ulcers are open sores on the surface of

the skin due to macroangiopathic complications
DEFINITIO resulting in vascular insufficiency and neuropa-
thy, furthermore, there are wounds in patients
N that are often not felt, and can develop into in-
fections caused by aerobic and anaerobic bacte-
ria.
 EPIDEMIOLOGIC

At Cipto Mangunkusumo In 1 year post-amputation

The prevalence of ulcers
General Hospital, Jakarta, 14.8% died and increased
in the population ranges
the amputation rate is still by 37% at 3-year follow-
from 2-10%,
very high, at 23%. up
 Etiologi SOP
polymicrobial with Staphylo
coccus and Streptococcus
being the most dominant
bacteria causing infection.
CLASSIFICATION
CLASSIFICATION
PATHOPHYSIOLOGY
CLINICAL MANIFESTATION

1. The foot diminished sensation

2. It invariably warm, with intact often
bounding pulses
3. Ulcers
4. Ulcer often preceded by callus formation
5. Ulcer can be secondarily infected
6. Quicly lead to cellulitis, abscess formation
and osteomyelitis
 Supporting investigation
1., ankle-brachial index (ABI)
 Supporting investigation
2. Radiiologis
•transcutaneous oxygen tension (TcP02),
•USG color Doppler
•digital subtraction angiography (DSA),
•magnetic resonance angiography (MRA)
•computed tomography angiography (CTA).
 Supporting investigation
3. Laboratory
Routine blood tests show an increased leukocyte count
when infection occurs. Fasting blood sugar and 2 hours
PP should be checked to determine the level of sugar in
fat. Kidney function, liver function, electrolytes
 Treatment

Diabetic
Metabolic
ulcer
control
management
 Metabolic Control
Non-pharmacological therapy

• Systemic medical management of diabetes.

Pharmacological therapy

1) Sulfonylureas
2) Glinide
3) Thiazolidinediones
4) Glucosidase Inhibitors
5) Biguanid
• 6) Combination drugs from the above groups
 Diabetic Ulcer Management
Debridement

• attempts to remove foreign bodies and necrotic tissue from the wound
• There are several options for debridement, namely: mechanical, enzy-
matic, autolytic, biologic debridement

Wound Management

• the moist wound healing method or keeping the wound moist

Infection Control

• Administration of antibiotics is based on the results of bacterial culture

 Diabetic Ulcer Management
Skin Graft

• A wound closure procedure in which skin is removed

from the donor site and transferred to the recipient
site.
• There are two types of skin grafts, namely full thick-
ness and split thickness

Amputation
Complication
 Analysis
After taking the history and physical examination to confirm the
diagnosis, supporting examinations were carried out in the form
of a laboratory, chest radiographs and left pedis.
The results of laboratory examinations showed the presence of
leukocytosis, anemia, and hyperglycemia.
This identifies that there is an infectious process in the patient
which is most likely due to the patient's high glucose level. On
the left pedis photo, osteomyelitis is found
From this history, several important things were obtained that
lead to Diabetic Ulcers on the left foot, namely there was a
wound on the left leg that felt painful and hot. In addition, the
patient also has a history of diabetes mellitus since 5 years and
regularly uses insulin.

The results of this history are supported by the results of a phys-

ical examination, namely there is a wound on the left leg with a
size of 10cmx7cmx5cm. Pus (+), blood (+). The patient still feels
touch on both feet.
 Diabetic ulcers are open sores on the surface of the skin due to
macroangiopathic complications resulting in vascular insufficiency
and neuropathy, furthermore, there are wounds in patients that
are often not felt, and can develop into infections caused by
aerobic and anaerobic bacteria.
Diabetic foot is a disorder of the lower limbs which is a chronic
complication of diabetes mellitus. A disease in diabetics of the
feet, with the following signs and symptoms: Frequent tingling/
grinding (asmiptomatus), The distance appears to be shorter
(intermil claudication), Pain at rest and Tissue damage (necrosis/
ulcer).
The definitive treatment in this case is debridement with the aim
of removing dead cells and cleaning the wound so that the heal-
ing process can occur and be better.
In addition, supportive drugs are also given to help the healing
process. In this case, Ceftriaxone 1x2gr Inj, Metronidazole
3x500mg inj (as an antibiotic against the infection process), Ke-
torolac 3x1 inj (relieves pain symptoms in the patient), Ranitidine
inj 2x1, Novorapid inj 3x12 IU and Lontus inj 1x8 IU (lowers
blood glucose levels) patient)
 Conclution
Diabetic ulcers are the 2nd most common combined atherosclerosis after
coronary artery atherosclerosis and those affected by lower leg blood
vessels.

Diabetic ulcers are the 2nd most common combined atherosclerosis after
coronary artery atherosclerosis and those affected by lower leg blood
vessels.

Clinicians must perform foot examinations which in a diabetic must be

integrated at every visit periodically. In addition, simple advice is needed
for people with diabetes mellitus for foot care.
Thanks