Laporan kasus

1. CLINICAL CONFERENCE
ENDOCRINOLOGI DIVISION
(NEW Case)
Sept 17TH 2021
Nurul Hikmah AM/Presenter
Irwandi Zakaria/Madya Divisi
Ahmad Ihsan, Zukmianty Suaib, Nur Ramdhani, A. Arwinny, Andi Emiral
Amal, Rini Wulandari/Senior Divisi

2. MR Number
Date of Birth
Admission Date
946920
July 30th 2010
Sept 15th 2021
RI, 11 years 1 month( Male)
MEDICAL DIAGNOSIS
TYPE II DIABETES MELLITUS + HYPONATREMIA +
OVERWEIGHT

3. Chief Complaint
Frequenty urination at night
History of Present Illness
Boy aged 11 years 1 month referred from Dr. Ratna Dewi Artati, Sp.A(K) with a diagnosis of
Type II Diabetes Mellitus. The boys with complaints of rrequenty urination at night since 1
month before admitted to the hospital.
No fever, no seizures.
No cough, no shortness of breath.
No vomiting. Good appetite.
Urination: normal, yellow. Defecation: normal

4. History of Past Illness
There was history of increased hunger and increased thirst since 1 month
ago
There was history of weight loss in 3 months (9 kg)
There was history of family with type-2 diabetes mellitus (Father), grand
mother and grand father from father, and grand mother from mother

5. Vital Sign
GCS 15 E4M6V5
Blood Pressure : 110/70 mmhg
Heart Rate : 90 bpm
Temperature : 36.8 °C
Respiration Rate : 24 times/min
SpO2 : 99% with nasal cannnule
Anthropometry
Body weight : 38 kg
Height : 141 cm
Head Circumference : 51 cm (N 50-55 cm)
Weight for Length : 38/34 x100% = 111% (overwight)
Weight for Age : 38/36 x100% = 106% (Normal)
Length for Age : 141/144 x100% = 98% (Normal)
BMI : located between percentil 75 – 85 (Normal)

6. Chart CDC / WHO / FENTON / LUBCHENCO

8. BMI
weight
(height in meter)²
= 38/(1,41) ²
= 38/1,9881
= 19,11
Located between
percentile 75 – 85
(normal)

9. Vaccine
Frequency
Not given 0 1 2 3 4
Hep B √ √ √ √ √
BCG √
DPT √ √ √ √
Hib
OPV √ √ √ √ √
IPV
MMR √ √
Rotavirus
Influenza
Japanese Encephalitis
PCV
Varicella
Hepatitis A
Tifoid
History of Vaccine

10. Pedigree
Ket :
: Passed away
: with DM
Mother
Father

11. No Acanthosis Nigricans
Pulmo
Vesicular breath sounds,
No ronchi. No wheezing.
Cardiovascular
I / II heart sound, Regular rhythm no murmur
Abdomen
Peristaltic sound : normal
Hepar and Lien are not palpable

12. Laboratory
September 15th
2021(Wahidin)
Normal Value
Hb 14,7 12.0 – 16.0 gr/dL
WBC 6.800 4.0 – 10.0 x 103/μL
ANC 3.168
PLT 264.000 150 - 400 /mm3
MCV 79 80 -100 μm3
MCH 29 27 - 32 Pg
% NEUT 46,60 52 – 75 103/μL
% LYM 46,8 20 – 40 103/μL
% MONO 4,2 2 – 8 103/μL

13. Laboratory
September 15th
2021(Wahidin)
Normal Value
Ureum 26 10 - 50 mg/dl
Creatinine 0.68 <1.1 mg/dl
SGOT 21 < 38 u/l
SGPT 44 < 41 u/l
Natrium 129
136-145
Kalium 4.6 3,5-5,1
Clorida 97 97-111
GDS 778

14. Laboratory
September
15th
2021(Wahidin)
NORMAL
PH 7.512 7.35-7.45
PO2 119,9 80-100
PCO2 35,6 35-45
HCO3 28,8 22-26
BE 5,6 -2 TO 2

15. Laboratory
September 15th
2021(Wahidin)
PH 6.0
SW ≤1.005
PROTEIN
GLUCOSE
NEG
Neg
BILIRUBINE
KETON
Neg
Neg
NITRIT NEG
BLOOD NEG
LEUKOCYTES Neg
SEDIMENT: LEUKOCYTES 1
SEDIMENT :
ERYTHROCYTES
0

16. Laboratory
September 15th
2021(Prodia)
NORMAL
C Peptide 1,75
0,78 – 5,19
ng/ml
HbA1C (NGSP) 16%
HbA1C (IFCC) 151

17. Type II Diabetes Mellitus
Hyponatremia
Overweight

18. - Fluid requirements :
Holiday Segar : 1.860 cc/day
- Enteral : 360 cc
- Parenteral : NaCl 0,9% infusion 63 cc/hour/intravenous
- Lantus 8U – 0 – 0
- Novorapid 3U – 4U – 4U
- Correction of hyponatremia (enough with maintenance fluid)

19. THANK YOU