CHAPTER III

CASE REPORT
Name

: LJ

Age

: 7 years 5 months

Sex

: Female

RM

: 00.65.50.90

Date of Admission

: 25 October 2015

Chief Complain

: loss of consciousness

History

LJ was referred to Haji Adam Malik General Hospital from Pringadi General
Hospital. Patient came in the state of unconscious which has been experienced by
patient for the past 5 days. Fever (-), seizure (-). Breathlessness has been
experienced by patient around 5 days before entering Haji Adam Malik General
Hospital. Breathlessness is not affected by whether and daily activity. According
to the information given by the patients parents, patient had an increased appetite,
but there was no increase in patients body weight, instead there was a decrease in
her body weight from 15kg to 14kg in a month. Besides, patient also had history
of polyuria with the frequency of urination more than 10 times per day in a month.
History of vomiting, cold, and cough was not found.
History of Previous position
The patient was referred from RSUP Pringadi with the diagnosis of ketoacidosis.
Birth history: RZ was the third boy. Birth spontaneously, helped by tocologist,
cried hard. Cyanosis (-), birth weight: 3.0 kg.
Pregnancy history: mother age 31 years old, medical history (-), drug exposure (-),
herb exposure (-).
Feeding History:
From birth to 6 months

: Breast feeding only

11

History of Growth and Development

Turning

: 6 bulan

Sitting

: 7 months

Crawling

: 8 months

Standing

: 10 months

Walking

: 15 months

Medical History: Patient was referred from RSU Pringadi with diagnosis of
ketoacidosis
Drug use history: Humulin R, Ceftriaxone injection 750 mg/12 hours
Physical Examination:
Generalized Status:
Body weight: 14 kg
Body length: 118 cm
Body weight according to age: ( Z Score <-3 SD)
Body length according to age: (-2 < Z score < 0)
Body weight according to body length: ( Z Score <-3 SD)
BMI according to age: (Z Score <-3 SD)
Head Circumference: 48 cm (15th-50th percentile)
Presence status:
Consciousness: loss of consciousness
Heart Rate: 106 x/i regular
Respiratory Rate: 28x/i regular
Body Temperature: 36,5C
Anemic (+), icteric (-), cyanosis (-), edema (-), dyspnea (+),
Localized Status

Head: light reflexes (+/+), pupil isochoric, inferior conjuctiva pale (+/+),
icteric sclera (-/-), face edema (-), inferior and superior palpebrae edema
(-), Ear/ Nose/ Mouth: within normal limit/ O2 nasal canula/ within normal

limit, bleeding gums (-)

Thorax: symmetrical fusiformis, chest retraction (-) epigastric and
intercostal, breathing sound: vesicular, additional sound: ronchi -/-,
wheezing (-), murmur (-)

12

Abdomen: Distention (+), peristaltic (+) Normal, liver and spleen is

difficult to palpate
Extremities: pulse 106 x/i, regular, adequate pressure and volume, warm,
CRT < 3 second, pitting edema (-). Hematoma (-)

Laboratory findings
Complete blood analysis
Test
Hemoglobin
Erythrocyte
Leucocyte
Thrombocyte
Hematocrite
Eosinophil
Basophil
Neutrophil
Lymphocyte
Monocyte
Neutrophil absolute
Lymphocyte

Result
10,7
3,37
5.51
151
30,40
0,60
0,200
79,30
11,50
8,40
5,16
0.75

Unit
G%
106/mm3
103/mm3
103/mm3
%
%
%
%
%
%
103/L
103/L

Referral
11,3-14,1
4,40-4,48
4,5-13,5
150-450
37-41
1-6
0-1
37-80
20-40
2-8
2,4-7,3
1,7-5,1

absolute
Monocyte absolute
Eosinophyl absolute
Basophyl absolute
MCV
MCH
MCHC

0,55
0,04
0,01
90,20
32,30
35,90

103/L
103/L
103/L
fL
pg
g%

0,2-0,6
0,10-0,30
0-0,1
81-95
25-29
29-31

Clinical Chemistry
Blood Gas Analysis
pH
pCO2
pO2
Bicarbonate (HCO3)
Total CO2
Excess Base
O2 Saturation

Result
7,13
9,0
215,0
3,0
3,3
-23,9
100

Unit
mmHg
mmHg
mmol/L
mmol/L
mmol/L
%

Referral
7,35-7,45
38-42
85-100
22-26
19-25
(-2)-(+2)
95-100

13

Test
Carbohydrate Metabolism
Blood Glucose
Electrolyte
Natrium
Kalium
Chloride

Result

Unit

Referral

241

mg/dL

< 200

139
2,9
105

mEq/L
mEq/L
mEq/L

135-155
3,6-5,5
96-106

Differential Diagnosis

: dd Type 1 DM + AKI stadium Failure

Type 2 DM

Working Diagnosis

: dd Type 1 DM + AKI stadium Failure

Type 2 DM

Management
-

O2 1-2 L/i
IVFD D5% NaCl 0,225% 20 gtt/i micro
Insulin (Novorapid)

Follow Up
September, 25th 2015
S Unconscious
O Cons: unconscious, Temp: 36,5 oC.
Body weight: 14kg, Body length: 118 cm.
Head

light reflexes (+/+), pupil isochoric, inferior conjuctiva pale (+/+), icteric

sclera (-/-), face edema (-), inferior and superior palpebrae edema (-),
Ear/ Nose/ Mouth: within normal limit/ O2 nasal canal/ within normal

Neck
Thorax

:
:

limit, bleeding gums (-)

Lymph node enlargement (-).
Symmetrical fusiformis, Kussmaul breathing (+), chest retraction (-)
epigastric and intercostal, breathing sound: vesicular, additional sound:
ronchi -/-, wheezing (-), murmur (-), HR : 104x/i, regular, RR : 24x/i,

Abdomen :

regular
Distention (+), peristaltic (+) normal, liver and Spleen difficult to palpate

14

Extremities: Pulse 104x/i, regular, adequate pressure and volume, warm, CRT < 3.
A

Hypoglycemia + dd/ -DM type 1

- DM type 2

Management:
-

O2 1-2 L/i

IVFD D 10% KCl 45cc/hour GIR : 5,3mg/kg/min

Humulin R 5 unit in 50cc Nacl 0,9% 2,5cc/hour (0,05 unit/ hour)

Blood glucose target : 90-180mg/dL

Dipstick to evaluate ketone

Consul eye department for papil oedem evaluation

Elektrolyte result : K 2,2meq/L ECG

Consul answer : Normofundus. Papil oedema is not found for time being

Blood glucose level : 13.30/14.00/14.30/ 15.30/16.00/16.15/19.30/20.00/20.30 :

29/74/83/66/66/50/85/153/101

Diagnostic Plannings : Check Blood gas analysis, blood glucose level and electrolyte
value
per 3 hours

September, 26th 2015

S Unconscious (+)
O Cons: unconscious, Temp: 36,1 oC.
Body weight: 14kg, Body length: 118 cm.
Head

light reflexes (+/+), pupil isochoric, inferior conjuctiva pale (+/+), icteric

sclera (-/-), face edema (-), inferior and superior palpebrae edema (-),
Ear/ Nose/ Mouth: within normal limit/ O2 nasal canula/ within normal

Neck
Thorax

:
:

limit, bleeding gums (-)

Lymph node enlargement (-).
Symmetrical fusiformis, Kussmaul breathing (+), chest retraction (-),
breathing sound: vesicular, additional sound: ronchi -/-, wheezing (-),

murmur (-), HR : 100x/i, regular, RR : 40x/i, regular

Abdomen : Distention (+), peristaltic (+) normal, liver and Spleen difficult to palpate
Extremities: Pulse 100x/i, regular, adequate pressure and volume, warm, CRT < 3.
BP : 90/50mmHg

15

Hypoglycemia + dd/ - DM type 1 + AKI stadium Failure

- DM type 2

Management:
-

O2 nasal canula 1L/min

IVFD D5% + KCl 4cc/hour GIR : 5,3mg/kg/min

Humulin R 5 unit dalam 50cc Nacl 0,9% 7,5cc/hour (0,05 unit/hour)

Dipstick every 6 hours

Blood Glucose level 10.30/12.00/13.00/14.00/15.00/16.00/17.00 :

134/134/173/212/426/538/500

Diagnostic Planning:

S
O

Check Blood gas analysis, Elektrolyte, Blood glucose level per hour, Dipstick

urine
Diet : RDA x Ideal body weight = 70 x 17
= 1820 kkal + 227 gr carbohydrate

September, 27th 2015

Conscious, Kussmaul breathing (-), diarrhea (-)
Cons: alert, Temp: 36,9oC.
Body weight: 7 kg, Body length: 78 cm.
Head

Eye: light reflex (+/+), isochoric pupil, pale inferior conjunctiva

palpebra (-/-).Ear/ Nose/ Mouth: within normal limit/ nasal canule /

Neck
Thorax

within normal limit.

Lymph node enlargement (-).
Symmetrical fusiformis, distention(+), Chest retraction (-).HR: 104x/i,

Abdomen
Extremitie

regular, murmur (-), RR: 40x/i, reguler, rhonchi (-/-)

Distention(+), peristaltic (+) normal, liver and Spleen difficult to palpate
Pulse 104x/i, regular, adequate pressure and volume, warm, CRT < 3.

s
A dd/ - DM type 1 + AKI stadium Failure
P

- DM type 2
Management:

- O2 nasal canule 1L/min

- If blood glucose level : <100mg/dL D10% + KCl 10meq
: 100-200mg/dL D5% NaCl 0,45% + KCl 10 meq
: >250mg/dL NaCl 0,9% + KCl 10meq
- Insulin dosis : 0,5 IU/kgBW/day 0,5x14=7 IU/day (Novorapid 3-2-2) SC
16

- Diet : 1820 kkal with 227gr carbohydrates

- Blood glucose level : 07.00/08.00 : 213/317
Laboratory findings :
pH/pCO2/pO2/HCO3/TCO2/BE/O2 Sat : 7,22/25/184/10,2/11,6/-15,3/99%

S
O

September, 28th 2015

Conscious, Kussmaul breathing (-), diarrhea (-)
Cons: alert, Temp: 37,0oC.
Body weight: 14 kg, Body length: 118 cm.
Head

Eye: light reflex (+/+), isochoric pupil, pale inferior conjunctiva

palpebra (-/-).Ear/ Nose/ Mouth: within normal limit/ nasal canule /

Neck
Thorax

within normal limit.

Lymph node enlargement (-).
Symmetrical fusiformis, distention (+), Chest retraction (-). HR: 110x/i,

Abdomen
Extremitie

regular, murmur (-). RR: 36x/i, reguler, rhonchi (-/-)

Distention (+), peristaltic (+) normal, liver and spleen difficult to palpate
Pulse 100x/i, regular, adequate pressure and volume, warm, CRT < 3,

BP 90/70 mmHG

A dd/ - DM type 1 + AKI stadium Failure

P

- DM type 2
Management:

- O2 nasal canula 1L/min

- If blood glucose level : <100mg/dL D10% + KCl 10meq
: 100-200mg/dL D5% NaCl 0,45% + KCl 10 meq
: >250mg/dL NaCl 0,9% + KCl 10meq
-

Insulin dosis : 0,5IU/kgBW/day 0,5x14=7IU/day (Novorapid 3-2-2)

Diet : 1820kkal with 227gr carbohydrates
Blood Glucose level : 12.30 : HIGH
Dosage Correction : 1800/7 = 250 mg/dL
Target blood glucose level : 90-180 mg/dL
Every increase of 250mg/dL in blood glucose level above target dose 180mg/dL
increase 1 unit of novorapid dosage
- Consul nephrology

17

September, 29th 2015

S Unconscious (-)
O Cons: unconscious, Temp: 36,1 oC.
Body weight: 14kg, Body length: 118 cm.
Head

light reflexes (+/+), pupil isochoric, inferior conjuctiva pale (+/+), icteric

sclera (-/-), face edema (-), inferior and superior palpebrae edema (-),
Ear/ Nose/ Mouth: within normal limit/ O2 nasal canal/ within normal

Neck
Thorax

:
:

limit, bleeding gums (-)

Lymph node enlargement (-).
Symmetrical fusiformis, Kussmaul breathing (+), chest retraction (-),
breathing sound: vesicular, additional sound: ronchi -/-, wheezing (-),

murmur (-), HR : 100x/i, regular, RR : 40x/i, regular

Abdomen : Distention (+), peristaltic (+) normal, liver and Spleen difficult to palpate
Extremities: Pulse 100x/i, regular, adequate pressure and volume, warm, CRT < 3.
BP : 90/50mmHg
A dd/ - DM type 1 + AKI stadium Failure
P

- DM type 2
Management:

- O2 nasal canule 1L/min

- If blood glucose level : <100mg/dL D10% + KCl 10meq
: 100-200mg/dL D5% NaCl 0,45% + KCl 10 meq
: >250mg/dL NaCl 0,9% + KCl 10meq
- Insulin dosis : 0,5 IU/kgBW/day 0,5 x 14=7 IU/day (Novorapid 3-2-2)
- Blood glucose level target : 90-180mg/dL
- Every increase of 250mg/dL in blood glucose level above target dose 180mg/dL
increase 1 unit of novorapid dosage
- Diet : 1820kkal with 227gr carbohydrates
- Blood glucose level : 07.00 : HIGH

September,30th 2015
S Unconscious (-)
O Cons: unconscious, Temp: 36,8 oC.

18

Body weight: 14kg, Body length: 118 cm.

Head

light reflexes (+/+), pupil isochoric, inferior conjuctiva pale (-/-), icteric

sclera (-/-), face edema (-), inferior and superior palpebrae edema (-),
Ear/ Nose/ Mouth: within normal limit/ O2 nasal canal/ within normal

Neck
Thorax

:
:

limit, bleeding gums (-)

Lymph node enlargement (-).
Symmetrical fusiformis, Kussmaul breathing (+), chest retraction (-),
breathing sound: vesicular, additional sound: ronchi -/-, wheezing (-),

murmur (-), HR : 90x/i, regular, RR : 20x/i, regular

Abdomen : Distention (+), peristaltic (+) normal, liver and Spleen difficult to palpate
Extremities: Pulse 90x/i, regular, adequate pressure and volume, warm, CRT < 3.
BP : 90/60mmHg
A dd/ - DM type 1 + AKI stadium Failure
P

- DM type 2
Management:

- O2 nasal canula 1L/min

- If blood glucose level : <100mg/dL D10% + KCl 10meq
: 100-200mg/dL D5% NaCl 0,45% + KCl 10 meq
: >250mg/dL NaCl 0,9% + KCl 10meq
- Insulin dosis : 0,6 IU/kgBW/day 12 IU/day
- Basal insulin dosage 80% x 12 = 9,6~10 (Novorapid 5 unit 2-2-1)
(Levemir 5 unit)
- Dosage correction : 1800/10 = 180
- Blood glucose level target : 90-180mg/dL
- Every increase of 180 mg/dL in blood glucose level above target dose 180mg/dL
increase 1 unit of novorapid dosage
- Diet : 1820kkal with 227gr carbohydrates
- Blood glucose level : 1830 : HIGH
- Nephrology : Given Captopril 2 x 6,25mg (dr.Rosmayanti M.Ked (Ped),Sp.A)

October, 1st 2015

S
O

Unconscious (-)
Cons: alert, Temp: 35,6oC.
Body weight: 14kg, Body length: 118 cm.
Head

Eye: light reflex (+/+), isochoric pupil, pale inferior conjunctiva

palpebra (-/-).Ear/ Nose/ Mouth: within normal limit/ nasal canule /
within normal limit.

19

Neck
Thorax

Lymph node enlargement (-).

Symmetrical fusiformis, Chest retraction (-). HR: 80x/i, regular, murmur

Abdomen
Extremitie

(-). RR: 26x/i, reguler, rhonchi (-/-)

Distention (+), peristaltic (+) normal, liver and spleen difficult to palpate
Pulse 76x/i, regular, adequate pressure and volume, warm, CRT < 3.

BP: 100/50 mmHg

A dd/ - DM type 1 + AKI stadium Failure

P

- DM type 2
Management:

- Visit dr. Siska M.Ked (Ped),Sp.A -stop infusion

- Increase in insulin dosage 0,7 unit/kgBW/day = 14 unit/day
- Basal insulin dosage 80% x 14 = 12 unit (novorapid 6 unit : 2-2-2)
(Levemir 6 unit)
- Blood glucose target level : 180mg/dL
- Correction dosage : 150mg/dl
- Every increase of 150mg/dL in blood glucose level above target dose 180mg/dL
increase 1 unit of novorapid dosage
- If blood glucose level : <100mg/dL D10% + KCl 10meq
: 100-200mg/dL D5% NaCl 0,45% + KCl 10 meq
: >250mg/dL NaCl 0,9% + KCl 10meq
- Diet : 1820kkal with 227gr carbohydrates
- Nephrology : Given Captopril 2 x 6,25mg (dr.Rosmayanti M.Ked (Ped),Sp.A)

October, 2nd 2015

S
O

Unconscious (-)
Cons: alert, Temp: 36,9oC.
Body weight: 14kg, Body length: 118 cm.
Head

Eye: light reflex (+/+), isochoric pupil, pale inferior conjunctiva

palpebra (-/-).Ear/ Nose/ Mouth: within normal limit/ nasal canule /

Neck
Thorax

within normal limit.

Lymph node enlargement (-).
Symmetrical fusiformis, Chest retraction (-). HR: 80x/i, regular, murmur

Abdomen
Extremitie

(-). RR: 26x/i, reguler, rhonchi (-/-)

Distention (+), peristaltic (+) normal, liver and spleen difficult to palpate
Pulse 76x/i, regular, adequate pressure and volume, warm, CRT < 3.

BP: 100/50 mmHg

20

A dd/ - DM type 1 + AKI stadium Failure

P

- DM type 2
Management:

- Blood glucose level : 12.45 : HIGH

- Increase in insulin dosage 0,6 unit/kgBW/day = 12 unit/day
- Basal insulin dosage 80% x 12 = 9,6 ~10 unit (novorapid 5 unit : 2-2-1)
(Levemir 5 unit)
- Blood glucose target level : 180mg/dL
- Every increase of 250mg/dL in blood glucose level above target dose 180mg/dL
increase 1 unit of novorapid dosage
- If blood glucose level : <100mg/dL D10% + KCl 10meq
: 100-200mg/dL D5% NaCl 0,45% + KCl 10 meq
: >250mg/dL NaCl 0,9% + KCl 10meq
- Diet : 1820 kkal with 227gr carbohydrates

October, 3rd 2015

S
O

Unconscious (-)
Cons: alert, Temp: 36,9oC.
Body weight: 14kg, Body length: 118 cm.
Head

Eye: light reflex (+/+), isochoric pupil, pale inferior conjunctiva

palpebra (-/-).Ear/ Nose/ Mouth: within normal limit/ nasal canule /

Neck
Thorax

within normal limit.

Lymph node enlargement (-).
Symmetrical fusiformis, Chest retraction (-). HR: 84x/i, regular, murmur

Abdomen
Extremitie

(-). RR: 24x/i, reguler, rhonchi (-/-)

Distention (+), peristaltic (+) normal, liver and spleen difficult to palpate
Pulse 76x/i, regular, adequate pressure and volume, warm, CRT < 3.

BP: 100/60 mmHg

A dd/ - DM type 1 + AKI stadium Failure

P

- DM type 2
Management:

Increase in insulin dosage 0,6 unit/kgBW/day = 12 unit/day

Basal insulin dosage 80% x 12 = 9,6 ~10 unit (novorapid 5 unit : 2-2-2)
Blood glucose target level : 90-180mg/dL
Correction dosage : 1800/7 = 250 mg/dL
Every increase of 250mg/dL in blood glucose level above target dose 180mg/dL
increase 1 unit of novorapid dosage
- If blood glucose level : <100mg/dL D10% + KCl 10meq
: 100-200mg/dL D5% NaCl 0,45% + KCl 10 meq
21

: >250mg/dL NaCl 0,9% + KCl 10meq

- Diet : 1820 kkal with 227gr carbohydrates

October, 4th 2015

S
O

Unconscious (-)
Cons: alert, Temp: 36,9oC.
Body weight: 14kg, Body length: 118 cm.
Head

Eye: light reflex (+/+), isochoric pupil, pale inferior conjunctiva

palpebra (-/-).Ear/ Nose/ Mouth: within normal limit/ nasal canule /

Neck
Thorax

within normal limit.

Lymph node enlargement (-).
Symmetrical fusiformis, Chest retraction (-). HR: 86x/i, regular, murmur

Abdomen
Extremitie

(-). RR: 26x/i, reguler, rhonchi (-/-)

Distention (+), peristaltic (+) normal, liver and spleen difficult to palpate
Pulse 76x/i, regular, adequate pressure and volume, warm, CRT < 3.

BP: 100/60 mmHg

A dd/ - DM type 1 + AKI stadium Failure

P

- DM type 2
Management:

- Insulin dosage 0,6 unit/kgBW/day = 12 unit/day

(novorapid 7 unit : 3-2-2)
- Blood glucose target level : 180mg/dL
- Every increase of 250mg/dL in blood glucose level above target dose 180mg/dL
increase 1 unit of novorapid dosage
- If blood glucose level : <100mg/dL D10% + KCl 10meq
: 100-200mg/dL D5% NaCl 0,45% + KCl 10 meq
: >250mg/dL NaCl 0,9% + KCl 10meq
- Diet : 1820kkal with 227gr carbohydrates

October, 5th 2015

S
O

Unconscious (-)
Cons: alert, Temp: 36,8oC.
Body weight: 14kg, Body length: 118 cm.
22

Head

Eye: light reflex (+/+), isochoric pupil, pale inferior conjunctiva

palpebra (-/-).Ear/ Nose/ Mouth: within normal limit/ nasal canule /

Neck
Thorax

within normal limit.

Lymph node enlargement (-).
Symmetrical fusiformis, Chest retraction (-). HR: 80x/i, regular, murmur

Abdomen
Extremitie

(-). RR: 24x/i, reguler, rhonchi (-/-)

Distention (+), peristaltic (+) normal, liver and spleen difficult to palpate
Pulse 80x/i, regular, adequate pressure and volume, warm, CRT < 3.

BP: 100/50 mmHg

A dd/ - DM type 1 + AKI stadium Failure

P

- DM type 2
Management:

- Increase in insulin dosage 0,8 unit/kgBW/day = 16 unit/day

- Basal insulin dosage 80% x 16 = 13unit (novorapid 7 unit : 3-2-2)
(Levemir 6 unit)
- Blood glucose target level : 90-180mg/dL
- Every increase of 250mg/dL in blood glucose level above target dose 180mg/dL
increase 1 unit of novorapid dosage
- If blood glucose level : <100mg/dL D10% + KCl 10meq
: 100-200mg/dL D5% NaCl 0,45% + KCl 10 meq
: >250mg/dL NaCl 0,9% + KCl 10meq
- Diet : 1820kkal with 227gr carbohydrates

October, 6th 2015

S
O

Unconscious (-)
Cons: alert, Temp: 37,0oC.
Body weight: 14kg, Body length: 118 cm.
Head

Eye: light reflex (+/+), isochoric pupil, pale inferior conjunctiva

palpebra (-/-).Ear/ Nose/ Mouth: within normal limit/ nasal canule /

Neck
Thorax

within normal limit.

Lymph node enlargement (-).
Symmetrical fusiformis, Chest retraction (-). HR: 92x/i, regular, murmur

Abdomen
Extremitie

(-). RR: 22x/i, reguler, rhonchi (-/-)

Distention (+), peristaltic (+) normal, liver and spleen difficult to palpate
Pulse 92x/i, regular, adequate pressure and volume, warm, CRT < 3.

23

BP: 100/50 mmHg

A dd/ - DM type 1 + AKI stadium Failure

P

- DM type 2
Management:

- Increase in insulin dosage 0,8 unit/kgBW/day = 16 unit/day

- Basal insulin dosage 80% x 16 = 13 unit (novorapid 7 unit : 3-2-2)
(Levemir 6 unit)
- Blood glucose target level : 180mg/dL
- Every increase of 250mg/dL in blood glucose level above target dose 180mg/dL
increase 1 unit of novorapid dosage
- If blood glucose level : <100mg/dL D10% + KCl 10meq
: 100-200mg/dL D5% NaCl 0,45% + KCl 10 meq
: >250mg/dL NaCl 0,9% + KCl 10meq
- Diet : 1820kkal with 227gr carbohydrates
Culture findings :
- Urine test result : E.Coli, ESBL (+)
- Sensitive on amoxicillin/clavulanic acid, imipenem, sulbectam, gentamycin,
Meropenem, nitrofurantein, and fosfomycin

October, 7th 2015

S
O

Unconscious (-)
Cons: alert, Temp: 37,1oC.
Body weight: 14kg, Body length: 118 cm.
Head

Eye: light reflex (+/+), isochoric pupil, pale inferior conjunctiva

palpebra (-/-).Ear/ Nose/ Mouth: within normal limit/ nasal canule /

Neck
Thorax

within normal limit.

Lymph node enlargement (-).
Symmetrical fusiformis, Chest retraction (-). HR: 80x/i, regular, murmur

Abdomen
Extremitie

(-). RR: 26x/i, reguler, rhonchi (-/-)

Distention (+), peristaltic (+) normal, liver and spleen difficult to palpate
Pulse 76x/i, regular, adequate pressure and volume, warm, CRT < 3.

BP: 100/50 mmHg

A dd/ - DM type 1 + AKI stadium Failure

P

- DM type 2
Management:

- Increase in insulin dosage 0,8 unit/kgBW/day = 16 unit/day

- Basal insulin dosage 80% x 16 = 13 unit (novorapid 5 unit : 3-2-2)
(Levemir 6 unit)
- Blood glucose target level : 90-180mg/dL
24

- Every increase of 150mg/dL in blood glucose level above target dose 180mg/dL
increase 1 unit of novorapid dosage
- If blood glucose level : <100mg/dL D10% + KCl 10meq
: 100-200mg/dL D5% NaCl 0,45% + KCl 10 meq
: >250mg/dL NaCl 0,9% + KCl 10meq
- Diet : 1820kkal with 227gr carbohydrates

October, 8th 2015

S
O

Unconscious (-)
Cons: alert, Temp: 36,9oC.
Body weight: 14kg, Body length: 118 cm.
Head

Eye: light reflex (+/+), isochoric pupil, pale inferior conjunctiva

palpebra (-/-).Ear/ Nose/ Mouth: within normal limit/ nasal canule /

Neck
Thorax

within normal limit.

Lymph node enlargement (-).
Symmetrical fusiformis, Chest retraction (-). HR: 80x/i, regular, murmur

Abdomen
Extremitie

(-). RR: 26x/i, reguler, rhonchi (-/-)

Distention (+), peristaltic (+) normal, liver and spleen difficult to palpate
Pulse 76x/i, regular, adequate pressure and volume, warm, CRT < 3.

BP: 100/50 mmHg

A dd/ - DM type 1 + AKI stadium Failure

P

- DM type 2
Management:

- Increase in insulin dosage 0,8 unit/kgBW/day = 16 unit/day

- Basal insulin dosage 80% x 16 = 13 unit (novorapid 5 unit : 3-2-2)
(Levemir 5 unit)
- Blood glucose target level : 90-180mg/dL
- Every increase of 150mg/dL in blood glucose level above target dose 180mg/dL
increase 1 unit of novorapid dosage
- If blood glucose level : <100mg/dL D10% + KCl 10meq
: 100-200mg/dL D5% NaCl 0,45% + KCl 10 meq
: >250mg/dL NaCl 0,9% + KCl 10meq
- Diet : 1820 kkal with 227gr carbohydrates
OUTPATIENT

25

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